“But.. but.. I just don’t know how to chew it!” –feeding therapy patient, age 4
These are the words that were said to me by a four year old during an occupational therapy feeding session. We were working on trying a singular piece of cooked pasta. After moving it around his mouth for a while, unsuccessfully attempting to chew it, he finally took the piece out. His statement of frustration reigns today as the most clear, genuine summary of the struggle of children with feeding deficits.
It is a general misconception that eating is instinctual. Infants just come out of the womb knowing how to eat, right? Eating is actually one of the most complex actions that the human body completes, using all of our senses and incorporating many different muscle groups. It’s an action that we learn. When there is a break down in any part of the individual components that make up eating, the whole process falls apart, and that’s where we see our picky eaters. Except: they might be picky for a legitimate, motor reason.
Breakdown in the sensory processing component of eating is a common one in picky and problem eaters; this is a topic necessitating its own post. Today what I want to address are the oral motor deficits in children who have limited diets.
“I can’t move it.” –feeding therapy patient, age 4
After we take a bite, there is a cascade of events that happen within our mouth that require coordination of the highest caliber. Seriously, if you have ever really been completely present to what exactly is happening in your mouth when you chew and swallow, it’s astounding. The first thing we do after we take a bite is move it to our rear molars, our strongest teeth that are made for grinding down food. This skill of tongue tip lateralization is learned at around 8-10 months, when babies begin to explore small dissolvable foods. Your mother wasn’t crazy when she dumped a pile of cheerios on your high chair tray- learning how to move a small item of food from the tip of your tongue to your rear molars is a vital part of learning how to eat. Now, we have glorious inventions such as the dissolvable Gerber puffs, which is a great food for babies to learn how to move food items within their mouth safely.
Once we’ve learned how to move the food to our rear molars, we have to keep it there. The side of our tongue along with our cheeks work together to keep the food in a cohesive unit on the back molars while chewing takes place. A piece escapes to the front of your mouth? No worries, your tongue can grab that and place it back with the group on the molars, no problem. Too big of a bite? That’s okay, your tongue can divide the food and swallow manageable amounts while keeping the rest in the side of the mouth. Our tongue then gathers the food together to the back as it elevates to the roof of the mouth, moving the cohesive bolus backwards for the swallow.
“I don’t eat that food. It’s too hard.” – feeding therapy patient, age 5
Eating is not so simple, is it? Just like learning any motor skill, sometimes you can learn an inefficient pattern in order to compensate for some sort of coordination or strength deficit. Often, “picky eating” is an adaptive strategy that children learn in response to their mouth failing them. Children with oral mechanical difficulty gravitate towards a food profile that they are able to successfully handle. By looking at a basic list of the foods a child “prefers,” we can start to hypothesize what difficulties may exist. Your child only eats processed, packaged foods and starches? These foods are mechanically easy to manage in the mouth, so there could be a coordination deficit. Your child doesn’t have any real meats in their diet besides chicken nuggets? Meats are mechanically difficult to manage and require a coordinated rotary chew along with sufficient strength and endurance; chicken nuggets are shaped pieces of already ground-up meat, so are much easier to chew and manage.
As we delve further into reports, we hear about gagging, coughing, and messy eating. Gagging? Maybe their tongue can’t keep all of their food in a cohesive unit, losing pieces to the back of the mouth and gagging as a protective response. Coughing? Maybe they have an inefficient and unsafe swallow that is causing them to cough up pieces that go down the wrong way. Messy eating? Maybe your child cannot lateralize their food to the back molars, resulting in doing most of their chewing on their front teeth with their lips open. Or, they have to eat with their hands in order to place the piece of food in the back where it needs to go, because their tongue cannot do it for them.
As we watch a child eat during an evaluation, these deficits show themselves. Specific inefficiencies are identified and we can begin treatment to address them. Treatment activities are chosen in such a way to teach more efficient patterns for improved success when eating. This feeding therapy can take a long time, because often children have gone months or years with these inefficient patterns, requiring lots of practice and skill building.
Once we realize how complex the process of feeding actually is, we begin to change our mind set and can see how real of a struggle our “picky eaters” can have. Some children, like my insightful patients mentioned throughout this article, are aware of their difficulty and can verbalize it, but many cannot. If you think your child’s picky eating is affecting their health and well being, it’s worth looking into. There could be an underlying mechanical deficit that can be treated.