How to Teach Biting and Chewing

For infants, learning how to bite and chew is a crucial stage of feeding development.  At approximately 5 months of age, babies begin using their fingers and teethers for oral exploration using a bite and release pattern.  The development of biting and chewing continues from this point on, with the baby refining the movements of the jaw, tongue, and lips.  When infants miss a part of this developmental process, intervention may be necessary to develop the ability to bite and chew.

1. One of the ways I like to begin is to provide the child with the opportunity to mouth ARK’s oral motor chew tools (the Grabber, Y-Chew, Probe, and/or Animal Tips).  These tools were specifically designed to increase oral awareness, to provide stimulation and tactile sensation, and to exercise the lips, cheeks, tongue, and jaw.  Through oral exploration, the child just might begin to bite on his/her own, and from there you can progress to chewing.
2. Demonstrate how to bite so that the child can see and learn what the word actually means.  Knowing the vocabulary will be an important part of therapy as you encourage the child to bite and chew.  Over-exaggerate the movement to help communicate the concept.  Use actual food when illustrating/showing.  You can also use puppets with mouths to help illustrate biting (and later chewing).  Take turns with the child to feed the puppet.  Make it fun and playful.  Make a bite sound or a glottal /um/ sound.  Have the child feed you!
3. A vertical chewing pattern (an up-and-down opening and closing of the mouth) will begin to develop first. Place either a Grabber or Y-Chew in between the molar area and assist the jaw to open and close.  Use the word ‘bite’ as you are directing the jaw to close on the tool being used.  Use a mirror for the child to watch himself/herself and you demonstrating a bite.  Discontinue using the mirror if it becomes too distracting.
4. Once the child knows the vocabulary word ‘bite’ and can perform the skill, add the word ‘chew.’  Have the child place his/her hands on yours to feel the bite-and-chew movement.  Work up to 20-25 chews in a row on each side of the mouth.  However, if using ARK’s Probe, switch over to a Grabber or Y-Chew after the child is able to chew 3-5 times in a row.
5. If using a Grabber, have the child bite and chew on the loop as well.  If using a Y-Chew, place the handle sideways across the front teeth.  This works both sides of the mouth at once for bilateral chewing and jaw strength and stability.
6. Alternate sides to promote the development of a rotary chewing action.  Have the child bite and chew 3-5 times on one side of the mouth and then switch to the other side.  Remember to have the chew tools placed to the side of the mouth, in between the pre-molar area.  As the child progresses, move the Grabber or Y-Chew to the back molar area where the chewing of foods occurs.  If the child gags, move back toward the bicuspids and slowly, over time, progress to the molar area.
7. Once you are comfortable with the child’s ability to bite and chew, dip ARK’s tools into puréed or sticky foods and continue the biting and chewing exercises.  Pairing these tools with real food helps to bridge the gap between practicing chewing and actually chewing real food.
8. To assist with texture acceptance, begin using the Grabber and progress to the Textured Grabber.  Then dip the Textured Grabber into puréed or sticky foods and continue with biting and chewing exercises.
9. Have a drink handy in case the child needs to take a sip in between exercises.

Additional Tips:

• It is important to note that some children may seem frightened to eat because they know they do not have the oral motor skills necessary to handle food.  These children are reacting to a real fear and not just refusing to eat.  In this instance, you will need to work on bolus formation, tongue awareness, and/or tongue lateralization.  To work on these skills, use ARK’s Probe or Z-Vibe to stimulate the top and sides of the tongue.  Specific techniques can be found in Tips & Techniques for the Z-Vibe.
• It is also important to note that anyone who has direct contact with the child (caregivers, interventionists, ABA therapists, etc.) should be on board to follow through with intervention strategies.  The best results happen when therapy is reinforced at home in between sessions.  The more opportunities presented, the better.  However, the child should never be forced to mouth, bite, or chew.  Teaching these skills takes time, lots of patience, and creative thinking.
• Talk about the tools and let children feel them in their hands and on their arms first.  Then progress to the face, cheeks, lips, and inside the oral cavity.  Incorporate play therapy into your feeding sessions.
• Remember to praise, praise, praise.  Use reinforcements that cater to the child’s interests.  Get excited about progress.  Be an actress/actor!

For more tips to work on texture acceptance, check out this post: http://arktherapeutic.wordpress.com/2011/08/16/tips-to-accepting-different-food-textures/

Duration and Frequency of Use for the Z-Vibe® & DnZ-Vibe®

Question:  What is the frequency and duration of use that you recommend for the Z-Vibe during therapy?  Also, my patients only see me 1-2 times per week.  Can parents use the Z-Vibe in between therapy sessions?

Answer:  As long as you or another speech therapist shows the parents how to use the Z-Vibe, then by all means they should use it at home to reinforce what you are working on in therapy.  Following through with therapeutic intervention at home is a very important part of the treatment program.  Just be sure to remind the parents that the Z-Vibe must be used under adult supervision, as the unit contains small parts.

As for the recommended frequency and duration of use, this varies for each individual. Provide stimulation with the Z-Vibe, observe the response, and modify the use according to each person’s tolerance/needs. Some individuals may not be able to tolerate a lot of stimulation, while others may crave it. Work on individualized progress and remember that frequent exercises throughout the day are more important than the amount of exercises completed in any one session.

 

Instructions for ARK’s Cip-Kup, Sip-Tip, Bear Bottle, and more

ARK manufactures three main product lines – oral sensory chews, drinking aids, and vibratory oral motor products. The instruction booklet below describes all of our drinking aids and includes tips for how to use, clean, and care for them. Click on the image to read, and feel free to ask if you have any questions.

 

Instructions for ARK’s Grabber & Y-Chew

ARK manufactures three main product lines – oral sensory chews, drinking aids, and vibratory oral motor products.  The instruction booklet below describes the Grabber and Y-Chew and includes tips for how to use, clean, and care for them.  Click on the image to read, and feel free to ask if you have any questions.

 

 

Gum Massage for Oral Stimulation

Q:  For a teenager who is very much seeking oral stimulation, can the Z-Vibe be used to give additional input to allow him to self-soothe?  I appreciate any help you can give me.

A:  Dear Lisa,

Before I can fully answer your question, I’d like a little bit more background information.  What kind of oral behaviors is your son exhibiting?  Excessive chewing?  Mouthing objects?  Does he eat a normal diet?   Any dental concerns?  Is there an oral care program in place?  Is a vibrating toothbrush used?  Any pattern to when he needs/wants oral stimulation?  May it be communication for being thirsty?  Hungry?  For pain or frustration?

Instructions for ARK’s Z-Vibe and DnZ-Vibe

ARK manufactures three main product lines – oral sensory chews, drinking aids, and vibratory oral motor products.  The instruction booklet below describes our Z-Vibe and DnZ-Vibe and includes tips for how to use, clean, and care for them.  Click on any image to read, and feel free to ask if you have any questions.

G-Tube Advice

Q:    I am a mother to a baby who is 6.5 months old, corrected age.  He was born at 29 weeks gestational age.  Because of being on a high level of O2 support for a long period of time, being intubated several times, and experiencing reflux, he has had an aversion to liquids and was not able to learn how to suck on a bottle effectively.  A g-tube was placed before he left the NICU.  He is now fed exclusively through the g-tube, but his speech therapist and I are making progress on his oral acceptance of liquids and solids.  However, his oral mechanics still do not allow him to process more than .1 to .2 ml for each swallow.  He has marked tongue thrusting.

Regarding tools —  at this point we are making use of the Baby Grabber and are using a 1 ml syringe for liquid practice.  We have attempted to use several sippy cups without much success so far.  His speech therapist has not suggested any other tools/devices at this point.  Could you suggest products that we could use for feeding practice, tongue placement/mechanics, and general oral work that will help us work towards g-tube independence?  Our speech therapist cannot provide them, so we are looking to purchase just a few items that will have maximum usage and effect.

How to Teach Straw Drinking

1. To start, cut a regular straw in half.  Not only is a shorter straw easier to handle, but it also takes less strength for a child to suck liquid from a shorter straw.
2. Dip the straw into a cup with liquid preferred by the child. Place the tip of your pointer finger over the top of the straw to keep the liquid in the straw. Remove the straw from the cup, keeping the top of the straw covered with your fingertip.
3. Place the straw on the child’s lips at a slightly tilted down angle (so that if you release your finger, the liquid will flow into the mouth).
4. Remove your fingertip, allowing the liquid to flow into the child’s mouth. The goal here is for the child to comprehend that he/she is getting liquid from the straw.  As you are doing this, tell the child to “take a sip.”

Q&A – Tongue Protrusion & Lateralization

Q:  Do you have a tool to increase tongue protrusion and tongue lateralization?

A:  We do have a tool specifically for tongue lateralization called the Oro-Navigator™.  It’s pretty easy to use.  Simply place it on the side of the tongue and move the tongue to the opposite side.  Repeat on the other side of the tongue.  Imagine an OT sitting behind a child and guiding his/her arm across midline so that he/she can feel and visualize the movement.  Similarly, the Oro-Navigator™ allows the individual to feel and see (using a mirror) what their tongue is doing.

However, the need to increase both tongue protrusion and tongue lateralization raises a red flag for me.  It sounds as if there is a larger problem at hand here.  Tongue protrusion and tongue lateralization difficulties are symptoms of ankyloglossia.  A few factors to consider are the following:

• Can the individual extend his/her tongue OUTSIDE the mouth to lick an ice cream cone or lollipop?  Or, does he/she position the food inside the oral cavity, compensating for the inability to extend the tongue for licking? 
• Have the individual open his/her mouth wide and position the tongue tip up to the alveolar ridge (the piece of skin behind the upper front teeth). Can the tongue reach that spot?  Is the individual closing the mouth in order to reach it?  
• Is the individual speaking with a more closed mouth?  Elevating the tongue to the alveolar ridge is how we produce the tongue tip sounds t/d/n/l/s/z.  If an individual cannot properly elevate the tongue, his/her speech will be affected.  Observe carefully, as the individual may be making these sounds with the tongue tip behind the bottom teeth instead. 

Without seeing the child, it’s difficult for me to accurately assess the situation.  I would refer to a medical doctor such as a dentist or ENT, who can work in conjunction with an SLP to diagnose this case.  If there is ankyloglossia, the parent will ultimately decide what she/he wants for her child.  I hope this information points you in the right direction.  Please let me know if you have any further questions.

All my best,

Debbie

What to Look for in a Sippy Cup

Sippy cups cause a number of problems for speech sounds and swallowing patterns.  However, many individuals like them for their no-spill convenience.  If you are going to buy a sippy cup, it is important that it meets several guidelines.  Sandra Holtzman addresses these issues in this recent video:

 

Another feature of the sippy cup to consider is the size of the holes where the fluid comes out.  If the holes are too large, too much fluid will come out at too fast of a pace, which makes it difficult to manage swallowing.  If the holes are too small, it will be too difficult to draw liquid from the cup.  The best way to determine if the sippy cup is suitable is to try it out yourself, keeping in mind that your little one has a smaller mouth size.  What position is your tongue in?  Does your tongue go forward and under the spout?  Is it too big and uncomfortable?  Is it difficult to close your lips around the spout?  Does the plastic taste funny?  If it is, imagine what it would be like for your child.  The next thing to do is to observe your child drinking from the cup.  The tongue should not protrude under the spout, and the child should not be biting on the spout.  Check for teeth marks.  The lips should also be firmly closed around the spout so that no fluid leaks out of the corners of the mouth.