Oral feeding problems in infants and young children without neuromuscular dysfunction may occur at any stage of feeding development. Upon discharge from a prolonged hospital stay, some infants/toddlers are non-oral feeders; some are able to accept only liquid from a bottle; and others can tolerate pureed food from a spoon but are unable to manage textured foods or mixed consistencies such as beef stew or chicken noodle soup. Oral intake may be poor and weight gain may be slow. Many infants seem disinterested in eating or just not hungry. Some infants may subsequently be diagnosed with Failure to Thrive. These feeding problems may be secondary to a sensory processing disorder.
Feeding transitions are difficult for these infants and they are not able to adapt to changes in food textures, utensils, or placement of food in the mouth. Upon examination, oral-motor patterns are within normal limits which just serves to confuse further the issue of why these infants do not eat or transition to a more developmentally age appropriate diet, i.e., by six months infants should be able to manage pureed foods from a spoon; by 9 months they should be able to use the central incisors for biting on soft solids that dissolve easily in the mouth such as cookies, crackers, and teething biscuits; and by 12 months of age they are able to bite and chew small pieces of soft solids that do not dissolve easily in the mouth, i.e., cooked carrots, bananas, and soft meats. Medical diagnostic work-ups often fail to determine the etiology of the oral feeding problems or to identify the cause of the feeding aversion.
For those infants whose primary medical conditions resolve, clinical signs of cerebral palsy and related oral-motor dysfunction may not be present. A sensory feeding aversion, however, does not arise just from a physical disability or a genetic syndrome. Because of this, neurodevelopmental treatment or the use of more traditional facilitation techniques is not usually successful in treatment feeding disorders that involve a sensory processing disorder.
When neurologic findings are negative and oral-motor skills are within normal limits and age appropriate, the feeding aversion is assumed to have a sensory base. This may have an underlying etiology of such conditions as cardiac defect, diaphragmatic hernia, chronic lung disease, tracheoesophageal fistula, necrotizing enterocolitis, and gastroesophageal reflux, all of which may result in a sensory processing disorder.
Characteristics of an Oral-Sensory Feeding Aversion
Birth to 3 months:
– Unable to sustain a suck pattern; habituates to the nipple
– Feeds better in a less than alert stay with eyes closed; usually at night
– Demonstrates “nipple confusion” if offered both bottle and breast
– Although suck is intact, infant is unable to differentiate changing tastes offered through nipple
– Poor oral intake; infants falls off the growth curve
Over 3 months of age:
– Normal oral-motor patterns
– Able to swallow liquids, particularly water, but has difficulty with thicker consistencies such as pureed – – Tolerates own fingers in mouth but no one else’s
– Tongue retracts in response to touch
– Gag is hypersensitive
– Volitional open mouth posture occurs when food is placed in the mouth
– Holds food under tongue or in buccal cavity to avoid swallowing
– Able to sort out small pieces of solids from sauces and gravies and then expels solid food pieces while swallowing liquids
– Able to bite and chew solids in mouth but unable to swallow
A diagnostic check list has been developed that offers some suggestions to help differentiate between oral feeding disorders with a motor versus sensory base. Once a basis for the feeding disorder has been determined, an appropriate treatment program can be initiated.
Oral Feeding Disorders Assessment: Motor Versus Sensory
| Description | SENSORY | MOTOR |
| 1. Normal oral-motor patterns | Yes | No |
| 2. Liquids are easier to manage than textures or pureed food | Yes | No |
| 3. Mixed consistencies are difficult | No | Yes |
| 4. Able to chew solids well | Yes | No |
| 5. Gags when food approaches or contacts lips | Yes | No |
| 6. Holds food in mouth to avoid swallowing | Yes | No |
| 7. Hypersensitive gag for solids with normal liquid swallow | Yes | No |
After having worked for many years as a neonatal and pediatric feeding specialist in the Department of Pediatric Gastroenterology, Hepatology, and Nutrition at the University of California-San Francisco School of Medicine where I was also a Clinical Instructor in the Department of Pediatrics, I learned much about the esophageal phase of swallow and its’ influence on the development of oral feeding abilities in infants.
Typically infants who have gastroesophageal reflux accompanied by some degree of esophageal dysmotility do well with water but may have difficulty swallowing the thicker and heavier food textures, such as pureed and solids and thus are not able to transition onto an ae appropriate diet as expected. The esophageal phase of swallow also influences their sucking pattern on the bottle. Since liquid is not able to clear the esophagus in a timely manner, which for neonates is the rate of 1 suck/1 swallow/ in one second during the normal continuous burst paten of the term infant, the infant with poor esophageal motility will modify the suck either by taking frequent breaks or by sucking several times without an accompanying swallow after the suck. You and I would do the same if liquid began to back up in our esophagus and did not clear at the same rate of suck and swallow. As the liquid backs up in the esophagus it may spill into the trachea causing aspiration in some infants who are not able to use some strategy to protect themselves.
If you are a professional who feeds preterm or sick term infants in the NIUC please be aware of the infant who struggles to protect his airway so that aspiration does not occur. Such an infant may take long pauses, suck without swallowing, turn away from the nipple, and/or demonstrate stress signs.
Marjorie Meyer Palmer MA, NLP, CCC-SLP, Neonatal / Pediatric Feeding Specialist, Speech-Language Pathologist, Founder / Director NOMAS® International