By: Nancy Swigert, MA, CCC-SLP, BCS-S
Infants gain all their nutrition through breast or bottle feeding until they are at least six months of age. The ability to suck successfully from breast or bottle requires the infant to coordinate three actions: suck-swallow-breathe. Suck is accomplished with slightly different motions on the breast compared to the bottle, but essentially the lips must close on the nipple and the tongue moves in and out in a suckle motion and presses the nipple against the roof of the mouth, creating pressure on the nipple. As the jaw moves down, it helps create suction to pull the liquid into the mouth. The infant then has to swallow the liquid, and the infant must stop breathing during each swallow and then breathe after swallowing. The suck-swallow-breathe sequence then starts again. Many things can interfere with this sophisticated system for swallowing. Here are some examples of possible causes of difficulty with feeding in infants. Many of these problems can continue to affect the child’s ability to eat and swallow as they grow.
Prematurity – Premature infants as young as 32 weeks post gestation show some emerging skills in sucking and swallowing, but generally are not ready for full oral feeding until between 34 and 37 weeks post gestation. It takes those extra weeks for the infant’s neurological system to develop so it can support the coordination needed. Difficulty with suck-swallow can persist even after that age.
Lip or tongue “tie”– If an infant immediately has trouble with sucking, in the absence of any obvious medical or developmental problems, the infant may be presenting with restricted “frenum” of the lips or tongue. For infants who are breast fed, the mother may experience unusual nipple soreness. The frenum is the little piece of tissue that connects the top and bottom lip to the gum and the tongue to the floor of the mouth. If these are too tight, then the infant can’t get a good latch on the nipple or can’t adequately move the tongue. This restriction may not be obvious, but a speech-language pathologist who works with infants can help decide if that is the problem. It is then easily corrected with minor surgery.
Cleft lip/palate– Because the lips and palate (roof of the mouth) are essential in helping the infant create a good seal and suck, a cleft of the lip and/or palate can cause difficulty. However, most infants with cleft lip/palate can feed successfully with the right intervention. A speech-language pathologist can help determine if the infant will be able to breast feed and what kind of nipple or feeding system will be needed for successful bottle feeding.
Neurological Conditions– Conditions such as Cerebral Palsy or Down syndrome, and other neurological conditions or syndromes that affect muscle tone, can make it challenging for the infant to get a good seal on the nipple or effectively pull milk from the nipple.
Cardiac problems – Infants with cardiac problems often have a hard time during feeding. They may become fatigued and not be able to finish the feeding. Because infants stop breathing each time they swallow, this can cause a change in heart rate. Some compensations, like frequent breaks during feeding, can help the infant be successful.
INFANTS AND SPOON AND CUP FEEDING
Infants are typically introduced to “solids” like cereals and Stage I baby foods sometime after 4 months of age. Each pediatrician will guide the parents in knowing the right age to begin spoon feeding. The ability to suck soft, runny foods from a spoon requires the infant to develop even more sophisticated oral skills. Initially the infant will use the same in-out suckling motion of the tongue they have been using on the bottle/breast, but by around six months of age they don’t have to move their tongue in and out of the mouth to get the food to the back of the mouth for the swallow. In addition, they get better at using their lips to remove the food from the spoon and help bring the food into the mouth.
Most infants are able to drink from a cup by six months of age. There are advantages and disadvantages to using a spouted cup when introducing liquids. If the child is having trouble with spouted cups, the speech-language pathologist can help determine what kind, if any, the child should use. When drinking from an open top cup the child must be able to sit up, hold their head up and close their jaw and lips on the edge of the cup. They then use their tongue to pull the liquid into the mouth.
CHILDREN EATING SOLID FOODS
Moving to solid foods requires even more coordination of the lips, tongue and jaw to allow the child to bite food, move it to the side teeth for chewing, recollect it on the tongue and move it to the back of the mouth for swallowing. Toddlers and children may experience feeding and swallowing problems related to some of the medical problems described above. They may also present with feeding/swallowing problems if they are delayed in development of their motor skills. Still other children may present with feeding problems without an obvious cause. Feeding/swallowing problems in children can be classified into several main categories, although many children have problems in more than one category:
Related to motor problems– Children who have trouble with the coordinated movement of lips, tongue, or jaw will likely have trouble with successful eating. They may not be able to handle foods like other children their age.
Physical problems – Children with craniofacial problems like cleft lip/palate or jaw abnormalities will encounter difficulty with feeding. Physical problems might also be in the intestinal tract that prevent the child from digesting food.
Related to sensory problems – Some children have trouble processing the many different sensations related to food: temperature of the food, texture or smell of the food, taste and even color of the food may present a challenge. Children with sensory problems may develop food selectivity or food refusal. Their nutritional intake may be very limited. Not all food selectivity or refusal is related to sensory problems, and any physical problems interfering with safe, successful eating must first be ruled out.
WHAT TO DO IF YOUR INFANT OR CHILD HAS FEEDING/SWALLOWING PROBLEMS
Discuss your concerns with the child’s pediatrician right away. The next step will likely be a referral to a speech-language pathologist with expertise in this area, or perhaps to a multi-disciplinary feeding team. The sooner a feeding/swallowing problem is identified and appropriate treatment begun, the better chance the child has to improve their skills.