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/

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.

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?

While the Z-Vibe and DnZ-Vibe have been used with individuals to self soothe, I recommend that it be used with supervision.  I also recommend consulting with a speech therapist and/or occupational therapist who has experience in working with sensory processing disorders.

I’d also like to share a case of mine with you that I think you may find useful.  A teacher once came to me asking for advice for her 5-year-old son, who had begun to chew excessively.  As they were literally leaving school to go on a 6 hour road trip, I explained and demonstrated how to use the Grabber XT.  His shirt at the time was already wet and well chewed, but they made it to their destination in relief.  Instead of chewing on his shirt and other objects during the car ride, he was able to get the oral stimulation that he needed from the Grabber XT.  She also increased his diet with harder-to-chew foods, and the excessive chewing has since subsided.  When watching tv, however, the behavior returned.  So I recommended a hand fidget to see if that would help to keep his shirt out of his mouth.

I also suggested that she do gum massage for him on a routine basis.  Gum massage is a simple and effective way to provide oral stimulation.  Place your pointer finger just above the upper middle teeth.  Move it across the gum to the back molars and back to where you began.  Repeat about 3 times.  Next, repeat the same motion on the lower gums.  Place your finger just below the lower middle teeth.  Move it across the gums to the back molars and back to the front again.  Repeat about 3 times.  Then switch to using your thumb and repeat the same movements on the other side of the mouth.  Start in the center of the teeth and move your thumb back along the gums to the molar area.  Repeat about 3 times on both the upper and lower gums.  You may have to decrease the number of times depending on his reaction.  It’s not the number of times that matters, it’s your son’s response.  Is he relaxing?  Is he tensing?  It also doesn’t matter which fingers you use, I just described the motions that are the most comfortable for me.  What does matter, however, is the frequency of the exercise.  I recommend that this be done as often as possible throughout the day.  I once had a 5-year-old girl in therapy who was mouthing/eating inappropriate objects in the classroom.  So during therapy, I did this exercise every 10-15 minutes during the session.  When she sat on my lap for the massage, she just melted into me, she enjoyed it so much.  Eventually, she stopped eating/mouthing inappropriate objects in the classroom.

Please let me know if this helps.  Any other suggestions from our readers are welcome!

All the best,

Debbie

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.

A:  Dear parent,

I would recommend doing a gum massage during his g-tube feedings, or having him bite/chew/mouth some chew tools.  You said you have a Baby Grabber® that he enjoys, which would be great to use.  ARK also sells the Beckman Tri-Chew, which is another safe mouthing tool to use.  The ProMini can be used to stroke the sides of the tongue, stimulate the inside of the cheeks, and brush or tap the tongue.  The goal is to provide stimulation to the tongue, lips, cheeks, and gums as if he were eating while being fed via g-tube.

In reference to his tongue thrust, please ask your SLP to explain the difference between a suckle and a suck.  I cannot comment since I cannot actually see what he is doing.  However, all infants have a tongue thrust swallowing pattern which will eventually change as he grows older.

You may try to work on straw drinking with the guidance of your SLP.  We do have several products that can be used to teach straw drinking (the Cip-Kup™, Sip-Tip®, Bear Bottle, etc.).  However, I recommend trying this first: cut a regular straw in half or even smaller.  While holding your finger over one end, dip the other end in his formula or any stage 1 baby food that he enjoys.  Since he has a good strong suck, this may just work.   Hydration and caloric intake as you well know is very important to maintain health and continued growth.

While sippy cups have their place in helping transition between bottle to cup, some SLPs don’t like them because they can promote tongue thrust.  The liquid comes out too fast inside the child’s mouth and he/she uses compensatory tongue movements to manage the overflow.  The mouthpiece can also be too wide and large for the child’s oral cavity size, again creating problems.  If you are going to try zippy cups again, I recommend reading this post first.

Just a note on reflux – I have known parents to take their children off their medication without consulting the pediatrician.  They usually do this between the age of two and three because their child appears to be symptom free.  But then feeding issues begin.  So, please consult with his pediatrician first before doing so, and I know that you will.  You are an investigative parent, who only wants to do the best for your wonderful baby.

Please give me updates as to his progress.  If you have any other questions or concerns, please do not hesitate to contact me.
All the best,
Debbie

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.