In response to the many recent blog posts on the topic, I’ve decided to chime in with a series on oral-motor therapy, feeding, and DS. We’re going to start with the basics, move into myths I’ve read online, and finish up with what really works!
So what are pre-feeding exercises? Pre-feeding exercises are activities the parent or caregiver completes with the child prior to feeding in order to improve eating. You may see them called mouth exercises, oral stimulation, or non-speech oral motor exercises (NSOME). Regardless of the name, there are varying ideas of what pre-feeding exercises look like and how they should be performed. They can be as passive as massaging the child’s face to as invasive as brushing the roof of the mouth with a NUK brush.
Am I personally against pre-feeding exercises? In short, no. However, I want to emphasize that little research has been done on these techniques. Peer-reviewed research specific to DS and pre-feeding exercises is non-existent. However, that doesn’t mean a well-trained SLP shouldn’t use them with your child. Instead, these exercises may be one part of the feeding/swallowing treatment plan developed by a therapist who understands swallowing disorders.
Pre-feeding exercises do not apply to ALL children with DS. There is no evidence to support that they “prevent” feeding disorders from developing.
Children with DS are a very diverse group! Part of the reason why they (and children without DS) gain feeding skills at different times is in part due to, “…the cultural and individual differences among families in the timing for introducing new eating experiences.” (Sheppard, 2008). In addition, children with DS have a variety of underlying factor contributing to feeding difficulties. These include:
- Motor (muscle strength & coordination) ***Not simply low-tone***
- Sensory (sight, taste, touch, etc.)
- Emotional/behavioral (avoidance, refusal, or “no off switch”)
- Medical/health reasons (cardiac defects, reflux, seizures, etc.).
It is important to understand reason(s) behind the feeding problem to effectively provide treatment.
Today, we’ll focus on the sensory aspects of feeding. You may think this is an odd place to begin, but I choose it for good reason. Many of the types of oral-stimulation techniques used in feeding therapy are sensory based. Recently, The Speech Mama posted a list of pre-feeding exercises for children with Down syndrome. She wrote,
“The goal of the exercises is to improve strength and mobility of the muscles needed for feeding and also for speaking.”
While I appreciate Speech Mama’s list of techniques, it is important to understand that these techniques are not for promoting speech. Multiple studies and reviews on NSOME do not support their use to improve speech clarity. (This is a huge topic for another day!)
Pre-feeding techniques usually require you to get in your child’s space. You know, really close. This can be overwhelming for your child. I highly recommend that you try out any technique on yourself before trying it on your child. Even better, have the therapist show the technique on you! Then you will really get an idea of how it feels to have these exercises completed. Some may feel great – others intruding – of course, your own level of acceptance will affect the way they feel on you.
When looking at children with DS with feeding disorders we can break children into 4 categories:
- Over-responders: Children who have a heightened response to sensations in the mouth. These feelings may be interpreted as painful or dangerous. They may respond to other sensations outside of the mouth and have difficulty focusing on feeding. For instance they may be distracted by the Velcro on their bib.
- Under-responders: The threshold for sensations in these children is high. Therefore, they don’t respond to the natural cues given during feeding. The child may see the spoon coming, but not anticipate it by opening her mouth. He may feel the food on his tongue, but lose track of the bite once it slides into the cheeks resulting in “stuffing” the mouth.
- Sensory-seekers: Children who interpret input poorly and seek strong sensations to alert the nervous system. These children often like high flavor, crunchy foods like chips or pretzels.
- Sensory-avoiders: Children who avoid sensations (like different textures) at all costs because of their low sensory thresholds. I see this frequently in children with DS for the following reasons:
- Prolonged alternative feeding with oral stimulation (tube feeders)
- Reflux, medicated or not
- Ongoing cardiac/pulmonary issues
- Poor oral coordination combined with a diet too advanced in texture
Under the care of a feeding specialist (either SLP or OT) you may be using some of the techniques listed on Speech Mama to advance your child’s feeding skills. However, it is important to recognize when to stop using these techniques. Yes, they can be harmful.
- Averted gaze (looks away from you)
- Increased rate of breathing
- Color changes
- Finger splaying
- Warding off gesture (hands up in front of face)
Stop as soon as you notice these signals in order to prevent the child from shutting down and refusing future feeding attempts. Continued attempts may contribute to oral aversion and food refusal.
I am thankful that more people today are interested in helping children with DS who have feeding disorders. As you start feeding treatment with your child use caution and insight. Ask questions. And remember with feeding there is no such thing as a quick-fix, but successful eating is possible for most children with DS!