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From Milk to Table Foods: A Parents Guide to Introducing New Food Textures
by Joan E. Guthrie Medlen
Learning to eat foods, from the first bites of baby cereal to regular table foods is a long process. For children with Down syndrome, learning to coordinate tongue and mouth movements from the first bites of baby cereal to eating table foods takes longer and can cause parents concern. It helps to understand the developmental stages and skills children must go through learning to chew. This article discusses what chewing skills to look for before changing the texture of food and how to encourage and teach your child with Down syndrome to chew different foods. With this information you can sit back and enjoy the fun and messiness of discovering foods together with your child.
There is little information available to parents explaining what to look for when introducing new food textures to children with Down syndrome. Most information is written for children without disabilities and presents the introduction of different food textures as an age-related table. The ages for different types of foods (strained baby food, pureed, ground, chopped foods) reflect the typical age that certain tongue and jaw movements develop. Some children with Down syndrome will follow these tables and have little trouble with the introduction of foods, or chewing. Others will experience delays because of lower muscle tone or a smaller mouth cavity. Understanding chewing development and the key tongue and jaw movements that signal readiness for a new food texture such as going from strained, pureed foods to thickened, pureed foods is essential to the process.
Before your baby is offered her first bite from a spoon, she is getting her food through breast-feeding or from a bottle. The mechanism for swallowing during that time is called, suckling, which is combination of extension and retraction of the tongue, forward and backward jaw movements, and a loose closure, or connection, of the lips around the nipple.
Throughout those first months of breast or bottle feeding, your baby builds strength in her tongue and mouth and a new pattern begins to emerge, which is called sucking. Sucking includes a more rhythmic up and down jaw movement, an elevation of the tip of the tongue, and a firm closure of the lips around the nipple, which creates a negative pressure in your baby's mouth. It is usually shortly after this sucking period begins that the first bites of baby food are introduced, commonly between four and six months of age.
That first bite of baby cereal is a big event for everyone involved. Not only is it a new developmental stage, but it is a change in the relationship between your baby and everyone around her. Eating requires more participation and interaction from her. Those who feed her will learn to listen to her cues regarding how fast or slow to present each bite. In these early interactions the groundwork is laid for other give-and-take situations. It is a natural time for parent and child to develop an awareness of overall body tone, stamina and to develop a feeling of mutual trust and respect.
Those first bites of baby cereal are also very messy. Generally babies will lose a certain amount of the cereal as they try to coordinate their tongue and jaw movements to this new, foreign food. Babies with Down syndrome often lose more food than those without Down syndrome as they coordinate these movements. If too much food is lost, your baby’s jaw movements may still be more of a suckling pattern -- tongue and jaw thrusts resulting in loss of food -- than a sucking pattern. A good rule of thumb to use is if your baby with Down syndrome seems to be losing 75 percent or more of the food from each bite, it might be best to wait a few days and try a bite of cereal again. Once she is eating baby cereal successfully, follow the typical pattern for introducing first baby foods. This category of foods is called, strained, pureed foods which includes baby cereals; jarred, strained baby foods; and homemade, pureed, strained foods.
If your baby continues to lose a lot of food with each bite due to jaw and tongue thrusts, there are some things you can do to help her learn to control her mouth and tongue while eating:
- Check your child's positioning. The best position is as near a sitting position as possible, with her legs, head, back and feet supported as needed.
- Your baby should be able to look straight ahead at you or the person feeding her during her mealtime. Looking up to see the person feeding her causes her to lift her head back and makes swallowing more difficult.
- Spoonsful of food should be small. Too much food makes the process more tiring and frustrating for both of you. It's easier to move a small amount of food around in her mouth than a large one.
- Present the spoon from slightly below your baby's mouth. As she accepts the spoon, place the bowl of the spoon firmly (but do not push hard) on the center-front of her tongue. This helps her keep her jaw and tongue from thrusting forward.
- Remove the spoon straight out of her mouth (do not lift the spoon to scrape food off). This will encourage her to use her lips to close around the spoon to get the food.
- Watch your baby’s cues. Learning to handle food is not easy. Wait for her to completely finish her bite before offering her another. It may take her extra time to coordinate her movements between bites Watch for her receptiveness for each bite rather than providing the spoonful of food before she is ready.
- Watch for signs of fatigue. Tiring early in a meal is very common for children with Down syndrome, particular in the beginning stages of eating. Try not to push her past her limit to frustration. If she tires too early to get enough calories, consider more frequent meals for her (6-8 times in a day). Focus on increasing the length of each meal until one or more can be eliminated from the daily schedule without sacrificing calories.
Give yourself and your baby some time together at this stage. It takes practice to develop a rhythm you are both comfortable with.
Some children will have tongue thrusting movements and continue to lose food as they eat. If she is eating her foods without coughing or gagging, then she has most likely found a way to adapt her tongue movements. If she is coughing, gasping, gulping or gagging after most bites of food, check with your doctor or speech pathologist to make sure she is swallowing safely. As your baby gets accustomed to strained, pureed foods, she will begin to develop a strong sucking action.
Once your baby is proficient with strained, pureed foods, which you can tell by the stronger sucking action, it is time to begin thickening her foods. While eating these thickened, pureed foods your child learns to use her tongue to move food in her mouth. To thicken foods, add instant potato flakes, wheat germ, bread crumbs, or dry baby cereals. Using wheat germ to thicken foods is also an excellent way to increase fiber. When you thicken strained, pureed foods, there are a few things to remember:
- Foods will continue to thicken after you are done mixing. Check the consistency of the food every three bites or so. You may need to add some liquid so it doesn’t become too pasty.
- Use a thickener (baby cereal, potato flakes, and so on) that makes sense for the food you are thickening. Strained pears with potato flakes have a funny flavor. Rice cereal might be a better choice because it has a less distinctive flavor.
During this stage (thickened, pureed foods), your child will develop what is called a phasic bite reflex which is a rhythmic bite and release pattern that looks like she is opening and closing her mouth when something touches her gums (a toy, a spoon, some baby food, or your finger). This is a good time to let her explore with a spoon or an empty cup. Although this stage does not signal time to change your child's food texture, it is an important step to being able to accept different textures. Allowing her to chew on things such as wash cloths and toothbrushes help her get used to the feeling of different textures in her mouth. This is helpful later when she is trying out new and different foods.
The next chewing stage to look for is munching, which is when your child moves food in her mouth by flattening and spreading her tongue while moving her jaw up and down. For some children with Down syndrome, this may look something like a flattening on the roof of the mouth followed by a pushing outward of the tongue to move the food as she opens her mouth.
When you see she is beginning to munch, it is time to introduce some finely ground foods, such as cooked, mashed vegetables; scrambled eggs, or cottage cheese. This is your child’s first experience with texture in her food. She may be surprised or react strongly. Be prepared for a lot of messes. If she rejects a food (throws it, spits it out, smears it all over), don't take it personally. Offer a small amount again in a few days. Eventually, the food will make it to her mouth.
It is not uncommon for children with Down syndrome to continue to struggle with low oral motor tone at this stage. Some children may find ways to move foods with their tongue that is slightly different from what is considered "typical." Again, if your child is choking, gasping or gagging a lot, ask for help from your doctor or speech pathologist. If, however, she is handling foods without choking or gagging, but is having trouble coordinating her chewing or tongue, here are some things you can do to help encourage her eating skills:
- During a meal, sit directly in front of your child. Place your thumb on her chin bellow her lower lip. Your index finger will be back by the joint of her jawbone and your middle finger under her jaw behind her chin. Gently encourage her jaw movements in an up and down action. Do not force this movement. If she protests and asks you to remove your hand, it's best to respect her wishes.
- Place food (scrambled eggs and small graham cracker pieces are good) between her gums or molars on one side of her mouth. This encourages her to move her tongue to get the food.
- If your child seems to prefer to chew on one side of her mouth, place food on the other side. This works especially well if it is a favorite food.
- Offer toasted bread strips, strips of soft cheese, and other appropriate finger foods. It is safest to hold on to one end of the food as she chews so she doesn’t get too much at once.
- Do not mix food textures! Foods that have more than one type of texture such as spagettio's , most junior foods (spaghetti with meatballs) or lumpy ground foods, require different chewing movements. It is confusing to your child to have more than one texture to deal with at a time in a bite of food.
- To encourage her to move her tongue from side-to-side (a skill needed for rotary chewing), offer ice cream cones to lick or place small dabs of smooth peanut butter in the corners of her mouth to lick off.
When your child is able to move foods from side-to-side with her tongue, it is time to introduce finely chopped foods. Use foods from the family meal that you chop very small. It’s best to begin with foods that are easy to chew, such as chopped pasta, cooked vegetables, cooked potatoes (without the skin), or canned or very ripe fruits. Let her watch you remove her food from serving dishes so she sees it is the same as what the rest of the family is eating. This usually makes these new foods particularly interesting to experiment with and eventually eat. As she becomes comfortable with finely chopped foods, gradually increase the size of her foods to bite-sized pieces.
During this time, your child will slowly work toward a mature rotary chew, which uses the tongue to move food from side-to-side in the mouth along with a coordinated movement of the jaw in vertical, lateral (side-to-side) and diagonal movements. A mature rotary chew looks like a smooth, circular motion while the jaw opens and closes to chew. For many children, with and without Down syndrome, this is easy to observe because it is difficult to do with their lips together, eliciting the familiar comment, "Chew with your mouth closed!"
For children with Down syndrome, it is quite helpful to understand what your child is learning to do as you introduce new food textures. Rather than using age to decide when to introduce a new texture, watch your child eat and look for the skills she needs to progress.
It takes children with Down syndrome longer to chew their food, which continues for many years or may be life long. This could be because of low oral motor tone, motor planning (coordinating the movements to do the chewing) or from general fatigue from the work of eating. Regardless of the reason, it is something to keep in mind at meal times, particularly as you help her learn to eat. It may also be something to consider at day care, preschool and as your child enters school; she may need more time to eat her lunch and snacks.
Learning to eat foods and progress through textures is more than developing chewing and swallowing skills. Though these skills are necessary to successfully eat regular table foods, there are many things that must be considered beyond chewing for your child to be able to eat well, including what goes on during the family meal. As with most things, there will be times of frustration, along with joy in accomplishments. Sometimes, in the middle of the frustrations we feel coupled with day-to-day living, it is hard to remain positive. When you are feeling frustrated, here are some things to remember that may be helpful:
- Learning to eat is a messy, messy process. This can be the hardest to remember. However, a lot of learning takes place in the midst of the mess. While exploring food, children learn about the feel, smell and temperature of foods (and sometimes the sound as they plunge to the floor).
- Children with Down syndrome often take longer to progress from baby food to regular table foods. However, that doesn’t mean you have to forfeit table manners. Your child is learning about table manners from everyone around her. It's a great time to remind others to eat politely and to encourage the same, when appropriate, for your child with Down syndrome.
- Try to make mealtime pleasant. Learning to eat, use utensils and try new foods is a lot to do. Children with Down syndrome may become overwhelmed if too much is going on around them during meal time. Try to limit the amount of extra activity where your child is eating or at your family table by turning off the television, radio, video games and so on.
- Remember your child is always growing. The seating position that is best for your child will change as she grows. It is most important to consider upper body support and a place to rest her feet so her knees are at a 90-degree angle. These two things will affect her ability to feed herself as well as her ability to chew and swallow safely. If she has to add the work of supporting her upper body or her legs while eating, she will not want to also work on using her spoon or fork.
- Eating takes time for children and adults with Down syndrome. It is worthwhile to allow for extra time whenever possible.
- Offer new foods one-at-a-time. As your child grows, continue to introduce new foods along with old favorites. This is good for all family members. Do not force her to try "just a bite." Instead, offer a small amount over the course of many meals. Consider it a side dish. Eventually, she’ll give it a try.
- Establish a family meal time. It is important for your child to be a part of the family meal. Whenever possible, even as a baby, include her in the family meal time so she can see how others eat and talk with each other. Try to serve foods that are as similar to what the rest of the family is eating (either in color or type of food) as possible.
There are times when despite your best effort, or because of medical complications, your child with Down syndrome may not be moving from baby cereal to table foods in the way you expected. Early Intervention Team members are available to ask questions about feeding your child. Each team usually has a speech pathologist, an occupational therapist and some will have dietitians all who are familiar with feeding concerns. In some cases, it may be necessary to consult a group of professionals who specialize in feeding concerns. If you are unsure if you need to consult a feeding team, guidelines are available to help you, your Early Intervention Team Members or your pediatrician decide.
Learning to eat is a delightful time for parents and children. It's a time full of new experiences and creative ways to explore foods, utensils and the reactions of others. Understanding when and why to introduce new foods to children with Down syndrome makes it possible to move forward while you relax and enjoy the messes together.
Some foods require caution for any child who is still learning to handle foods in her mouth. If your child has not yet mastered a "mature rotary chew," only offer these foods with strict, attentive supervision (or not at all).
- Hard, Small Foods
- Hard candies
- Raw carrot sticks
- Snack puffs
- Slippery Foods
- Whole grapes
- Hot dogs
- Large pieces of meat
Chewing Development with Suggested Food Textures
|Food Type||Pre-Food||Puree||Thick Puree||Ground||Chopped Food||Table Food|
|Munching||Chew progresses to a mature rotary chew||Well-practiced at mature rotary chew|
|Rooting||Attempts to hold bottle||Show interest in "guiding" spoon||Decrease in gag reflex. Increased us of cup. Grasps sppon and "plays" with it.||Assists with feeding and drinking with increasing independence.||Messy self feeder, switching back-and-forth between utensils and fiongers.|
|Types of Food to Offer||Breast milk or formula||Infant cereals should resemble a "Heavy Thick Liquid" or Applesauce. Other foods include blended, strained, baby foods (jar or homemade)||Gradually increase the thickness of pureed foods with baby cereal, wheat germ, or potato flakes. Provide opportunities for chewing using tething type foods (pretzels, toast and so on)||Mashed, cooked vegetables, scrambled egg, mashed soft-boiled egg, cotttage cheese||Chop regular table foods in small, fine pieces.Introduce finger foods that are easily chewed.||Monitor easy-choke foods (see table above) for safety. Modify list as appropriate. Introduce crunchy and chewy foods to build jaw strength|
|The beginning of a sucking motion||Strong well-developed sucking mothion.||Emergence of up-and-down chewing motions.||Side-to-side movement of foods with tongue.||Individualize for preferences and abilities.|
|Precautions||Heed choking precautions.||Do not mix textures (such as spaghetti with meat balls, peas in mashed potatoes)||Avoid easy-choke foods (see table above)|
If after reading the article above, you are wondering if you should seek the help of a feeding team, here are some questions to consider:
- Am I talking to more than one or two professionals about feeding (for instance, what foods my child eats, oral motor skills and exercises or other medical conditions that affect feeding)?
- Am I getting advice from more than one or two professionals about feeding that is difficult to blend together or is conflicting?
- Is my child's eating or feeding taking a lot of time and therefore a lot of time away from other family members?
- Is my concern about my child's eating or feeding taking time away from family due to stress or worry?
- I would like to have one, concise plan for helping my child learn to eat different textures and participate in family meals (yes/no).
If you answered yes to two or more of these, I highly recommend you seek out a feeding team in your community. Feeding teams consist of a multidisciplinary team dedicated to solving concerns about eating and feeding. They are usually associated with the children's hospital in the area.
Joan E. Guthrie Medlen is the mother of Ryan, 13, and Andy, 10, who has Down syndrome and autistic spectrum disorder. Joan is a registered dietician and the editor of Disability Solutions. She and her family reside in Portland, Oregon.
The article above is reproduced with the permission of its author, Disability Solutions editor Joan E. Guthrie Medlen. In accordance with federal copyright restrictions, the contents of this article may not be reproduced by photocopying or any other means without written permission from the copyright holder. © 1999 Disability Solutions