Sensory-Motor Approach to Feeding:
     Encompasses sensory processing and oral sensory-motor skill development needed for safe, effective, nutritive feeding

This includes:
     ●the oral phase of feeding
     ●factors that influence feeding
     ●Nutrition
     ●sensory-processing

Example 1
Freshly Popped popcorn

• What sensations do you experience?
  • You smell it and your Mouth salivates and you reach for a handful
  • You open mouth wide to accommodate several pieces
  • Initially, you taste salt and butter, if these are tastes you enjoy the sensory feedback is positive- you may think “I like the way this tastes”
  • You bite down and experience the crunchy texture- this is another sensory experience that triggers a motor response. It’s crunchy, I can’t just swallow it I have to chew it
  • You move the popcorn to the chewing surface of your mouth- for most of us that’s the molar ridge where your first molars are located; but how did you get the popcorn from the front of your mouth to the molar ridge?
  • Most of us use our tongue tip and lateral borders of the tongue to collect the popcorn and sweep it to our chewing surface
  • We use the lateral border of the tongue and our cheek to stabilize the chewed popcorn as we break the food down
  • How do we know how hard to bite and how long to chew?
  • There is an ongoing interaction between our sensory and motor systems that allows us to determine when it is adequately broken down and we use sensory feedback to ascertain when the bolus can be swallowed
  • If we put a lot of popcorn in our mouth, we may lateralize the bolus with our tongue from one molar ridge to the other and jaw movement is activated to chew the popcorn
  • If the sensory-motor experience was positive-the next time you are offered this food, you recall the smell and taste of popcorn and are eager to eat

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Example 2
Freshly Popped popcorn

• What sensations do you experience?
  • You are offered the same salty, buttery popcorn. It smells good and you initial sensory response to the taste is very similar.
  • However, this time you do not have the motor skills to move the popcorn to the molar ridge to chew it
  • The popcorn sits on the surface of your tongue
  • You use an immature motor pattern like a suckle or munch chew to break down the popcorn
  • The kernels of corn feel rough on the surface of your tongue
  • You are pooling saliva because of the flavor, but you cannot swallow because of the large pieces sitting on the surface of your tongue
  • Very quickly, your initial pleasure with the taste turns to discomfort
  • What am I going to do with this food on my tongue? It’s not breaking down
  • Your jaw and tongue start to get tired, can you spit it out? Can you swallow it whole? You panic and you swallow
  • The popcorn gets stuck on the back of your tongue
  • You gag and throw up
  • The sensory feedback you get is a feeling of panic
  • Next time you are offered popcorn you turn away, shut your mouth tightly and refuse

*Now, sometimes, not always, well-meaning parents and therapists might give food to kids that they don’t have the sensory-motor skills to handle. They haven’t gone through the “typical” development of oral-sensory motor skills due to medical issues, tone issues, or sensory processing issues.  Their compensatory motor skills are not adequate to handle the food they are offered and they have these scary experiences with food.  For these clients food refusal is not behavioral, it is adaptive.
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Oral Phase
​We place food in our mouth and our tongue, lips, teeth, and jaw all work together to chew the food until it's ready to be swallowed. We then use our tongues to push the food backwards towards our throat. When we move our tongues back it sets in motion the epiglottis.

The epiglottis is one of the most important things you need to know about to understand the swallow. The epiglottis is the little "flap" that will lower down and cover your airway when you are swallowing food.  The epiglottis can't always be lowered or we wouldn't be able to get any air in and out of our lungs! So, during the swallow our tongue pushes back, the hyoid bone is elevated which pulls the larynx up and then the epiglottis flaps down to cover the trachea and direct the food to go into the esophagus and safely down into our stomach.

Now the problem:

• Most everyone has hear the expression "it went down the wrong pipe."
• Anyone who has ever breathed in food or liquid in your mouth or has swallowed too quickly, has experienced this. You probably coughed uncontrollably, your face may have turned red, and your eyes watered.

Coughing is a good thing! It's the body's natural response to getting food, liquid, and any other object out of the airway and away from the lungs.
When this experience occurs you experienced one of the following:

• Penetration- food or liquid goes into the trachea (airway tube) and stays above the vocal cords (speech tools)
• Aspiration- food or liquid goes into the trachea (airway tube) and goes below the vocal cords (speech tools)
• The problem is when a person experiences food going into the airway and doesn't cough. In these instances the person does not feel the food or liquid going into the airway and the body can't trigger that "coughing reaction" or gag reflex.
• This is called silent aspiration.

Sensory-Processing

• Is Our ability to take in info from our internal environment and the world around us, organize this info, and use it to respond in a well-regulated way
• Difficulty taking in or making sense of sensory input can manifest into behavioral, learning, feeding, emotional, and self esteem problems
• Various Sensory Areas
  • Vestibular
  • Proprioceptive
  • Tactile
  • Auditory
  • Visual
  • Olfactory
  • Gustatory
• Issues
  • Decreased ability or inability to tolerate smells in the environment to include food
  • Decreased ability or inability to handle the sights or sounds in the kitchen or dining area
  • Decreased ability or inability to tolerate the sound of chewing
  • Decreased ability or inability to sit at the table for mealtimes
  • Self-limited diet based on taste, texture, temperature, color, smell or brand
  • Decreased ability to control saliva and decreased awareness of saliva on the lips or chin
  • Decreased ability to feel food in the mouth and decreased awareness of remaining food in the mouth or on the lips
  • Decreased ability to discriminate hunger and satiation
  • Swallows food that is not adequately broken down
  • Has food in the mouth for long periods of time, even after it is adequately masticate and ready to swallow
  • Will put any non-food item in his/her mouth but will not put food in his/her mouth
  • Has a complicated routine related to mealtime
  • Decreased motor skills necessary to break down food effectively, resulting in gagging and choking

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Inter Relationships: When observing feeding and swallowing skills you also have to examine other developmental domains

Delays in one developmental domain can impact others. For example, delays in fine motor skills like a child's ability to successfully hold things or use a pincer grasp can delay their ability to learn to self feed. Inability to communicate and express their needs can impact their attitude towards food because they cannot express their dislike and not understand why mom keeps giving them a food they don't like. Medical conditions like a cleft palate, traumatic brain injury, or a trach tube can impact the textures a child is able to tolerate or safely swallow.

Development and Posture's Impact on Feeding

As a child grows and learns, specific skills tend to develop together.  Delays in one area of fine or gross motor, can impact successful achievement of correlated feeding skills.  Balance, posture, strength, reaching, grasping, and coordination are all skills that impact and refine feeding skills like holding a bottle, picking up finger foods, adequate lip closure on a cup, and chewing with lips closed. 

The Hierarchical Steps to Eating

Individuals with oral sensory demands need to approach feeding with a step by step approach.  These steps should be used to determine where a child currently stands with a particular food or texture and help them to make goals to achieve the next step.  If a child can't stand being in the same room as a particular food, you should not jump to touching the food- this can cause unnecessary stress on the feeding experience.  We have to remember to keep the entire process positive to have the best results.  If a child can't tolerate being in the same room as the food, that must be addressed first before moving on to a new goal.

Food Checklist:
Here is a sample checklist to discuss with parents about what food the child likes to eat.  These questions help to determine the textures, temperatures, and flavors the child is and is not able to tolerate. It also gives a brief look at some fine and gross motor skills that can impact the feeding experience. 

References:
​Arvedson, J. & Brodsky, L. (2002). Pediatric swallowing and feeding: assessment and management. Clifton Park, NY: Cengage Learning.
Bahr, D. (2001). Oral motor assessment and treatment: Ages and stages. Boston, MA: Allyn & Bacon.
Morris, S. & Klein, M. (2000). Pre-feeding skills: a comprehensive resource for mealtime development. Austin, TX: PRO-ED, Inc.
Overland, L. (2001). Food for thought. ADVANCE for Speech-Language Pahologists &  Audiologists.
Overland, L. & Merkel-Walsh, R. (2013). A sensory motor approach to feeding. Charleston, South Carolina: TalkTools.
Roche, W., Eicher, P., Martorana, P., Berkowitz, M., Petronchak, J., Dzioba, J., & Vitello, L. (2011). An oral, motor, medical, and behavioral   
​     approach to pediatric feeding and swallowing disorders: An interdisciplinary model. Perspectives on Swallowing and swallowing
     disorders (Dysphagia), 20, 65-74.
Thompson, S., Bruns, D., & Rains, K. (2009). Picky eating habits or sensory processing issues? Exploring feeding difficulties in infants and
​     toddlers. Young Exceptional Children, 13(2), 71-85.