FEEDING AND POSITIONING

Guidelines for Working with Babies and

Children
 TOPICS WE WILL COVER

o Malnutrition and feeding challenges

o Feeding basics
o Typical feeding development
o Common feeding challenges and solutions
o Strategies to support bottle feeding, spoon feeding, and cup drinking:
Hands-On Practice
o Additional ideas for supporting the entire child

OUR GOAL: Offer ideas and tools for caregivers that make all feedings a
safe and positive experience for both the child and the feeder.
MALNUTRITION AND FEEDING CHALLENGES

“If we wish to create a

lasting peace, we must
begin with the
children.”

Mahatma Gandhi
WHAT IS
MALNUTRITION?

A lack of proper nutrition caused by not

having enough to eat, not eating enough
of the right things, or being unable to use
the food that one does eat.
 o Children with disabilities
WHO IS AT
o Infants and children with feeding
GREATEST RISK OF challenges
MALNUTRITION? o Infants and children without consistent,
positive relationships
WHO IS AT GREATEST RISK
OF MALNUTRITION? (CONT.)
o Cerebral palsy
o Cleft lip and/or palate
o Fetal alcohol spectrum disorders
o Autism spectrum disorders
o Cardiac (heart) conditions
o Syndromes or
neurodevelopmental (brain)
conditions (Down syndrome)
o Prematurity (early) or exposure
to drugs, stress, etc.
o Hearing or vision impairments
 MALNUTRITION RISK FACTORS
Prenatal Factors

No breastfeeding or Limited or lack of

access to breastmilk time outside

Lack of adaptive Limited access to

(special) seating, medical interventions
bottles, cups, spoons for feeding and
digestion

Diets not Caregiver or facility

customized to fit feeding practices do
child’s needs not fit child’s needs

Lack of training in
feeding and child Lack of consistent,
development positive relationships
 o Positioning
FEEDING o Swallowing
BASICS o Food textures and liquid consistencies
o Sensory systems
FEEDING BASICS:
POSITIONING
WHAT IS POSITIONING?
Positioning relates to the way we hold a child in
our arms or our laps, and how we place a child
in a chair, seat or on the floor for mealtimes.

THE WAY WE POSITION A CHILD DEPENDS ON:

o age
o general developmental skills, especially
physical capabilities
o individual needs (higher elevation of body
during feeding due to reflux, increased
head/trunk support due to low tone)
o caregiver’s abilities
o resources available in environments
FEEDING BASICS: POSITIONING (CONT.)

BENEFITS RISKS
↑ efficiency of feedings (e.g., faster) ↓ efficiency of feedings (i.e., slower)
↑ oral intake during feedings ↓ oral intake during feedings
↑ capacity for children to try different food textures ↓ capacity for children to try different food textures
↑ breathing capacity ↓ breathing capacity
↑ digestion of foods and liquids ↓ digestion of foods and liquids
↑ skills for using vision and hands for self-feeding ↓ skills for using vision and hands for self-feeding
↑ capacity for children to feed themselves ↓ capacity for children to feed themselves
↑ enjoyment during feedings (for children & caregivers) ↓ enjoyment during feedings (for children and
caregivers)
↑ growth and nutrition
↓ growth and nutrition
↑ capacity to interact socially with others
↓ capacity to interact socially with others
↓ INCIDENCE OF ASPIRATION, ILLNESS, DEATH
↑ INCIDENCE OF ASPIRATION, ILLNESS, DEATH
FEEDING BASICS: POSITIONING (CONT.)

Hips Positioned at 90 degrees

Trunk Upright, not leaning forward, backward or sideways

KEY ELEMENTS
Shoulders Level and facing forward
OF
POSITIONING Head Chin slightly tucked toward chest; head upright and
facing forward

Knees Positioned at 90 degrees

Feet Supported on the floor, chair footrests or other

object; flat position
FEEDING BASICS: POSITIONING (CONT.)

KEY ELEMENTS OF POSITIONING

FEEDING BASICS: POSITIONING (CONT.)

REMEMBER:
Where the feeder sits matters! Sit eye
level facing a child so that he does not
need to extend his head and neck to see
you and reach the food or liquids.
FEEDING BASICS: POSITIONING (CONT.)

EXAMPLES OF GOOD AND POOR POSITIONING

GOOD POSITIONING POOR POSITIONING POOR POSITIONING

FEEDING BASICS: POSITIONING (CONT.)

EXAMPLES OF GOOD AND POOR POSITIONING

GOOD POSI TI ONING POOR POSI TIONING

FEEDING BASICS: POSITIONING (CONT.)

EXAMPLES OF GOOD AND POOR POSITIONING

GOOD POSI TIONIN G POOR POSI TIONING

FEEDING BASICS: POSITIONING (CONT.)

EXAMPLES OF GOOD AND POOR POSITIONING

GOOD POSI TIONING POOR POSI TIONING

FEEDING BASICS: POSITIONING (CONT.)

POSITIONING TIPS

o Consider individuality of a child.

o Consider child’s developmental skill level.
o Consider comfort of the caregiver (yourself!) during a feeding.
o Remember that children grow!
o Finding the best position can sometimes take a lot of work.
GROUP ACTIVITY:
POSITION YOURSELF
ACTIVITY: As a group, practice good
positioning with your own body using
the 6 Key Elements and discuss your
observations.

BONUS:
o Try sitting in a poor position
(unstable feet, head/neck
extended back, slouched to side,
etc.)
o What do you notice?
FEEDING BASICS:
SWALLOWING
WHAT IS SWALLOWING?
Swallowing is the movement of saliva,
liquids and foods from the mouth into the
stomach. Swallowing requires coordinated
use of 26 muscles!

HOW DO WE SWALLOW?
Swallowing can be separated into four
phases:
o Phase 1: Oral Preparatory phase
o Phase 2: Oral Transit phase
o Phase 3: Pharyngeal phase
o Phase 4: Esophageal phase
 FEEDING BASICS: SWALLOWING (CONT.)

CHALLENGES OR DIFFICULTIES SWALLOWING ARE LINKED WITH

THE FOLLOWING RISKS:

↓ efficiency of feedings (i.e., slower)

↓ oral intake during feedings
↓ capacity for children to try different foods and liquids
↓ capacity for children to feed themselves
↓ growth and nutrition (malnutrition and dehydration)
↓ enjoyment during feedings (for children and caregivers)
↑ INCIDENCE OF ASPIRATION, ILLNESS, DEATH
 FEEDING BASICS: SWALLOWING (CONT.)

WHAT IS ASPIRATION?
When food or liquid pass into the lungs
instead of moving into the stomach
where they belong.
Aspiration can lead to illness,
malnutrition, dehydration and even
death.
 FEEDING BASICS: SWALLOWING (CONT.)

Figure shows dysfunctional

Figure shows normal
swallow and aspiration of
swallowing and no aspiration
liquid moving down the
with liquid moving down the
trachea toward the lungs.
esophagus.
 FEEDING BASICS:
SWALLOWING (CONT.)
REASONS A CHILD MIGHT ASPIRATE:
o Gastroesophageal reflux disease or reflux
o Abnormal or impaired anatomy (cleft
lip/palate)
o Delayed growth (born early)
o Brain injury (cerebral palsy)
o Muscle weakness or rigidity (Down syndrome
or cerebral palsy)
o Muscle discoordination (cerebral palsy)
o Medical procedures (tracheostomy,
nasogastric feeding tube)
 FEEDING BASICS: SWALLOWING (CONT.)

WATCHING FOR ASPIRATION: SIGNS AND SYMPTOMS

COUGHING OR CHOKING Child coughs or chokes during or after swallowing food or liquid

GURGLY “WET” SOUNDING

Child’s voice or breathing sounds wet during or after swallowing food or liquid
VOICE
OR BREATHING

COMPLAINTS OF Child experiences sensation of food being stuck in throat during, following
DISCOMFORT and/or in-between meals; or food comes back up into mouth after swallowing

WATERY EYES Child’s eyes water during or after swallowing food or liquid

Child’s face changes color

CHANGE IN COLOR
(pale, red, or purple/blue) during or after swallowing food or liquid
 FEEDING BASICS: SWALLOWING (CONT.)

WATCHING FOR ASPIRATION: SIGNS AND SYMPTOMS

FEVER Child experiences fever following a meal

FACIAL GRIMACE Child displays uncomfortable faces during or following feedings

Child’s breathing becomes unusually fast or slow, child stops breathing while
CHANGE IN BREATHING feeding or child wheezes or gasps for air during or after swallowing food or
liquid

LUNG INFECTIONS Child experiences infections in the lungs or airway

FEEDING BASICS:
SWALLOWING (CONT.)

SWALLOWING TIPS

o Consider individuality of a child.

o Good positioning is KEY.
o Small and slow.
o Adjust texture or thickness of foods
and liquids.
o Change how you are feeding a child
(different bottle, cup, etc.).
o Finding what works best can
sometimes take a lot of work!
GROUP ACTIVITY:
SWALLOW IT DOWN
ACTIVITY: In small groups,
practice swallowing bites and
sips of food/liquid using the 6
Key Elements of Positioning.
BONUS:
o Take a bite of food or sip of
liquid when not positioned
well.
o Feed a friend!
o What do you notice?
FEEDING BASICS:
TEXTURES AND
CONSISTENCIES

WHAT ARE FOOD TEXTURES

AND LIQUID CONSISTENCIES?
Foods and liquids come in a variety of
textures and consistencies. They are
either naturally this way or they can be
altered to be more well-suited for a
child.
FEEDING BASICS: TEXTURES AND
CONSISTENCIES (CONT.)

FOOD TEXTURES LIQUID CONSISTENCIES

1. Pureed/Extremely Thick 1. Thin Liquids
2. Minced and Moist 2. Slightly Thick Liquids
3. Soft and Bite-Sized 3. Mildly Thick Liquids
4. Regular Solids/Table Foods 4. Moderately Thick Liquids
5. Extremely Thick/Pureed
Liquids
FEEDING BASICS:
TEXTURES AND
CONSISTENCIES (CONT.)
PUREED FOOD
o Usually eaten with a utensil
o Cannot drink from a cup or straw
o Does not require chewing
o Smooth, no lumps
o Does not pour
o Falls off spoon in single spoonful and
holds shape on plate/tray/table
EXAMPLES: BLENDED VEGETABLES, FRUITS
AND MEATS, THICK CEREALS
FEEDING BASICS:
TEXTURES AND
CONSISTENCIES (CONT.)
MINCED AND MOIST FOOD
o Can eat with utensil, chopsticks or
sometimes hands
o Can be shaped and scooped on
plate/tray/table
o Small lumps visible
o Lumps are easy to squish with tongue
o Moist and soft
o Minimal chewing is required
o Does not require biting
EXAMPLES: FINELY MINCED MEATS, FINELY
MINCED OR MASHED FRUITS, VEGETABLES AND
FISH, THICK CEREALS WITH SMALL LUMPS
FEEDING BASICS:
TEXTURES AND
CONSISTENCIES (CONT.)
SOFT AND BITE-SIZED FOOD
o Can eat with utensil, chopsticks or hands
o Soft, tender and moist bite-sized pieces
o Can be cut without a knife
o Can be mashed or broken down with utensil
o Chewing is required
o Does not require biting
EXAMPLES: COOKED-TENDER MEATS, FLAKY
FISH, MASHED FRUITS, STEAMED OR BOILED
VEGETABLES, SOFT CHEESE AND EGGS, SOAKED
BREADS THAT ARE “MOIST” TO TOUCH
FEEDING BASICS:
TEXTURES AND
CONSISTENCIES (CONT.)
REGULAR SOLID TABLE FOOD
o Normal, everyday foods of varying textures
(soft, hard, crunchy, fibrous, chewy, dry,
stringy, crispy, crumbly, etc.)
o Includes mixed or dual consistencies (foods
+ liquids → soups and stews)
o Age-appropriate
o Developmentally appropriate based on skill-
level
o Chewing and biting may be required
EXAMPLES: ALL MEATS, VEGETABLES, FRUITS,
CHEESE, EGGS, BREADS
FEEDING BASICS:
TEXTURES AND
CONSISTENCIES (CONT.)
THIN LIQUID
o Fastest flowing liquid
o Flows like water
o Can drink from any nipple, cup, syringe or
straw
EXAMPLES: WATER
FEEDING BASICS:
TEXTURES AND
CONSISTENCIES (CONT.)
SLIGHTLY THICK LIQUID
o Slightly slower flow than water
o Slightly thicker than water
o Can drink from any nipple, cup,
syringe or straw
EXAMPLES: BREASTMILK, FORMULA
FEEDING BASICS:
TEXTURES AND
CONSISTENCIES (CONT.)
MILDLY THICK LIQUID
o Slower flowing than slightly thick
liquids
o Thicker than slightly thick liquids
o Flows off of spoon quickly, but slower
than thin liquids
o Can drink from spoons, most open
cups and some closed cups and
straws
o More effort required to drink from
straw
EXAMPLES: FRUIT NECTARS
FEEDING BASICS:
TEXTURES AND
CONSISTENCIES (CONT.)
MODERATELY THICK LIQUID
o Slower flowing than mildly thick
liquids
o Thicker than mildly thick liquids
o Flows off of spoon slowly in dollops
o Can drink from spoons and open
cups
o Smooth texture without lumps
o No chewing or processing required
EXAMPLES: RUNNY PUREED FRUITS
AND RICE CEREALS, SAUCES, GRAVIES,
FEEDING BASICS:
TEXTURES AND
CONSISTENCIES (CONT.)
EXTREMELY THICK/PUREED LIQUID
o Slowest flowing liquid
o Thickest liquid
o Usually eaten with a utensil
o Cannot drink from cup or straw
o Does not require chewing
EXAMPLES: BLENDED VEGETABLES,
FRUITS AND MEATS, THICK CEREALS
FEEDING BASICS: TEXTURES AND
CONSISTENCIES (CONT.)
Liquid Consistencies:
From Thinnest to Thickest (Fastest to Slowest Flowing)
FEEDING BASICS: TEXTURES
AND CONSISTENCIES (CONT.)

REASONS A CHILD MIGHT NEED A

DIFFERENT TEXTURE OR CONSISTENCY:
o Medical conditions (reflux, lungs, heart)
o Born early
o Born exposed to substances (drugs
and/or alcohol)
o Structural differences (cleft lip or palate)
o Neuromuscular disorders (cerebral palsy)
o Developmental disabilities (Down
syndrome)
o Social-emotional or environmental factors
(limited experience, no caregiver,
stressful experiences)
FEEDING BASICS: TEXTURES AND
CONSISTENCIES (CONT.)
SIGNS A CHILD MIGHT NEED A DIFFERENT TEXTURE OR CONSISTENCY:

o Coughing or choking on o Oral aversions or “refusals”

food/liquid to eat or drink
o Frequent congestion o Unusually long meal times
(more than 30-40 minutes)
o Noisy or “wet” sounding
voice or breathing o Difficulty chewing
o Upper respiratory infections o Avoiding certain textures or
o Difficulty breathing while consistencies
eating o Vomiting
o Crying or unhappy at meal o Concerns with weight and
times nutrition
o
 FEEDING BASICS:
TEXTURES AND
CONSISTENCIES (CONT.)
BENEFITS OF USING APPROPRIATE
TEXTURES AND CONSISTENCIES:
o Improved oral-motor skill
development
o Improved sensory development
o Improved overall health and well-
being
FEEDING BASICS: TEXTURES AND
CONSISTENCIES (CONT.)

REMEMBER:
If a child is not exposed to a variety of textures
they are at higher risk of:
o Having poor skills for chewing and
swallowing
o Becoming a messy eater
o Becoming a picky eater
o Being an unsafe eater with a greater risk of
choking or aspirating
FEEDING BASICS: TEXTURES
AND CONSISTENCIES (CONT.)
TEXTURE AND CONSISTENCY
CONSIDERATIONS
o Age-appropriate
o Developmentally appropriate
o Match oral-motor and swallowing skills of a child
o Promote efficiency
o Promote safety, comfort and enjoyment
FEEDING BASICS:
TEXTURES AND
CONSISTENCIES (CONT.)
TEXTURE AND CONSISTENCY TIPS
o Consider individuality of a child.
o Consider developmental skill level --- not
just age.
o Good positioning is KEY.
o Start small and slow.
o Finding the best texture and consistency
can take a lot of work!
o Children learn best in the context of
positive relationships.
GROUP ACTIVITY:
TASTE TESTING

ACTIVITY: As a group, organize foods

and liquids from your environment
into each texture and consistency
category.
BONUS:
o Practice modifying foods and
liquids.
o Using foods/liquids found in
your environment, modify them
to at least 3 different textures
and consistencies.
 WHAT IS THE SENSORY SYSTEM?
A complex group of neurons (cells in the body),
cell pathways and parts of the brain that work
together to allow an individual to feel different
sensations from the environment.

8 SENSES MAKE UP OUR SENSORY SYSTEMS:

FEEDING o Seeing (Vision)
BASICS: THE o Hearing (Auditory)
SENSORY o Smelling (Olfactory)
SYSTEM o Tasting (Gustatory)
o Touching or Feeling (Tactile)
o Joint and Muscle Awareness (Proprioceptive)
o Balance and Movement (Vestibular)
o Internal Body Awareness (Interoception)
 FEEDING BASICS: THE SENSORY
SYSTEM (CONT.)

SEEING (VISION)
o Information that comes to the body
through the eyes (what one sees)
o Examples: Bright lights, dim lights,
colors, shapes, faces, fast- or slow-
moving objects, distance to objects
and faces (near or far), etc.
 FEEDING BASICS: THE SENSORY
SYSTEM (CONT.)

HEARING (AUDITORY)
o Information that comes to the body
through the ears (what one hears)
o Examples: Loud and soft noises,
voices, music,
high- and low-pitched sounds, etc.
 FEEDING BASICS: THE SENSORY
SYSTEM (CONT.)

SMELLING (OLFACTORY)
o Information that comes to the body
through the nose (what one smells)
o Examples: Strong and light smells,
unpleasant and pleasant smells,
scents of people, places and
foods/liquids, etc.
 FEEDING BASICS: THE SENSORY
SYSTEM (CONT.)

TASTING (GUSTATORY)
o Information that comes to the body
through the tongue (what one tastes,
eats or drinks)
o Examples: Different flavors (sweet,
sour, salty,
bitter, etc.)
 FEEDING BASICS: THE SENSORY
SYSTEM (CONT.)

TOUCHING (TACTILE)
o Information that comes to the body
through the skin and mouth (what one
feels on the body)
o Examples: Light touch, deep pressure
touch, temperatures, pain, vibration,
different textures (smooth, lumpy,
crunchy, hard, etc.)
 FEEDING BASICS: THE SENSORY
SYSTEM (CONT.)

BALANCE AND MOVEMENT (VESTIBULAR)

o Information that comes to the body
through movements (what one feels
when the body moves up, down,
backward, forward, sideways,
rotationally, etc.)
o Examples: Rocking, swaying, swinging,
turning, bouncing, spinning, standing
up, sitting down, balancing, etc.
 FEEDING BASICS: THE SENSORY
SYSTEM (CONT.)

JOINTS AND MUSCLE AWARENESS

(PROPRIOCEPTION)
o Information that comes to the body through
sensations felt in the joints and muscles (what
one feels when their body is in different
positions and in contact with objects such as
people, chairs or the ground)
o Examples: Sitting, walking, running, crawling,
climbing, stomping feet, jumping, clapping
hands, pushing and pulling heavy items,
lifting and carrying items, etc.
 FEEDING BASICS: THE SENSORY
SYSTEM (CONT.)

RECOGNIZING SENSATIONS INSIDE THE

BODY (INTEROCEPTION)
o Information coming from within the body
that relates to one’s physical state or
condition (what one senses from the
organs)
o Examples: Hunger, thirst, fullness, heart
rate, breathing rate, temperature, bowel
and bladder needs, etc.
FEEDING BASICS: THE
SENSORY SYSTEM (CONT.)

Eating is the most sensory rich activity a

child will experience. This means that
understanding how our sensory systems
impact feeding development is very
important.
FEEDING BASICS:
THE SENSORY
SYSTEM (CONT.)
BENEFITS OF SENSORY SYSTEM:
o Improved learning and
development in daily activities
o Improved understanding of the
world
o Improved overall health
and well-being
 FEEDING BASICS: THE SENSORY
SYSTEM (CONT.)

o Coughing, choking, gagging, spitting, o Overstuffing mouth or giant gulps

vomiting with foods or liquids o “Pocketing” or holding foods in mouth
o Difficulty transitioning to new food (and child unaware)
flavors and/or textures
o Foods, liquids or saliva falling out of
o Flinching, grimacing or pulling away mouth or on face (and child unaware)
during feedings o Frequent crying, fussing or
o Avoiding certain flavors, textures or unhappiness at meal times
consistencies o Frequent falling asleep at meals
o Oral aversions or “refusals” to eat or
o Frequent need for or avoidance of
drink
physical contact
o Unusually long meal times (30-40+
minutes per meal)
 FEEDING BASICS: THE SENSORY
SYSTEM (CONT.)

HYPERSENSITIVE (INCREASED
SENSITIVITY):
When a child shows a strong
reaction to a specific sensation
or sensory information.
This reaction is stronger than we
would expect.
FEEDING BASICS: THE SENSORY
SYSTEM (CONT.)
COMMON EXAMPLES OF HYPERSENSITIVITY REACTIONS:
o Frequently startled by noises or touch
o Jerking, pulling away or withdrawing from touch
o Increased tightness in the body when fed by a caregiver
o Covering ears in a noisy room
o Closing eyes or falling asleep in loud or visually “busy” spaces
o Preferring less food on a plate or tray at a time
o Gagging on new food flavors or textures
o Grimacing, gagging, vomiting or pulling away from certain foods
o Shaking, rocking or banging body in loud or visually “busy” spaces
o Low pain tolerance — may be easily hurt or in pain
FEEDING BASICS: THE SENSORY SYSTEM
(CONT.)

HYPOSENSITIVE (REDUCED
SENSITIVITY):
When a child shows a reduced
reaction to a specific sensation
or sensory information.
This reaction is less than we
would expect.
 FEEDING BASICS: THE SENSORY
SYSTEM (CONT.)

COMMON EXAMPLES OF HYPOSENSITIVITY REACTIONS:

o Less responsiveness to loud noises or light touch
o Excessive need for deep pressure touch
o Stuffing mouth full of food -- sometimes causing gagging, vomiting or
choking
o Not noticing or sensing food, liquid or excessive saliva on face or left in
mouth
o Preferring harder, crunchier textures to soft, smooth and wet textures
o Preferring flavorful foods
o High pain tolerance — may hurt self and not show any sense of pain or
discomfort
FEEDING BASICS: THE
SENSORY SYSTEM (CONT.)

COMMON REASONS A CHILD MIGHT HAVE A

SENSITIVE SENSORY SYSTEM:
o Medical conditions, frequent medical procedures or
hospitalizations
o Born early
o Born exposed to substances (drugs and/or alcohol)
o Structural differences (cleft lip/palate)
o Neuromuscular disorders (cerebral palsy)
o Developmental disabilities (Down syndrome)
o Social-emotional or environmental factors (limited
experience, stressful experiences, force feeding, no
access to positive caregiving)
o Frequent congestion (limits ability to smell and taste
 food refusals or reduced intake
FEEDING BASICS: THE
SENSORY SYSTEM (CONT.)

SENSORY SYSTEM CONSIDERATIONS

o Listen to a child – watch what they are showing
you
o Prepare the environment
o Prepare the child
o Prepare the caregiver
o Promote safety, consistency, and comfort
FEEDING BASICS: THE SENSORY SYSTEM
(CONT.)

SENSORY SYSTEM TIPS

o Be observant --- A child will show you their
sensory preferences.
o Preparation is KEY.
o Preferences are different for everyone.
o Choose foods that are enjoyable.
o Start with what is familiar.
o Make changes one at a time.
o Offer lots of exploration time.
o Children learn best in the context of positive
relationships.
GROUP ACTIVITY:
TASTE TESTING

ACTIVITY: As a group, try different

food textures and liquid consistencies.
Describe each item based on your 8
senses.

o What do you notice?

o What are your own sensory
sensitivities and preferences?
TYPICAL FEEDING
DEVELOPMENT

FEEDING READINESS =
o Determined by SKILL LEVEL and not
just AGE.
o Does a child:
o Sit upright with little support?
o Hold their neck/head upright?
o Show interest when offered food,
a cup, or a spoon?
 TYPICAL FEEDING DEVELOPMENT

AGE EATING/DRINKING EXPECTATIONS FEEDING SKILLS

0-5 months Bottle and/or breast Rooting reflex, rhythmical sucking, easy breathing, no choking

5-6 months Breastmilk or formula, cereal, pureed foods Opens mouth for spoon, spoon easily placed in mouth, closed lips
around spoon

7-9 months Pureed foods, minced and moist foods, meltable crackers, Tongue movements side to side, “munching”
teething biscuits

8-10 months Pureed, minced and moist, soft bite-sized foods, cup Tongue movements side to side, using fingers to feed, interested in
drinking using utensils, drinking from cups with support

10-12 months Purred, minced and moist, soft bite-sized Biting through foods, chewing soft foods, cup drinking and utensil (self-
feeding) improves

12-18 months Eating most solid foods Rotary (mature) chewing, holding cup between lips, no gagging or
choking,
18-24+ months Eating most solid foods Safety tolerating most foods, feeding self (fingers, utensils, cups)
without support
GROUP ACTIVITY:
FAMILY FOODS

ACTIVITY: As a group, share examples

of foods specific to your environment
that are appropriate for:

• Babies 0-6 months of age

• Babies 6-12 months of age
• Children 12-18 months of age
• Children 18-24+months of age
 WHAT IS INTERACTION?
o Interaction = “relationships”
o The relationships children have with their
FEEDING caregivers, including the day-to-day moments
they share during feedings, are interactions.
BASICS:
INTERACTION Positive relationships are essential
for growing healthy and
strong children!
FEEDING BASICS: INTERACTION (CONT.)

Enjoyable connections
with others that happen
often strengthen a
child’s development.
FEEDING BASICS: INTERACTION (cont.)

POSITIVE RELATIONSHIPS …
o teach children about the world and
themselves.
o show children they are loved.
o help them learn if the world is safe or
scary.
o explain what happens when they
become upset or happy.
o allow them to observe and learn how to
treat others.
o shape and help their brains grow.
o create healthier and happier human
beings!
FEEDING BASICS: INTERACTION (cont.)

WITH LIMITED OR NO ACCESS TO POSITIVE

RELATIONSHIPS CHILDREN ARE …
o at greater risk of chronic illnesses and death.
o at greater risk of malnutrition and dehydration.
o at greater risk of mental health issues such as depression,
anxiety, behavioral difficulties, etc.
o less likely to recover from difficult, traumatic life
experiences.
o less likely to develop necessary developmental skills to
become thriving, functional adults.
FEEDING BASICS: INTERACTION (cont.)

5 Elements Every Child Needs

for Robust Development:
1. A healthy, safe and low-stress experience
in the womb
2. The chance to experience love with a
nurturing and safe adult
3. Support learning how to calm themselves
when upset
4. Support discovering how to become calm
with the help of others
5. Reliable, thoughtful and developmentally
matched care from others
FEEDING BASICS: INTERACTION (cont.)

OPTIMAL CAREGIVER QUALITIES

o Present - Be fully present during interactions with a child
— physically and mentally.
o Attentive - Be observant of the physical and emotional
needs of a child.
o Responsive - Be consistent and quick to respond to a
child’s needs.
o Attuned - Be deeply connected to a child and learn her
individual wants and needs.
FEEDING BASICS: INTERACTION (CONT.)

INTERACTION TIPS
o Healthy relationships help brain
development. Strong brains grow from
quality time with caregivers.
o Healthy relationships heal brains.
o Be present, attentive, responsive and
attuned.
o Optimal caregiving doesn’t take extra
time.
o Children learn best in the context of
positive relationships.
GROUP ACTIVITY:
INTERACTION

ACTIVITY: As a group, share different

ways to support interaction across a
child’s everyday activities and
routines.
COMMON FEEDING CHALLENGES & SOLUTIONS

“Let us put our minds together

and see what life we can make
for our children.”

Sitting Bull
 o Have high expectations!
COMMON o Children with special needs can do a lot
more than we might expect. Yet, it’s hard
FEEDING to grow and learn when you aren’t given
the chance.
CHALLENGES &
o Caregivers must give these children lots of
SOLUTIONS opportunities to play, interact, learn and
try new things.
 COMMON FEEDING CHALLENGES &
SOLUTIONS (CONT.)
EXAMPLES OF COMMON EXAMPLES OF COMMON
CONDITIONS/DISABILITIES WITH CONDITIONS/DISABILITIES WITH
FEEDING CHALLENGES: FEEDING CHALLENGES (CONT.)

o Autism spectrum disorders o Gastrointestinal disorders

o Cardiac conditions o Prematurity
o Cleft lip and/or palate o Sensory sensitivities
o Deaf or hard of hearing o Substance (drug) exposure
o Down syndrome o Vision impairments
o Fetal alcohol spectrum
disorders
o Cerebral Palsy
COMMON FEEDING
CHALLENGES &
SOLUTIONS (CONT.)
COMMON YOUNG CHILD
FEEDING CHALLENGES:
1. The sleepy, hard to wake baby
2. The fussy baby who is hard to calm
3. The baby who tires easily
4. The baby who has difficulty sucking
5. The baby who coughs, chokes or gags
6. The baby who frequently spits up
7. Special population: The baby who has cleft lip and/or palate
8. Special population: The baby who is born early
9. Special population: The baby who is born substance
exposed
COMMON FEEDING
CHALLENGES &
SOLUTIONS (CONT.)

COMMON OLDER CHILD FEEDING

CHALLENGES:
1. The child who has problems with
muscle tone
2. The child who has difficulties with
structures of the mouth
3. The child who has a sensitive
sensory system
4. The child who has trouble biting
and/or chewing
5. The child who has problems
swallowing
 COMMON FEEDING CHALLENGES
& SOLUTIONS (CONT.)

CHALLENGE #1: THE SLEEPY,

HARD TO WAKE BABY
o Falls asleep during feedings
o Difficult to keep awake
o Does not alert caregivers to hunger
May include: Babies with Down syndrome, heart
conditions, medically fragile babies, or babies born
exposed to substance in the womb
 COMMON FEEDING CHALLENGES
& SOLUTIONS (CONT.)

CHALLENGE #1: THE SLEEPY,

HARD TO WAKE BABY
HOW TO SUPPORT:
o Feeding and Timing
o Positioning
o Equipment
o Other Ways
 COMMON FEEDING CHALLENGES
& SOLUTIONS (CONT.)

CHALLENGE #2: THE FUSSY BABY

o Fusses when fed and when not fed
o Appears hungry but fusses with bottle
o Very difficult to soothe
o Confusing for caregivers
May include: Babies with heart conditions,
medically fragile babies, babies born early or
exposed to substance in the womb, babies with
vision or hearing impairments or
neurodevelopmental delays
 COMMON FEEDING CHALLENGES
& SOLUTIONS (CONT.)

CHALLENGE #2: THE FUSSY BABY

HOW TO SUPPORT:
o Feeding and Timing
o Positioning
o Equipment
o Other Ways
 COMMON FEEDING CHALLENGES &
SOLUTIONS (CONT.)

REMEMBER:
Watch for baby “stress cues” such as crying, back
arching, a wrinkled forehead, wide open eyes, raised
eyebrows, fast, loud breathing, turning his head or eyes
to look away, yawning, sneezing, hiccupping, etc.
Never force a bottle into a baby’s mouth when she is
distressed. Calm a baby first and then offer a bottle. If
bottles are forced, babies can become more upset and
even refuse feedings.
 COMMON FEEDING CHALLENGES
& SOLUTIONS (CONT.)

CHALLENGE #3: THE BABY WHO

TIRES EASILY
o Tires after brief feedings
o Falls asleep during feedings
o Difficulty finishing feedings
o Rapid breathing when feeding
o Poor endurance for other activities
May include: Babies with heart or lung conditions,
Down syndrome, medically fragile babies, or babies
born early or exposed to substance in the womb
 COMMON FEEDING CHALLENGES
& SOLUTIONS (CONT.)

CHALLENGE #3: THE BABY WHO

TIRES EASILY
HOW TO SUPPORT:
o Feeding and Timing
o Positioning
o Equipment
o Other Ways
 COMMON FEEDING CHALLENGES
& SOLUTIONS (CONT.)

CHALLENGE #4: THE BABY WHO

HAS TROUBLE SUCKING
o Weak suck
o Disorganized sucking pattern
o Difficulty compressing nipples
o Messy feedings
o Rapid breathing when feeding
o Tires easily
May include: Babies with heart or lung
conditions, babies with low muscle tone,
medically fragile babies or those with
neurodevelopmental delays, babies born
early or exposed to substance in the womb
 COMMON FEEDING CHALLENGES
& SOLUTIONS (CONT.)

CHALLENGE #4: THE BABY WHO

HAS TROUBLE SUCKING
HOW TO SUPPORT:
o Feeding and Timing
o Positioning
o Equipment
o Other Ways
 COMMON FEEDING CHALLENGES
& SOLUTIONS (CONT.)
CHALLENGE #5: THE BABY WHO
COUGHS, CHOKES
OR GAGS
o Frequent coughing, choking, gagging, or
spitting up with feedings
o Struggles to eat and breathe
o Gasping while feeding
o Tires easily
May include: Babies with heart conditions,
Down syndrome, babies with low muscle
tone or cleft lip/palate, medically fragile
babies or those with neurodevelopmental
delays, babies born early or exposed to
substance in the womb
 COMMON FEEDING CHALLENGES
& SOLUTIONS (CONT.)

CHALLENGE #5: THE BABY

WHO COUGHS, CHOKES OR
GAGS
HOW TO SUPPORT:
o Feeding and Timing
o Positioning
o Equipment
o Other Ways
 COMMON FEEDING CHALLENGES
& SOLUTIONS (CONT.)
CHALLENGE #6: THE BABY WHO
FREQUENTLY SPITS UP
o Frequently spitting up
o Appears uncomfortable and hungry, but frustrated
while feeding
o Feeding refusals
o Confusing for caregivers
May include: Babies with low muscle tone, babies
born early or exposed to substance in the womb,
babies with neurodevelopmental delays, babies with
GERD or GER
 COMMON FEEDING CHALLENGES
& SOLUTIONS (CONT.)
CHALLENGE #6: THE BABY WHO
FREQUENTLY SPITS UP
HOW TO SUPPORT:
o Feeding and Timing
o Positioning
o Equipment
o Other Ways
 COMMON FEEDING CHALLENGES
& SOLUTIONS (CONT.)

REMEMBER:
Not all babies who spit up have GER or GERD.
“Happy spitters” = babies who spit up often, but it
doesn’t bother them or impact feedings. They do
not appear in pain or upset.
“Unhappy spitters” = babies who act like they
want to eat, but appear afraid or upset when
offered a bottle. They most likely have
GERD/GER.
 COMMON FEEDING CHALLENGES
& SOLUTIONS (CONT.)

CHALLENGE #7: THE BABY WITH

CLEFT LIP AND/OR PALATE
o Born with birth defect that affects lip, nose
and/or roof of mouth
o Difficulty forming a tight seal for sucking
o Coughing or choking with feedings
o Feeding refusals
 COMMON FEEDING CHALLENGES
& SOLUTIONS (CONT.)

CHALLENGE #7: THE BABY WITH

CLEFT LIP AND/OR PALATE

HOW TO SUPPORT:
o Feeding and Timing
o Positioning
o Equipment
o Other Ways
 COMMON FEEDING CHALLENGES &
SOLUTIONS (CONT.)

This image shows how to hold a baby

with cleft lip or palate. The 45-degree
angle helps keep liquids in a baby’s
mouth and stomach and reduces the
chance of liquids flowing back up
through the nose.
 COMMON FEEDING CHALLENGES
& SOLUTIONS (CONT.)
CHALLENGE #8: THE BABY WHO
IS BORN EARLY (PREMATURITY)
o Bodies and systems not fully developed 
feeding skills not fully developed
o Weak, disorganized sucking
o Tires easily
o Sensitive around mouth or face due to
frequent medical procedures
o Fussy and irritable
 COMMON FEEDING CHALLENGES
& SOLUTIONS (CONT.)
CHALLENGE #8: THE BABY WHO
IS BORN EARLY (PREMATURITY)
HOW TO SUPPORT:
o Feeding and Timing
o Positioning
o Equipment
o Other Ways
 COMMON FEEDING CHALLENGES
& SOLUTIONS (CONT.)
CHALLENGE #9: THE BABY WHO IS
BORN EXPOSED TO SUBSTANCES
(DRUGS/ALCOHOL)
o Very sensitive systems  sensory sensitivities
o Frequent spitting up
o Discomfort during feedings
o Weak, disorganized sucking
o Tires easily
o Fussy and irritable
o Difficult to soothe and stay calm
o Difficult to stay awake
 COMMON FEEDING CHALLENGES
& SOLUTIONS (CONT.)
CHALLENGE #9: THE BABY WHO IS
BORN EXPOSED TO SUBSTANCES
(DRUGS/ALCOHOL)
HOW TO SUPPORT:
o Feeding and Timing
o Positioning
o Equipment
o Other Ways
 COMMON FEEDING CHALLENGES &
SOLUTIONS (CONT.)

REMEMBER:
When making changes to how you are
feeding a baby, start by changing one
element at a time. Too many changes
all at once can be stressful for a baby
and it can make it hard to know what
changes worked well and which did not.
 COMMON FEEDING CHALLENGES
& SOLUTIONS (CONT.)
CHALLENGE #10: THE CHILD WHO
HAS PROBLEMS WITH MUSCLE TONE
o Floppy or rigid muscle tone
o Difficulty maintaining good (safe) positioning
o Difficulty self-feeding
o Difficulty transitioning to different textures
o Tires easily
o Hyper- or hypo-sensitivities
May include: Children with cerebral palsy, Down
syndrome, heart conditions, medically fragile
children, or children born early or exposed to
substances in the womb
 COMMON FEEDING CHALLENGES
& SOLUTIONS (CONT.)
CHALLENGE #10: THE CHILD WHO
HAS PROBLEMS WITH MUSCLE TONE
o Hypotonia  Low Tone
o Cerebral palsy, muscular dystrophy, Down
syndrome, autism spectrum disorders
o “rag doll” or “floppy”
o Slow to acquire fine and gross motor skills
o Difficulty holding head upright, balancing selves,
grabbing/holding onto foods and utensils, and
maintaining safe positioning
o Difficult with sucking and/or chewing
o Tire easily
o Stuff large amounts of food in mouth
 COMMON FEEDING CHALLENGES
& SOLUTIONS (CONT.)
CHALLENGE #10: THE CHILD WHO HAS
PROBLEMS WITH MUSCLE TONE
o Hypertonia  High Tone
o Cerebral palsy, spinal cord injuries, brain
injuries, substance exposure in womb
o Rigid or clenched posture
o Slow to acquire fine and gross motor skills
o Difficulty holding head upright and forward, opening
hands, straightening arms and legs, getting into and
maintaining safe positioning
o Difficult with sucking and/or chewing
o Difficulty using utensils and cups
o Frequent coughing and choking
 COMMON FEEDING CHALLENGES
& SOLUTIONS (CONT.)
CHALLENGE #10: THE CHILD WHO
HAS PROBLEMS WITH MUSCLE TONE

HOW TO SUPPORT:
o Feeding and Timing
o Positioning
o Equipment
o Other Ways
 COMMON FEEDING CHALLENGES
& SOLUTIONS (CONT.)
CHALLENGE #11: THE CHILD WHO
HAS PROBLEMS WITH STRUCTURES OF
THE MOUTH
o Problems with structures  difficulty sucking,
biting, chewing, swallowing
o Difficulty transitioning to different textures
o Food refusals or avoidance
o Tires easily
o Hyper- or hypo-sensitivities
May include: Children with Down syndrome, cerebral
palsy, autism spectrum disorders,
neurodevelopmental delays, medical fragile children,
or children born early or exposed to substances in
the womb
 COMMON FEEDING CHALLENGES
& SOLUTIONS (CONT.)
CHALLENGE #11: THE CHILD WHO HAS
PROBLEMS WITH STRUCTURES OF THE
MOUTH
COMMON PROBLEMS INCLUDE:
o Jaw thrust
o Tonic bite
o Tongue thrust
o Tongue retraction
o Lip retraction
o Cleft lip
o Poor lip closure
o Cleft palate
 COMMON FEEDING CHALLENGES
& SOLUTIONS (CONT.)
CHALLENGE #11: THE CHILD WHO
HAS PROBLEMS WITH STRUCTURES
OF THE MOUTH

JAW THRUST: Jaw opens through strong down, out

and forward movement.
o Difficulty removing food off utensils and
positioning lips, tongue, jaw for cup
drinking
o Difficulty closing mouth for swallowing
o Difficulty transitioning to more complex
food textures
o Tires easily and quickly  reduced
consumption
 COMMON FEEDING CHALLENGES
& SOLUTIONS (CONT.)
CHALLENGE #11: THE CHILD WHO
HAS PROBLEMS WITH STRUCTURES
OF THE MOUTH

TONIC BITE: Teeth touch object and jaw moves up

into tightly clenched position.
o Difficulty opening mouth to receive food
and liquid
o Difficulty using spoons and cups
o Difficulty closing mouth for swallowing
o Highly sensitive to input
o Difficulty getting enough to eat as behavior
is confusing to caregivers
 COMMON FEEDING CHALLENGES
& SOLUTIONS (CONT.)
CHALLENGE #11: THE CHILD WHO
HAS PROBLEMS WITH STRUCTURES
OF THE MOUTH

o TONGUE THRUST: Strong protrusion (forward

pushing) of tongue out of mouth.
o TONGUE RETRACTION: Pulling of tongue far
back in the mouth toward throat.
o Difficulty opening mouth for nipple, cup,
spoon
o Difficulty swallowing
o Difficulty transitioning to more complex
food textures
o More sensitive to sensory input
 COMMON FEEDING CHALLENGES
& SOLUTIONS (CONT.)
CHALLENGE #11: THE CHILD WHO
HAS PROBLEMS WITH STRUCTURES
OF THE MOUTH

o LIP RETRACTION: Lips pulled back tightly.

o POOR LIP CLOSURE: Inability to close lips when
desired.
o Difficulty sucking and swallowing
o Difficulty removing foods from cups and
utensils
o Difficulty munching and chewing
o Difficulty transitioning to more complex
food textures
o More sensitive to sensory input
 COMMON FEEDING CHALLENGES
& SOLUTIONS (CONT.)
CHALLENGE #11: THE CHILD WHO
HAS PROBLEMS WITH STRUCTURES
OF THE MOUTH

o CLEFT PALATE: Hole in roof of mouth allowing

air, food and liquid to escape into nose or
lungs.
o Difficulty sucking and swallowing
o Difficulty transitioning to more complex
food textures
o Vomiting and spitting up
o Messing feedings
o Food and liquid refusals or avoidance
 COMMON FEEDING CHALLENGES
& SOLUTIONS (CONT.)
CHALLENGE #11: THE CHILD
WHO HAS PROBLEMS WITH
STRUCTURES OF THE MOUTH

HOW TO SUPPORT:
o Feeding and Timing
o Positioning
o Equipment
o Other Ways
 COMMON FEEDING CHALLENGES
& SOLUTIONS (CONT.)
CHALLENGE #12: THE CHILD
WHO HAS A SENSITIVE SENSORY
SYSTEM
o Hypo- or hyper-reactive system
o Very sensitive to new flavors, textures, and
even how a food may look or feel
o Difficulty transitioning to new textures
o Difficulty with self-feeding
May include: Children with Down syndrome,
cerebral palsy, autism spectrum disorders,
fetal alcohol spectrum disorders, children with
visual or hearing impairments, medically
fragile children, or children born early or
exposed to substances in the womb
 COMMON FEEDING CHALLENGES
& SOLUTIONS (CONT.)
CHALLENGE #12: THE CHILD
WHO HAS A SENSITIVE
SENSORY SYSTEM
HOW TO SUPPORT:
o Feeding and Timing
o Positioning
o Equipment
o Other Ways
 COMMON FEEDING CHALLENGES
& SOLUTIONS (CONT.)
CHALLENGE #13: THE CHILD
WHO HAS PROBLEMS BITING OR
CHEWING
o Tires easily with eating, especially harder
textured foods
o Avoidance of certain textures
o Difficulty transitioning to different textures
May include: Children with Down syndrome,
cerebral palsy, heart conditions, dental
problems, children with visual or hearing
impairments, medical fragile children, or
children born early or exposed to substances
in the womb
 COMMON FEEDING CHALLENGES
& SOLUTIONS (CONT.)
CHALLENGE #13: THE CHILD
WHO HAS PROBLEMS BITING OR
CHEWING
HOW TO SUPPORT:
o Feeding and Timing
o Positioning
o Equipment
o Other Ways
 COMMON FEEDING CHALLENGES
& SOLUTIONS (CONT.)
CHALLENGE #14: THE CHILD
WHO HAS PROBLEMS
SWALLOWING (OLDER CHILD)
o Frequently coughing or choking with
feedings
o Struggles to eat and breathe
o Gasping during feedings
o Poor weight gain/growth
May include: Children with heart conditions,
Down syndrome, muscle tone issues or cleft
lip/palate, or children born early, with
neurodevelopmental delays, or exposed to
substances in the womb
 COMMON FEEDING CHALLENGES
& SOLUTIONS (CONT.)
CHALLENGE #14: THE CHILD
WHO HAS PROBLEMS
SWALLOWING (OLDER CHILD)
HOW TO SUPPORT:
o Feeding and Timing
o Positioning
o Equipment
o Other Ways
 COMMON FEEDING CHALLENGES &
SOLUTIONS (CONT.)

REMEMBER:
Children who cough, choke and/or gag
with feedings may be aspirating — liquid
goes into lungs instead of into their
stomachs. This can make them very sick
with upper respiratory infections and/or
pneumonia, which can lead to poor
weight gain and even death.
STRATEGIES TO SUPPORT BOTTLE FEEDING,
SPOON FEEDING, AND CUP DRINKING

“It is easier to build strong

children than to repair
broken men.”

-Frederick Douglas
STRATEGIES TO SUPPORT BOTTLE FEEDING,
SPOON FEEDING AND CUP DRINKING (CONT.)

SPECIFIC STRATEGIES:
o Jaw and Chin Support for Sucking (Bottle Feeding)
o L-Shape Technique
o Chin Cupping Technique
o Tonic Bite Spoon/Cup Removal Technique
o Lip and Cheek Support for Sucking (Bottle Feeding)
o Facial Molding Techniques (aka: Pat-Pat Facial Massage)
o Lip and Chin Closure Technique
o Lip Stimulation/Stroking Technique
o Press-Down Technique for Bottle Feeding
o Press-Down Technique for Spoon Feeding & Cup Drinking
o Pacing Strategies
STRATEGIES TO SUPPORT BOTTLE FEEDING,
SPOON FEEDING AND CUP DRINKING (CONT.)

STRATEGY: JAW AND CHIN SUPPORT FOR

SUCKING (BOTTLE FEEDING)
BEST FOR: Young babies 0-6 months of age.
WHEN TO USE: The baby who…
o Tires easily
o Has trouble sucking
o Has a weak or disorganized suck
o Is born early or exposed to substances
HOW TO USE:
o Hold baby in a semi-upright position (45-60-degrees)
o Place one finger under baby’s chin and give gentle
pressure while offering the bottle.
STRATEGIES TO SUPPORT BOTTLE FEEDING,
SPOON FEEDING AND CUP DRINKING (CONT.)

REMEMBER:
If providing support to a baby’s cheeks and
jaw results in coughing or choking, this type
of support should be immediately stopped.
STRATEGIES TO SUPPORT BOTTLE FEEDING,
SPOON FEEDING AND CUP DRINKING (CONT.)

STRATEGY: L-SHAPE TECHNIQUE

o BEST FOR: Slightly older children 6+ months
o WHEN TO USE: The child who…
o Has jaw thrust, tonic bite, poor lip closure, difficulty
controlling opening/closing of jaw
o HOW TO USE:
o Caregiver positioned in front of child
o Place thumb on child’s chin or below lower lip
o Place index finger at side of face in front of/near ear
and upper jaw
o Place middle finger under jaw behind chin
o Provide assisted control of jaw by gently guiding it
up and down while a child eats and drinks
o Gradually reduce amount of physical support and
control as child shows greater jaw control
STRATEGIES TO
SUPPORT BOTTLE
FEEDING, SPOON
FEEDING AND CUP
DRINKING (CONT.)
STRATEGY: L-SHAPE TECHNIQUE
STRATEGIES TO SUPPORT BOTTLE FEEDING,
SPOON FEEDING AND CUP DRINKING (CONT.)

STRATEGY: CHIN CUPPING TECHNIQUE

o BEST FOR: Slightly older children 6+ months
o WHEN TO USE: The child who…
o Has jaw thrust, tonic bite, poor lip closure, difficulty
controlling opening/closing of jaw
o HOW TO USE:
o Caregiver positioned behind or to side of child
o Place thumb at side of face in front of/near ear and
upper jaw
o Place index finger on child’s chin or below lower lip
o Place middle finger under jaw behind chin
o Provide assisted control of jaw by gently guiding it
up and down while a child eats and drinks
o Gradually reduce amount of physical support and
control as child shows greater jaw control
STRATEGIES TO SUPPORT
BOTTLE FEEDING, SPOON
FEEDING AND CUP
DRINKING (CONT.)
STRATEGY: CHIN CUPPING TECHNIQUE
STRATEGIES TO SUPPORT BOTTLE FEEDING,
SPOON FEEDING AND CUP DRINKING (CONT.)

REMEMBER:
Good positioning and a quiet calm environment
can help reduce high muscle tone or physical
response, including the strength and frequency of
jaw thrust.
 STRATEGIES TO SUPPORT BOTTLE FEEDING,
SPOON FEEDING AND CUP DRINKING (CONT.)

STRATEGY: TONIC BITE/SPOON REMOVAL

TECHNIQUE
o BEST FOR: Slightly older children 6+ months
o WHEN TO USE: The child who…
o Has hypertonicity, hyperreactivity, difficulty controlling
opening/closing of jaw or tendency to clench jaw
o HOW TO USE:
o Reduce external stimulation during feeding
o Help child become calmer and less tense
o When child is biting down, relax and apply light pressure
on bottom of his chin
o Wait to feel jaw drop and then remove spoon/cup from
mouth
o If this does not help, gently guide child’s head forward
(chin to chest) to naturally open mouth and release
utensil/cup
STRATEGIES TO SUPPORT BOTTLE FEEDING,
SPOON FEEDING AND CUP DRINKING (CONT.)

REMEMBER:
When a child has a tonic bite, do not pull on the
bottle, cup or spoon to release. The child’s reflex
will only cause them to bite down harder.
Use the Tonic Bite Technique.
STRATEGIES TO SUPPORT
BOTTLE FEEDING, SPOON
FEEDING AND CUP
DRINKING (CONT.)
STRATEGY: LIP AND CHEEK SUPPORT FOR SUCKING
(BOTTLE FEEDING)
BEST FOR: Young babies 0-6 months of age.
WHEN TO USE: The baby who…
o Tires easily
o Has trouble sucking
o Has a weak or disorganized suck
o Is born early or exposed to substance
HOW TO USE:
o Hold baby in semi-reclined position (45-60
degrees) OR
o Position baby in an elevated position on a cushion
o Place thumb and one finger on each cheek
o Give gentle pressure toward baby’s mouth to help
move her lips around the nipple
 STRATEGIES TO SUPPORT BOTTLE FEEDING,
SPOON FEEDING AND CUP DRINKING (CONT.)

Pat-Pat Technique
STRATEGY: FACIAL MOLDING
TECHNIQUES
o BEST FOR: Slightly older children 6+
months
o WHEN TO USE: The child who…
o Has poor lip closure, lip retraction,
low or high muscle tone in the face
Washcloth Technique
 STRATEGIES TO SUPPORT BOTTLE FEEDING,
SPOON FEEDING AND CUP DRINKING (CONT.)

STRATEGY: FACIAL MOLDING TECHNIQUES

HOW TO USE:
o Caregiver positioned in front or beside child
o Place 2-4 fingers high upon child’s cheeks, patting 3 times
in a downward motion moving toward lips
o Vibrate fingers while pulling downward – slowly, deeply, or
rapidly --- Repeat 3 times
o Place 2-4 fingers above upper lip and gently apply pressure
while massaging in a downward motion 1 time
o Place 2-4 fingers below lower lip and gently apply pressure
while massaging in an upward motion 1 time
o Place 2-4 fingers on child’s lips and gently apply pressure
for final time
o Repeat as necessary up to 8-10 times

*Washcloth technique: Wipe each part of face in a downward

motion (from the outer cheeks toward the nose and mouth) and
upward motion from chin to lips. Complete wiping of both cheeks
first before moving on to wiping chin and lips.
STRATEGIES TO SUPPORT BOTTLE
FEEDING, SPOON FEEDING AND CUP
DRINKING (CONT.)
STRATEGY: LIP AND CHIN CLOSURE TECHNIQUE
BEST FOR: Young babies 0-6 months of age.
WHEN TO USE: The baby who…
o Has poor lip closure
o Has trouble sucking
o Has a weak or disorganized suck
o Is born early or exposed to substance
HOW TO USE:
o Hold baby in semi-reclined position (45-60
degrees) OR
o Position baby in an elevated well-supported
seated position
o Place thumb slightly under bottom lip and index finger
on chin
o Support baby’s bottom lip and bony part of chin by giving
gentle pressure toward mouth to assist lip closure around
nipple
 STRATEGIES TO SUPPORT BOTTLE FEEDING,
SPOON FEEDING AND CUP DRINKING (CONT.)

STRATEGY: LIP STIMULATION/STROKING TECHNIQUE

BEST FOR: Young babies 0-6 months of age (Breast of Bottle
Feeding).
WHEN TO USE: The baby who…
o Needs extra encouragement to suck
o Has trouble sucking
o Has a weak or disorganized suck
o Is born early or exposed to substances
HOW TO USE:
o Hold baby in semi-upright position (45-60 degrees) OR
o Using breast or bottle nipple, gently stroke baby’s
bottom lip from side to side
o Pause after several strokes to allow baby a chance to
receive the nipple
 STRATEGIES TO SUPPORT BOTTLE FEEDING,
SPOON FEEDING AND CUP DRINKING (CONT.)

STRATEGY: LIP
STIMULATION/STROKING TECHNIQUE
STRATEGIES TO SUPPORT BOTTLE
FEEDING, SPOON FEEDING AND
CUP DRINKING (CONT.)
STRATEGY: PRESS-DOWN TECHNIQUE (BOTTLE FEEDING)
BEST FOR: Young babies 0-6 months of age.
WHEN TO USE: The baby who…
o Needs extra encouragement to suck
o Tires easily
o Has trouble sucking
o Has a weak or disorganized suck
o Is born early or exposed to substances
HOW TO USE:
o Hold baby in semi-upright position (45-60 degrees) OR
o Position baby in an elevated well-supported position on a cushion
o Using breast or bottle nipple, give gentle pressure downward on the
middle of baby’s tongue for 1-3 seconds
o Pause to allow baby the chance to move her tongue around the
nipple.
o Repeat as necessary.
STRATEGIES TO SUPPORT BOTTLE FEEDING,
SPOON FEEDING AND CUP DRINKING (CONT.)

STRATEGY: PRESS-DOWN TECHNIQUE

(SPOON AND BOTTLE FEEDING)
BEST FOR: Older children 6+ months of age.
WHEN TO USE: The child who…
o Has tongue thrust
HOW TO USE:
o Caregiver is positioned in front of child at eye level --
- not above them
o Spoon Feeding: Place a level spoon on center of
child’s tongue and apply firm downward pressure
while offering firm pressure under chin using a
finger. Remove spoon and repeat as necessary.
o Cup Drinking: Place a cup on lower lip below child’s
tongue while offering firm pressure under chin (to
tongue).
STRATEGIES TO SUPPORT BOTTLE FEEDING,
SPOON FEEDING AND CUP DRINKING (CONT.)

REMEMBER:
Proper positioning will reduce tongue thrust.
Always first ensure that a child is in a well-
supported position for feedings and that his head
is in a slightly forward, neutral position.
STRATEGIES TO SUPPORT
BOTTLE FEEDING, SPOON
FEEDING AND CUP
DRINKING (CONT.)

STRATEGY: PRESS-DOWN
TECHNIQUE (SPOON AND
BOTTLE FEEDING)
STRATEGIES TO SUPPORT
BOTTLE FEEDING, SPOON
FEEDING AND CUP
DRINKING (CONT.)

STRATEGY: PACING TECHNIQUE (BOTTLE

FEEDING)
BEST FOR: Young babies 0-6 months of
age.
WHEN TO USE: The baby who…
• Tires easily
• Has trouble sucking
• Has a weak or disorganized suck
• Coughs, chokes or gags
• Frequently spits up
• Is born early or exposed to
substances
 STRATEGIES TO SUPPORT BOTTLE FEEDING,
SPOON FEEDING AND CUP DRINKING (CONT.)

STRATEGY: PACING TECHNIQUE (BOTTLE FEEDING)

o HOW TO USE:
o Hold baby in semi-upright position (45-60-degrees)
OR
o Position baby in an elevated position on a cushion
o Hold bottle horizontally to reduce flow of liquid
o Allow baby to feed from bottle for ~20-30 seconds
(or 3-5 swallows) and then gently tip bottle to side of
baby’s mouth or downward.
o This side or downward action temporarily stops
the flow of milk and “paces” the feeding. The
bottle is never removed from baby’s mouth.
o When baby starts sucking again, return bottle to
horizontal position to resume feeding
o Repeat process until baby is able to pace feedings on
his own
STRATEGIES TO SUPPORT BOTTLE FEEDING,
SPOON FEEDING AND CUP DRINKING (CONT.)

REMEMBER:
When feeding challenges arise, always consider
positioning, rate and volume. Change one of these
elements at a time and determine if the problem
is solved or needs additional support.
 ADDITIONAL IDEAS FOR SUPPORTING THE
ENTIRE CHILD

“What a child doesn’t

receive, he can seldom later
give.”

P.D. James
 ADDITIONAL IDEAS FOR SUPPORTING
THE ENTIRE CHILD

o CALMING ACTIVITIES
o Use with the child who has a hypersensitive sensory system
o Use before feedings, especially if a child becomes overstimulated

o WAKING/ALERTING ACTIVITIES
o Use with the child who has a hyposensitive sensory system
o Use before feedings, especially if a child tends to be understimulated
 ADDITIONAL IDEAS FOR SUPPORTING
THE ENTIRE CHILD
CALMING ACTIVITIES
o Use rhythmic, repetitive touch, movements and sounds
o Offer age-appropriate objects to suck on, mouth or chew before and after meals
o Provide dim lighting or a darker room with minimal visual distractions before,
during or after feedings
o Feed in a quiet space with minimal sounds and voices
o Interact using slower rates of movement, softer voices or sounds and reduced
animation
o Use consistent activities and routines so a child knows what to expect, which
reduces stress and creates calmness
 ADDITIONAL IDEAS FOR SUPPORTING
THE ENTIRE CHILD
WAKING/ALERTING ACTIVITIES
o Use gentle activities before or during feedings or that wake a child if she has fallen
asleep
o Offer age-appropriate objects or activities to wake up the face and mouth before eating
o Provide brighter lighting or a room with more light and/or sound before, during or after
feedings for a sleepy child
o Feed in a space with typical noise and sound levels
o Interact using faster rates of movement, louder voices or sounds and increased
animation
o Use consistent activities and routines so a child knows what to expect, which reduces
stress and creates a readiness for participating in feeding
 ADDITIONAL IDEAS
FOR SUPPORTING
THE ENTIRE CHILD
ORAL-MOTOR PREPARATION AND PLAY
ACTIVITIES
o Prepares children for mealtimes
o Aids in development of skills need
for eating, chewing, and swallowing
o Offers soothing and comforting for
many children
o Increasing sensations for
hyposensitive children
o Reduces sensations for
hyersensitive children
o Fun exploration and play!
ADDITIONAL IDEAS
FOR SUPPORTING
THE ENTIRE CHILD
FINGER FEEDING TIPS
o Offer lots of opportunities to
practice.
o Find a good position.
o Offer foods that suit the child and
work well for finger feeding.
o Start small.
o Expect a mess.
o Consistency is key.
o Eat together!
ADDITIONAL IDEAS
FOR SUPPORTING
THE ENTIRE CHILD
CUP DRINKING TIPS
o Offer lots of opportunities to practice.
o Start small, slow and thick.
o Offer help in the beginning.
o Offer a cup that suits the child.
o Consistency is key.
o Drink from cups together!
ADDITIONAL IDEAS
FOR SUPPORTING
THE ENTIRE CHILD
SPOON FEEDING TIPS
o Find a good position.
o Offer lots of opportunities for
practice.
o Offer foods that suit the child and
work well for spoon feeding.
o Start small.
o Make it stick.
o Consistency is key.
o Expect a mess.
o Eat together!
ADDITIONAL IDEAS
FOR SUPPORTING
THE ENTIRE CHILD
SELF-FEEDING TIPS
o Find a good position.
o Offer lots of opportunities for
practice.
o Offer foods that suit the child
and work well for spoon feeding.
o Offer utensils, plates and bowls,
and mats that suit a child well.
o Consistency is key.
o Expect a mess.
o Eat together!
THANK YOU VERY MUCH!