University of North Dakota

UND Scholarly Commons

Occupational Therapy Capstones Department of Occupational Therapy

2007

Occupational Therapy Feeding and Eating Manual

for Parents of Children with Oral Motor Deficits
Jessica Kovacevich
University of North Dakota

Genevieve Ziegler
University of North Dakota

Follow this and additional works at: https://commons.und.edu/ot-grad

Part of the Occupational Therapy Commons

Recommended Citation
Kovacevich, Jessica and Ziegler, Genevieve, "Occupational Therapy Feeding and Eating Manual for Parents of Children with Oral
Motor Deficits" (2007). Occupational Therapy Capstones. 113.
https://commons.und.edu/ot-grad/113

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 OCCUPATIONAL THERAPY FEEDING AND EATING
MANUAL FOR PARENTS OF CHILDREN WITH ORAL MOTOR DEFICITS

by

Jessica Kovacevich, MOTS

and
Genevieve Ziegler, MOTS

Advisor: Gail Bass, Ph.D., OTR/L

A Scholarly Project

Submitted to the Occupational Therapy Department

of the

University of North Dakota

In partial fulfillment of the requirements

for the degree of

Master’s of Occupational Therapy

Grand Forks, North Dakota

May 2007

i
 This Scholarly Project Paper, submitted by Your Name(s) in partial fulfillment of
the requirement for the Degree of Master’s of Occupational Therapy from the University
of North Dakota, has been read by the Faculty Advisor under whom the work has been
done and is hereby approved.

________________________
Faculty Advisor

________________________
Date

ii
 PERMISSION

Title Occupational Therapy Feeding and Eating Manual for Parents of

Children With Oral Motor Deficits

Department Occupational Therapy

Degree Master’s of Occupational Therapy

In presenting this Scholarly Project/Independent Study in partial fulfillment of the

requirements for a graduate degree from the University of North Dakota, I/we agree that
the Department of Occupational Therapy shall make it freely available for inspection.
I/we further agree that permission for extensive copying for scholarly purposes may be
granted by the professor who supervised our work or, in his/her absence, by the
Chairperson of the Department. It is understood that any copying or publication or other
use of this Scholarly Project/Independent Study or part thereof for financial gain shall not
be allowed without my/our written permission. It is also understood that due recognition
shall be given to me/us and the University of North Dakota in any scholarly use which
may be made of any material in our Scholarly Project/Independent Study Report.

Signature___________________________ Date ________

Signature___________________________ Date ________

iii
 TABLE OF CONTENTS

ACKNOWLEDGEMENTS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . V

ABSTRACT . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . VI

CHAPTER

I. INTRODUCTION . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1

II. REVIEW OF LITERATURE . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3

Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7

Development . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4

Types of Feeding Disorders in Infants and Toddlers . . . . . . . . . . . . . 8

Care for Children With Eating and Feeding Difficulties. . . . . . . . . . . 12

Conclusion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 23

III. METHODOLOGY . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 26

IV. PRODUCT . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 29

V. SUMMARY . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 81

REFERENCES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 84

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 ACKNOWLEDGEMENTS

The authors wish to thank our advisor Dr. Gail Bass for the guidance,

direction, and support for this scholarly project. We also wish to thank all

Occupational Therapy faculty members at the University of North Dakota who

have all taught us the subject matter and skills needed to be successful in both the

profession of occupational therapy and the general medical profession. Lastly,

thanks to our peers who assisted us in many ways through support and

encouragement. This project could not have been completed without the

contributions of all of these people.

v
 ABSTRACT

Having a child with feeding and eating difficulties can be a very stressful event

for parents, and the process of occupational therapy assessment and treatment may also

be stressful and confusing for the parents. Most parents are not familiar with feeding and

eating difficulties in children, and many parents do not know where to find the

information that they need to learn about their child’s diagnosis. After an initial review

of literature, it was found that parents of children with special needs have few resources

for eating and feeding strategies and approaches for oral motor deficits. It was also found

that information about assessment and intervention for working with children who have

oral motor deficits is readily available for occupational therapists, but most resources are

not written in terms that can be easily understood by parents and caregivers.

After an extensive literature review and with input from occupational therapists

working in an out-patient pediatric therapy clinic, we decided that parents may benefit

from a manual designed to assist them to prepare for and understand the initial

occupational therapy evaluation process and subsequent intervention program. The

methodology for the development of the manual was an in-depth review of current

resources, literature, and research in the area of eating and feeding strategies for children.

This manual was designed for use by an occupational therapists and it can be

given to parents prior to the first occupational therapy visit. The manual includes

information on: feeding disorders, instrumental assessments, descriptions of the

professionals that provide treatment for feeding disorders and their role, and a detailed

vi
description of the occupational therapist role. It also includes information for parents on

how to prepare for occupational therapy assessment and intervention, and a description of

their role in assessment and intervention. The manual includes definitions of terms,

additional resources, forms for parents to fill out prior to the initial occupational therapy

evaluation, and treatment/intervention notes pages to help parents to keep treatment

information organized.

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 CHAPTER I

INTRODUCTION

Project Background

The incidence of feeding and eating disorders in infants, toddlers, and children

and the interventions to treat them have been increasing steadily in recent years. This

may be due to an increased understanding of feeding and eating disorders, advances in

medical technology, and increased survival rates of high risk infants. Occupational

therapists need to keep up with the ever-changing trends in treatment of these disorders.

A component of treating feeding and eating disorders in children is education and

interaction with the parents or caregivers of these children. The initial occupational

therapy evaluation can be a very stressful time for parents because of a lack of knowledge

and education about their child’s disorder, an uncertainty about what the future holds for

them, and what their role will be in the treatment of their child. The literature and

research reviewed in Chapter II of this document and first-hand experience indicates that

a manual that can provide the parents or caregivers with education about feeding

disorders and about the professionals that will be working with their child would help the

parents or caregivers feel more comfortable beginning the occupational therapy

assessment and intervention process. The purpose of the project was to develop an

1
occupational therapy feeding and eating manual for parents of children with oral motor

deficits.

Occupational Adaptation

The theory guiding this scholarly project was the theory of Occupational

Adaptation (OA). OA was developed by Schkade and Schultz (2003), and was described

as a normative process that leads to competence in occupational functioning. In children

with feeding difficulties, the normal process of feeding and eating is interrupted by either

a behavioral or physical abnormality. OA describes the occupational process as setting a

stage for the parents of the child to be the agent of change in facilitating normal

occupational functioning. The occupational therapist sets the stage and gives the parents

the tools they need. Together the occupational therapist and parents evaluate the process

of change and decide if it is happening effectively or if other changes need to be made in

the intervention strategies. The overall goal is for the parents and children to demonstrate

increased functional independence in the co-occupations of feeding and eating.

Summary

The parent manual which is the product of this scholarly project had its

foundations in current research and literature; a review of that literature is found in

Chapter II of this document. Chapter III is a description of the methodology used to

develop the manual and Chapter IV contains the manual in its entirety. Chapter IV

contains a summary of the significant findings, limitations of the project, and

recommendations.

2
 CHAPTER 2

REVIEW OF LITERATRE

Introduction

Recently medical professionals have been increasingly identifying feeding and

eating disorders with infants and children. According to McCurtin (1997), this may be

due to advances in medical technology, the increased understanding of these disorders

through research, and the importance of the multidisciplinary team approach. Children

with medical problems are also living longer because of the advancements in medical

technology. Research provides ongoing findings to assist professionals in gaining new

insight and knowledge on different aspects of feeding and eating disorders.

The purpose of this scholarly project was to develop a manual for parents of

children with oral motor deficits that prepares and guides them through the occupational

therapy evaluation and treatment process. In order to support the validity of the project,

the development of the manual had its foundation in current research and literature. The

following chapter is a review of that research and literature and it is divided into the

following sections: normal eating and feeding development, types of feeding disorders,

and care for a child with feeding and eating difficulties.

3
 Development

In order to treat children with feeding and eating disorders, it is crucial to

understand the normal processes and the development of neurological, anatomical, and

physiological structures. Feeding difficulties may potentially have many systems

involved, thus contributing to the complexity of treating individuals with feeding and

eating disorders.

Neurological Developmental

According to Chapman Bahr (2001), “reflexes and responses are an important

aspect of the infant movement until the infant's neurological system has matured enough

to develop motor control” (p. 4). Some of the initial reflexes diminish as the infant's

neurological system develops, but can potentially recur with neurological injury such as a

traumatic brain injury.

The infant's rooting reflex is present at birth, causing the infant to seek out the

nipple. “The suckling, swallowing, and tongue reflexes are used by the infant to obtain

and manage the fluid expressed from the nipple” (Chapman Bahr, 2001, p. 4). The infant

should automatically be able to coordinate sucking and swallowing with breathing; the

infant stops breathing during the swallow. Sucking immediately followed by a swallow

is termed a “suckle.” According to Ernsberger and Stegen-Hanson (2001), the entire

sequence together is referred to as the suck-swallow-breathe rhythm (p. 20). The grasp

reflex is used by the infant to hold onto the mother with their hands while feeding. The

gag reflex is present at birth, and present throughout life; it is extremely sensitive during

the first few months of birth, but becomes less sensitive when the infant develops

4
chewing skills. The cough reflex, also present at birth, is present to close the vocal cords

of the infant in order to prevent materials from entering the airway (Winslow, 1994). The

bite and transverse reflexes assist the infant in establishing the movements needed for the

later developmental mechanisms of chewing and tongue lateralization (Chapman Bahr,

2001).

Anatomical/ Oral Motor Development

According to Ernsperger and Stegen-Hanson (2004), “Oral motor skills refer to

the movements of the muscles in the mouth, lips, tongue, cheeks, and jaw. Oral motor

skills include the functions of sucking, biting, crunching, chewing, and licking” (p. 15).

Children require sufficient development of oral motor skills in order to effectively

succeed in the occupation of feeding. There are multiple oral motor characteristics that

children may exhibit during different developmental stages. Infant and toddler oral motor

development is described and categorized by age in the following section. This

information is from Ernsperger & Stegen-Hanson (2004, pp. 17-30) and Chapman Bahr

(2001).

0-3 months

At 0-3 months, an infant has a small, slightly retracted jaw. The oral space is

small, because of the limited amount of food that enters it. An infant has sucking pads in

the cheeks, and these larger cheeks and tongue take up the majority of the oral cavity.

The larynx sits high in the neck to eliminate the need for complex laryngeal closure. The

eustachian tube lies in a horizontal position, and will move into a more vertical position

5
as the infant moves toward adulthood. The infant moves the jaw, tongue, and lips as one

unit.

4-6 months

At this stage of oral motor development, the infant is constantly putting objects in

their mouth for oral exploration. The infant develops an up and down chewing pattern of

the jaw, and the tongue is able to flatten out. Because the infant's gag reflex diminishes,

the child is able to take into the mouth and swallow soft solids.

7-9 months

At 7-9 months, the infant has lateral closure of the lips. The jaw works

independently from the tongue and lips, and the tongue is able to differentiate between

collecting the food entering the mouth and swallowing the food. Tongue movement is

becoming more complex, and the infant has the ability to move food from the center to

the edge of the tongue and back. Teething usually starts at this stage, and the sensation of

teeth piercing the gums causes the infant to want to put objects in their mouth.

10-12 months

By the time the infant reaches this stage, the bite is usually well-developed, and

the infant is able to consume food with lumps that require chewing before swallowing.

Infants explore the use of utensils and cups at mealtimes and use hand-eye coordination

to bring these objects to the lips. These movements are not necessarily smooth and fluid

often leading to messy mealtimes where the infant frequently spills the liquids and food

all over.

6
13-15 months

At this stage the child is able to chew by using coordinated jaw movements. The

muscles around the lips and cheeks are more developed to assist with controlling the

movement of food. The infant has the ability to elevate the tongue in order to explore the

roof of the mouth. The overall mealtime may be less messy because the infant has

developed more polished drinking and chewing skills.

16-18 months

At 16-18 months the child perfects the oral motor skills listed in the above stages.

The child is better able to regulate the skill during feeding and drinking contributing to

less spills of liquids and foods.

25-36 months

By 2 years, the child's oral motor skills continue to be refined and adapted to the

growth changes of the child. In this stage, the child uses the tongue to move food that is

stuck in different places of the oral cavity such as in the space between the lips and teeth.

Three different chewing patterns are used during the chewing process; these patterns are

differentiated by the directionality of the jaw. A variety of food should continually be

explored in order for the children to adequately practice the recently developed oral

motor skills (Ernsberger & Stegen-Hanson, 2004; Chapman Bahr, 2001).

Oral motor skills developed in infancy are essential for success in the occupations

of feeding and eating. It is necessary to understand normal neurological, anatomical, and

physiological development in order to distinguish between the different types of feeding

disorders in infants and toddlers.

7
 Phases of Swallowing

According to Miller and Willging (2003), pediatric feeding difficulties may occur

in one or more of the phases of swallowing. There are three phases of swallowing

referred to as the oral, pharyngeal, and esophageal phases. The oral phase is when the

child ingests or masticates the food in the mouth to form a bolus. The bolus is pushed to

the posterior aspect of the mouth before swallowing. The pharyngeal phase involves the

trigger of the swallow and transfer of food or liquids through the pharynx. As food passes

through the pharynx to the larynx the airway should close in order to prevent aspiration.

The esophageal phase allows for food or liquids to pass through the esophagus into the

stomach.

Types of Feeding Disorders in Infants and Toddlers

Rudolph and Link (2002) reported that feeding problems occurred in 25% to 35%

of normal children and with 40% to 70% of infants who were born prematurely or who

have some other type of medical condition. Feeding and eating disorders can be mild and

children may grow out of them, or they can be severe enough to affect the child for his or

her entire life.

A review of research on pediatric feeding disorders indicated that there are

multiple ways to categorize or classify feeding disorders. According to Woolston (1991),

the most common classification method of feeding disorders is the dichotomy of organic

versus non-organic failure to thrive. Organic feeding disorders include factors associated

with structural abnormalities, neuromuscular problems, and other physiologic problems.

8
Non-organic feeding disorders include factors related to the social environment

(Burklow, 1998). Feeding disorders may potentially be caused by one independent factor

or several factors working together. The organic versus non-organic dichotomy

classification fails to consider that multiple factors, both physiologic and environmental,

may contribute to a feeding disorder. Rommel (2003) categorizes feeding problems as

medical, oral and/or behavioral instead of using the dichotomy organic versus non-

organic. Because there are multiple factors that contribute to feeding and eating disorders

in children, classification is a difficult process.

Digestive Disorders

There are several disorders associated with digestive problems in infants and

toddlers. The most common types include dysphagia, aspiration, constipation, celiac

disease, motility disorders, Hirschsprung disease, short bowel syndrome, food allergy

intolerance, and gastroesophageal reflux. Pain, discomfort, appetite suppression, and

reduced motivation to feed are all symptoms that can indicate a digestive disorder

(Manikam, 2000).

Dysphagia is not a specific diagnosis, but is used to describe a variety of

childhood feeding dysfunctions. Dysphagia is categorized into three phases: oral,

pharyngeal, and esophageal. Oral dysphagia deals with defects either in the physical

structure of the mouth or defects in the central nervous system; an example is low tone in

the cheeks which can cause pocketing. Pharyngeal dysphagia is caused by enlarged

tonsils and adenoids or retropharyngeal abscesses. Esophageal dysphagia results from

structure abnormalities or impairments in the movement of esophageal muscles.

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Conditioned dysphagia is a term used to describe children developing hypersensitivity to

touch and defensive posturing when food is brought to their mouth, due to medical

procedures performed around the face and mouth (Miller & Willging, 2003).

Gastroesophageal reflux is a progressive disorder commonly observed in

pediatrics. It can cause discomfort, irritation, and pain when not treated properly.

Children may develop aversions to food, resulting in gagging, choking, or emesis

(Manikam,2000).

According to McCurtin (1997), aspiration is “the inhalation of food material into

the lungs.” (p. 12) Aspiration is classified in 3 ways: which stage of swallowing is child

at when aspiration occurs, type of occurrence, and severity of occurrence. Aspiration can

occur before, during, or after the swallow. Aspiration occurring before the child

swallows is caused by oral motor deficits, usually poor tongue movement. Aspiration

during swallowing is usually caused by defects in functioning of the larynx. Classifying

aspiration by types of occurrence looks at aspiration as either being chronic, which is

continually occurring aspiration; state related, which is when the child is respiratorially

compromised; fatigued, which is when the child wears out during feeding; or silent,

which is not evidenced by the child's behavior, but can be detected by radiological testing

(McCurtin, 1997, pp. 12-13).

Oral Motor

A child with oral motor deficits lacks the ability to coordinate and initiate

movements needed for normal eating and feeding. These problems may be caused by

numerous medical conditions such as structural abnormalities, neurological conditions,

10
and cardiorespiratory problems. An example of a structural abnormality may be a cleft

lip, which interferes with proper lip closure. A neurological condition may be cerebral

palsy which may cause problems such as poor tongue movements, aspiration, and reflux .

An example of a cardiorespiratory problem is the inability to coordinate the suck swallow

breath pattern needed to eat properly (Burklow, 1998; Manikam, 2000).

Behavioral

Behavioral issues with feeding stem from psychosocial difficulties, negative

feeding behaviors shaped and maintained by internal and/or external reinforcement, or

emotional based difficulties (Burklow, 1998). Many times, the issues are a combination

of two or more of these difficulties.

Environmental factors play a large part in the development of feeding difficulties.

Stress or negative external reinforcement can cause a child to develop food aversions and

other feeding difficulties. An example of an environmental stressor is a child having

parents with hectic work schedules, which leads disorganized meal times, and which can

put extra stress on the child when feeding (Ernsperger & Stegen-Hanson, 2004; Franklin

& Rodger, 2003).

Psychosocial difficulties can stem both from the child and the parent. A negative

or dysfunctional interaction between the child and the feeder is an example of this.

Parents may become distressed and frustrated with not being able to feed their distressed

child. The child may also have feelings of distress if they do not have the adequate skills

for feeding and eating (Franklin & Rodger, 2003).

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 Culture can influence a child’s development of eating habits and behaviors, both

positively and negatively. “Don’t play with your food”, or “Use your spoon, not your

fingers”, can create a roadblock for resistive eaters. These cultural norms take away the

sensation of the food, and many children with feeding difficulties need multiple sensory

opportunities to develop functional eating habits (Ernsperger & Stegen-Hanson, 2004).

Care for Children With Eating and Feeding Difficulties

Children with feeding and eating difficulties may require care provided by a

variety of medical professionals who use their unique skills for evaluation and treatment.

The individual disciplines will contribute their skills and knowledge to the treatment

process based on the child’s needs. The treatment process starts with an initial evaluation

to determine the need for treatment and continues with interventions to aide the child in

progressing towards set goals.

The Treatment Process

The Treatment Team

An interdisciplinary team approach is necessary for evaluation and treatment due

to the complexity of eating and feeding difficulties in infants and toddlers. The team may

include a pediatrician, psychologist, occupational therapist, speech language pathologist,

dietitian, and nurse. Every patient will have a team made up of different professionals,

and depending on the needs of the child, this team may change over time as the child's

needs change. The interdisciplinary team members possess different functional roles

dependent on their profession. Children with eating and feeding difficulties are initially

evaluated by their pediatrician. The pediatrician is the medical leader who examines the

12
child to determine if there is a specific diagnosis that is having an impact on the child’s

eating and feeding. They may prescribe or administer treatments necessary for the

individual child's case. Pediatricians may also refer the child to other medical

professionals such as occupational therapists to get input into the evaluation and

diagnostic process and for treatment of the feeding and/or eating difficulty (Arvedson,

2006 ; Miller et. al., 2001).

The psychologist identifies and treats psychological and behavioral problems.

Examples of these behaviors during eating are gagging, vomiting, and spitting.

Psychologists examine the parent-child relationship interactions during mealtimes;

behavioral interventions may be used to treat feeding difficulties in children (Linscheid,

2006). Several standardized and normative based-instruments are available for assessing

the incidence and general nature of a feeding problem. An interview with the parents

also helps the psychologist to identify problem behaviors.

The speech language pathologist looks at the child's oral motor skills required for

eating. They evaluate oral motor skills through clinical observation, but often

recommends further diagnostic medical testing such as a videofluoroscopic swallow

study. The speech language pathologist can also help read the infant or toddler’s

communicative signals during feeding and eating (Morris & Klein, 1987). The

occupational therapist evaluates and treats problems related to posture, tone, oral motor,

oral sensory, and self feeding. The occupational therapist’s role often overlaps with the

speech language pathologist (Arvedson, 2006).

13
 The dietitian assesses past and current diets of the child to determine nutritional

needs. The dietitian may design specific meals to meet the nutritional needs of the child.

Ongoing monitoring of the child's diet will be necessary to make sure the child is

receiving the nutrition needed to support healthy growth and development (Arvedson,

2006).

The nurse is often the main coordinator for the treatment team. The nurse reviews

and records information gathered by the parents and/or caregiver prior, during, and after

clinic visits. Nurses are seen more in an acute inpatient setting or clinical setting and not

in an outpatient setting due to their role in the medical field (Arvedson, 2006 ; Miller et.

al., 2001).

Medical professionals are not the only members who make up the treatment team.

According to Pressman and Berkowitz (2003), the parents or caregivers should also be

included in the treatment team along with the professionals. Parents and/or caregivers can

provide valid subjective and objective data about the child that will aid in the evaluation

and treatment process (Arvedson, 2006 ; Miller et. al., 2001).

Occupational Therapist Role

All interdisciplinary members are important for the treatment process, but the role

of the occupational therapist during the treatment process will be the main focus of this

project. According to Miller and Burklow (2001), the occupational therapist frequently

explores the use of adaptive equipment to enhance the child's ability to eat and feed. An

example of adaptive equipment may be a positioning device that provides upright posture

necessary for an accurate swallow. Occupational therapists have a unique role because

14
they look at how the child’s eating and feeding problems affect their every-day

occupations. “By taking a broad view towards the activity of eating and recognizing the

occupation that it influences, occupational therapists and occupational therapist assistants

include physical, cognitive social, emotional, and cultural elements in evaluation and

intervention” (American Occupational Therapy Association [AOTA], 2000, p.629).

According to Schultz-Krohn (2006), occupational therapists and occupational therapy

assistants are uniquely positioned to meet the needs of infants and toddlers who have

problems eating and feeding. Feeding and eating are activities referred to as occupations,

which are various kinds of life activities that individuals engage in. An occupational

therapist’s main goal for treatment is to increase engagement in occupations that are

disrupted such as infants and toddlers with feeding and eating difficulties. Occupational

therapists offer a wide range of skills to evaluate and treat these infants and toddlers. The

first of these skills is the skill of activity analysis, which is a crucial part of assessing a

child’s feeding and eating patterns. Also, the occupational therapist has an “extensive

knowledge of anatomy and physiology of the phases of eating for the purpose of

assessing structural, neuromotor, and sensory factors that support or interfere with

function” (AOTA, 2000, p. 631). The occupational therapist is also skilled to educate

other professionals on the treatment team and the caregivers.

Evaluation

It is important for the parents and/or caregivers to organize subjective and

objective data in preparation for occupational therapy intervention services. This will

optimize the initial conversation and time with the occupational therapist (McNally,

15
2002). Data a parent and/or caregiver can bring into the initial evaluation scheduled with

the occupational therapist includes: 1) medical history, 2) feeding journal, 3) film of a

mealtime, and 4) list of educational or research materials that have been read.

The medical history should include dates of any surgeries, previous and current

medications, diagnostic testing procedures, and any information on previous therapies the

infants or toddlers have received. According to McNally (2002), medical professionals

appreciate the parents/caregivers compiling this medical information before the initial

evaluation because it is easier to read and understand compared to detailed medical

records. A feeding journal includes documented observations of the infants or toddlers

feeding and eating performance. The journal is used to organize these observations and

will aide the occupational therapist in the treatment process. Observations recorded may

include the infant or toddler behaviors, types of foods and or amounts eaten, and

interactions with the parent and/or caregiver. Filming a child at home during a mealtime

captures a child's typical responses to foods and provides the occupational therapist with

an understanding of the child's feeding and eating patterns in the context of the home.

Parent and/or caregivers should lastly read information on feeding and eating disorders to

gain a better understanding of the child's disorder. Resources can be found on the

Internet, in books, or articles. This data combined with the occupational therapist clinical

reasoning skills will contribute to the treatment of the feeding and/or eating disorder

(McNally, 2002).

Infants and toddlers with feeding and/or eating difficulties may be referred to a

licensed occupational therapist for treatment. In preparation for the initial evaluation the

16
occupational therapist will review the child's medical records to learn why the child is

referred to services and review any past medical history that is pertinent to the treatment

process. The initial clinical evaluation may include assessing a variety of feeding and

eating components. An occupational therapist will assess oral motor function, muscle

tone, posture, sensory response, behavior, self-feeding ability, parent-child interactions,

social and environmental components, and the child's physical abilities (Dmetteo, 2005).

The first thing the occupational therapist will do is review the medical history and

interpret the results to assess which areas reflect needs of the infant or toddler in therapy.

The next thing will be to assess the infant or toddler’s oral motor behaviors. In her book,

Oral Motor Assessment and Treatment, Chapman Bahr (2001) recommends several

assessment tools to observe these behaviors. The Developmental Pre-Feeding Checklist

developed by Suzanne Evans Morris and Marsha Dunn Klein is recommended as an

excellent assessment for infant feeding. The Neonatal Oral-Motor Assessment Scale is

recommended to assess oral motor function in new-born infants. Several other

assessments are available for use in assessment, and may be used based on the

occupational therapist’s preference and experience.

In an article, Arvedson (2006) concluded “instrumental assessments of

swallowing may be needed following a clinical evaluation when concerns are noted

regarding pharyngeal phase physiology and risks for aspiration with oral feeding” (p. 9).

Instrumental assessments of swallowing may include a videofluoroscopic study (VFSS),

fiberoptic endoscopic (FEES), functional magnetic resonance imaging, and

electromyography. The VFSS is a videotaped X-ray that records how food passes into the

17
mouth through the pharynx to determine if the child is aspirating and/or penetrating their

food or liquids. According to Miller and Willging (2003), “ the VFSS analysis of the

swallow remains the gold standard of objective swallowing assessment following the

clinical feeding evaluation for confirmation of airway protection adequacy during the

swallow” (p. 443). The VFSS may not be available to use in all clinical settings. Miller

and Willging describe fiberoptic endoscopic evaluation as placing a scope down the

infant’s throat to “directly visualize the hypopharynx during the swallowing process to

assess airway protection ability” (p. 444). Functional magnetic resonance imaging is still

under investigation as to the safety and effect on the infant.

The initial evaluation may be a brief process or extensive and time consuming,

based on the child’s strengths and deficits. The evaluation may include all or only some

of the processes described above. Interpretation of the results of the occupational therapy

initial evaluation will be used to guide the treatment and intervention process.

Intervention

Based on the findings of the initial evaluation, the occupational therapist will

develop a plan for treatment. Included in the treatment plan are a series of unique

interventions based on the infant or toddlers feeding and/or eating needs. Described

below are common oral motor, behavioral, and sensory intervention strategies used by

occupational therapists for infants and toddlers with feeding and eating difficulties as

described below.

18
Oral motor

Oral motor feeding and eating difficulties may be caused by abnormalities in the

oral anatomical structures, sucking mechanism, and swallowing mechanism. Oral motor

interventions for infants may include movement activities, whole-body massage, oral

sensory exploration, positioning,and handling techniques.

According to Chapman Bahr (2001), “ Typical oral motor treatment sessions for

infants should begin with massage and movement activities” (p. 112). Massage benefits

the infant by increasing circulation, body awareness, bowel function, sleeping patterns,

attention, focus, concentration and comfort level. As the infant develops and matures

movement activities in preparation for treatment are readily used. An occupational

therapist may set up an obstacle course using tunnels, scooters, and swings that allow the

child to crawl and move about. It is crucial for the therapist to provide appropriate

movement activities based on the child's response. Some children may be more apt to

become over stimulated with movement activities (Chapman Bahr, 2001).

Infants and toddlers with movement and muscle tone deficits often are unable to

complete self- initiated oral motor exploration which is required for proper oral motor

development. These children require assistance in learning how to mouth their toys and

their hands and feet. An occupational therapist can implement oral motor exploration into

the treatment session by using hand over hand assistance to get objects to the child's oral

motor region. There are a variety of mouthing toys available to use that have different

surfaces, textures, and sizes. The therapist may also try different positioning techniques to

19
determine if position is inhibiting the child’s ability to bring objects to the mouth.

(Chapman Bahr, 2001)

Proper positioning is necessary to promote oral motor functioning. The

occupational therapist may implement different positions that help the child achieve good

postural alignment. According to Case-Smith and Humphry (2005, p. 499), appropriate

alignment consists of the following: 1) neutral pelvic alignment of the trunk. Pelvis

alignment is promoted when the child sits well supported against a flat back, on a flat

seat, and on the buttox with 90 degree hip flexion and 90 degrees of knee flexion; 2) good

head, neck, and shoulder alignment with the head in slight flexion or neutral; and 3) chin

tuck with the back of the neck in a elongated position. Postural alignment through

positioning is crucial for normal oral motor movement during feeding and eating.

Handling techniques involve touch in and around the mouth and can be

implemented before and during feeding and eating treatment. Before feeding and/or

eating an occupational therapist can use the techniques of tapping, quick stretch, or

vibration to the cheeks and lips to improve muscle tone through sensory input. During

feeding, the occupational therapist can provide jaw support through finger positioning on

the chin and cheek of the child. This support will potentially enable the child to gain

adequate internal jaw control and tongue stability for eating without any physical

assistance (Case-Smith & Humphrey, 2005). During bottle feeding, touch pressure to the

cheeks can be used to improve suctioning of the nipple. Oral motor responses can also be

influenced by the placement of a spoon during eating; different spoon placements on the

tongue can inhibit tongue movements needed for the sucking response. Handling

20
techniques during feeding and eating can involve physical touch from the therapist or

touch from utensils such as a spoon (Case-Smith & Humphrey, 2005).

Behavioral

Behavioral problems related to feeding and eating difficulties can include

behaviors such as food refusal, food selection based on texture, not eating, and

overselectivity. Behavioral interventions are centered around two major areas: appetite

manipulation and contingency management. Appetite manipulation may involve

interventions such as inducing hunger, removing foods that the child is prone to eat, and

restricting all calories between meals. Contingency management includes positive and

negative reinforcement and mild punishment. Positive reinforcement may be verbal

praise, or giving the child the opportunity to play with their favorite toy or watch a

favorite movie. Positive reinforcement should be given immediately after the child

exhibits the desired behavior. An example of negative reinforcement is letting the child

“escape” as soon as they finish their food, making them think that they have won. An

acceptable form of mild punishment is a short time-out when the child refuses food

(Linscheid, 2006).

Sensory

According to Case-Smith and Humphrey (2005), “Young children with feeding

problems exhibit hypersensitivity in and around the mouth” (p. 493). Touch in or around

the mouth causes aversive responses in these children; they also commonly react to any

textured food placed in the mouth. Reactions to touch or texture in or around the mouth

may be gagging, spitting, coughing, or crying. Infants with oral hypersensitivities “may

21
hold the food in their mouths to avoid moving it through the mouth” (Case-Smith &

Humphrey, p. 494). Starting as soon as possible, exposing the infant to textured foods

will help to facilitate acceptance of textured foods and elimination of the adversive

reflexes. Doing activities between meal times will help the therapist to establish a

relationship of trust with the child, because the child will not associate the therapist with

an unhappy event. Encouraging the infant or toddler to explore their mouth with their

hands will help them to become comfortable with touch in or around the mouth. The

therapist can also use washcloths or rubber or regular toothbrushes to rub the gums of the

infant or toddler. Dipping the toothbrushes or washcloths in food before rubbing them in

the mouth will help the infant or toddler become accustomed to the taste and texture of

different food. Firm, all-over rubbing on the infant or toddler can also help desensitize the

infant, and get them used to touch. Firm pressure sustained to the upper palate “can

desensitize the entire mouth, enabling the child to accept touch in other parts of his or her

mouth” (Case-Smith & Humphrey, p. 494). In older children, vibration may be used

around the jaw and mouth.

During mealtimes, modifying textures of the child’s food is the first intervention

to be used. Thicker foods move more slowly through the mouth and provide more

sensory input to the child, therefore, foods can be thickened or thinned depending on the

child’s needs. The therapist also needs to assess the types of utensils being used to feed

the infant or toddler. When feeding the infant or toddler, food placement on the tongue

can often dictate the child’s response to the food. Food placed on the anterior of the

tongue rather than the posterior, and food placed in the center of the tongue rather than on

22
the sides seems to be tolerated better by the child (Case-Smith & Humphrey, 2005).

Lamm, Felice, and Cargan (2005) studied swallowing in children with dysphagia and it

was found that initiating a tactile stimulus to the child’s posterior tongue caused 100% of

children studied to have an induced swallow reflex.

The interventions described above may be used during occupational therapy

treatment sessions and may be implemented into the daily routines by parents to enhance

the feeding and/or eating process at home. Interventions used for treatment will differ

for each individual child; interventions are based on the child's needs. The occupational

therapist can provide a wide range of oral motor, behavioral, and sensory interventions to

improve the child's performance in the occupations feeding and/or eating.

Parent's Perspective

During the treatment process, medical professionals need to consider the role of

both the child and the parent. Parenting children with feeding and eating difficulties may

potentially affect the parent's mental and physical health. Children with feeding and

eating difficulties may have other interrelated conditions, and these conditions have to be

taken into consideration. Parents face the challenge of balancing the multiple tasks in

managing the child's medical needs with other parental role. (Franklin & Rodger, 2003).

Mental health issues such as anxiety, depression, and stress have the potential to

become prevalent within the parent. Most parents want to ensure that their child is

receiving adequate nutrition to enhance development and growth. When the feeding

and/or eating process is disrupted for their child, parents may become anxious or

depressed; this then contributes to stress in the parent/child interaction during feeding and

23
eating. Strategies that will decrease and/or alleviate the psychological issues exhibited by

parents include implementing training and education on a variety of topics that will aide

in a positive parent/child interaction, and medical professionals should take time during

treatment to acknowledge psychological aspects affecting the parents (Franklin &

Rodger, 2003).

Parents may have physical stress because of the increased demands,

responsibilities, time, and energy it takes to parent children with feeding and/or eating

difficulties. Physically the parent may demonstrate overall fatigue, headaches, weight

gain or loss, and sleep disturbances. Parents need to take care of their physical health by

using time management skills and by getting help from others. Parents should find ways

to take time out for themselves and to balance parental roles. ( Franklin & Rodger, 2003)

It is crucial for medical professionalS to be responsive to the needs of the parents

along with their child's needs inorder to make sure treatment is not contributing to further

stressful situations and therefore inhibiting the child from making progress. When a

parent is affected physically or mentally, there are ways to assist them through the

treatment process. In order to find out this kind of information, it may be beneficial for

the medical professionals to ask parents to complete a reflective journal that can be used

to share their thoughts and help medical professionals make sure all the parents’needs are

being met during the treatment process. Medical professionals may gain insight on the

problems the parents are having through the reflective journals. Helping parent's access

appropriate professional and non-professional support networks, information, resources

and implementing training and education during the treatment process will aide in

24
treating the infant or toddler and assist parent's in developing knowledge of feeding and

eating difficulties (Hanna & Rodger, 2002).

Conclusion

Raising a child with feeding and eating difficulties can be a confusing and

stressful situation for parents or caregivers. The process of evaluation and treatment for

the child may seem overwhelming, and it is the responsibility of the occupational

therapist to help parents, as well as the child, feel as comfortable as possible. The

occupational therapist can educate and guide the parent(s) through feeding and eating

intervention as well as help them develop stress management and coping skills.

Parents are important during the treatment process since they know their child

best. The parent can provide information about their child’s behaviors that a occupational

therapist may not see in the clinical setting. The information from the parent will aide in

developing a treatment plan for the child. Parent therapist collaboration is an essential

part of the treatment process to assure all needs are being met.

25
 CHAPTER III

METHODOLOGY

The topic of pediatric feeding interventions and the parent’s role became of

interest to the authors when one of the authors was on a Level-II pediatric fieldwork at

Capable Kids in Chaska, Minnesota. The author noticed that parents and caregivers who

brought their children in for therapy were often under-educated about their child’s

feeding disorders, and they also seemed to have many questions that they didn’t have

answered. The parents were given a very large binder with information from the clinic as

well as information from textbooks and medical journals to read. Because the binder was

so overwhelming, the follow-through of parents reading it was poor. The author

determined that the parents needed a better way to communicate their questions with the

occupational therapist and also a better way to learn about their child’s feeding

difficulties.

In order to support the author’s observations and assumptions, an extensive

review of literature, including textbooks, journals, and research articles was conducted.

Several pediatric textbooks, such as Chapman Bahr’s Oral Motor Assessment and

Treatment: Ages and Stages (2001) and Ernsperger and Stegen-Hanson’s Just Take a

Bite: Easy Effective Answers to Food Aversions and Eating Challenges were reviewed.

Also, the Harley E. French Library website was used to access the PubMed literature

26
database, OTSearch literature database, Cinahl literature database, and OTSeeker

literature database. These databases provided credible articles on children with feeding

disorders, and perspectives from clinicians and parents on this subject. The American

Occupational Therapy Association website was used to access articles from the American

Journal of Occupational Therapy.

Through the literature review, it was found that an interdisciplinary team

approach is necessary for evaluation and treatment due to the complexity of eating and

feeding difficulties in infants and toddlers. Patients will have a team made up of different

professionals, and depending on the needs of the child, this team may change over time

as the child's needs change (Arvedson, 2006). This indicates that the parents will need

information on more than just the occupational therapist, and the feeding manual will

offer a place to give parents a brief description of each team member and what their part

in the treatment process may be.

Occupational therapists look at the entire occupation of feeding. “By taking a

broad view towards the activity of eating and recognizing the occupation that it

influences, occupational therapists and occupational therapist assistants include physical,

cognitive social, emotional, and cultural elements in evaluation and intervention”

(AOTA, 2000, p. 629). Feeding and eating are activities referred to as occupations, which

are various kinds of life activities that individuals engage in. Occupational therapists

must help a child with difficulties in these occupations to regain normalcy or adapt to

feeding difficulties that aren’t going to change.

27
 Having necessary information already gathered to bring to the initial occupational

therapy evaluation will allow the parents and child to maximize their time with the OT

(McNally, 2002). This knowledge set the stage for including a feeding journal in the

manual that the parents can fill out and bring to the initial evaluation. This eliminates the

need for the OT to explain this to the parent during the first visit and then have the

parents bring the journal to the next visit; the OT can then use the information from the

feeding journal the first time they see the child.

Because the initial evaluation can be stressful, giving the parent or caregiver an

idea of what to expect can help to ease stress. The manual includes a section of basic

explanations of what the parent can expect during the initial evaluation. It also includes a

description of basic diagnostic testing that could possibly be used, and basic interventions

that may be used. Finding information on a feeding disorder can be difficult if the right

resources are not known to the parent; a list of educational resources for the parents is

included at the end of the manual for the parents to consult if they want to further their

knowledge.

28
 CHAPTER IV

PRODUCT

The product developed for this scholarly project is a manual for parents of

children with oral motor deficits. The purpose of the manual is to prepare and guide

parents through the occupational therapy evaluation and treatment process. This manual

was designed for use by occupational therapists and can be presented to parents prior to

the first occupational therapy visit; it may also be used as a parent resource during

treatment.

This manual provides facts on feeding disorders, descriptions of the professionals

that provide treatment for feeding disorders and their role, and a detailed description of

the occupational therapist role. This manual also includes the following: parent activities

to prepare for occupational therapy evaluation and services, an overview of occupational

therapy treatment/interventions for children with feeding and eating disorders, a

description of instrumental assessments commonly used, and a description of the parents

role during occupational therapy services. The final section of the manual includes a

word bank, additional resources, and treatment/intervention notes pages for parents to use

during the occupational treatment process

The theory used to guide this product was Occupational Adaptation (OA).

Schkade and Schultz (2003) described their theory as a normative process that leads to

29
competence in occupational functioning. In children with feeding or eating difficulties,

this normative process may be disrupted resulting in a maladaptive response. OA sets a

foundation for the parents to be their own agent of change in feeding and eating co-

occupations. The occupational therapist is responsible for setting the stage by designing

the environment for occupational adaptation to occur. The occupational therapist will

guide the parents as they design their own occupational treatment challenges. The

occupational therapist and parent will collaborate to evaluate the response to occupational

therapy treatment. The treatment process may be altered by the parents evaluation of

whether or not they are satisfied with their performance in the co-occupations of feeding

and eating. The overall goal is for the parents and children to demonstrate increased

functional independence in the co-occupations of feeding and eating. The following

section of this chapter contains the product in its entirety.

30
 Occupational Therapy
Feeding and Eating Manual
for Parents of Children
with Oral Motor Deficits
By Jessica Kovacevich and Genevieve Ziegler
Advisor: Gail Bass, Ph. D, OTR/L

31
 Table of Contents

Introduction..............................................................................................................3

Feeding Disorder Facts............................................................................................5

The Treatment Team................................................................................................7

Occupational Therapist Role....................................................................................9

Preparing for Occupational Therapy......................................................................11

The initial evaluation.............................................................................................22

Diagnostic tests......................................................................................................23

Initial evaluation summary....................................................................................25

Treatments/Interventions.......................................................................................26

Parent Role.............................................................................................................29

Definitions..............................................................................................................30

Additional Resources.............................................................................................32

Treatment/Intervention Notes................................................................................35

References..............................................................................................................50

32
 Introduction

The following manual is a manual designed to help you through the occupational therapy

evaluation/treatment process. There is information on basic feeding disorders, the

treatment team you will be working with, how to prepare for the occupational therapy

sessions, assessments that may be used, and basic interventions that occupational

therapists use. Included in this manual are forms to fill out to bring with you to the initial

therapy evaluation. These forms will help the occupational therapist develop a plan for

evaluation and treatment of your child. By completing the forms at home, it will be easier

for you, and you will have more time to think about your answers, making them more

accurate. The journal is helpful because your child is going to act differently in the clinic

than at home, and the history forms help the therapist see your child through your eyes

rather than just from medical chart information. There are pages at the end of this manual

with blank lines for notes; these notes can be taken both at home and during the treatment

session and then discussed with the occupational therapist. Additional resources that may

be helpful to you and your child are included. If you have any questions when filling out

the forms, don't hesitate to call your occupational therapist.

33
 Feeding Disorder Facts

Definitions

o The term "feeding disorder" refers to a condition in which an infant or child is

unable to or refuses to eat, or has difficulty eating; this can result in frequent
illnesses, failure to grow normally, and even death.
o “Feeding disorders” are different than an “eating disorder” such as anorexia
which are more common in adolescence and adulthood.

Prevalence

o The incidence of minor feeding problems ranges from 25% to 35% in normal
children and 40% to 70% in infants born prematurely or children with chronic
medical conditions (Rudolph & Thompson Link, 2002).

Feeding problem effects on children are:

o Dehydration
o Poor nutrition
o Risk of aspiration (food or liquid entering the airway or ‘going down the
wrong way’)
o Pneumonia
o Repeated chest infections that can lead to chronic lung disease
o Embarrassment or isolation in social situations involving eating

34
 Feeding Disorder Facts (continued)

Causes
There are a variety of medical conditions that can cause feeding disorders.

Listed below are common medical conditions that may be a cause of feeding difficulties:
o Prematurity/ low birth weight
o Conditions affecting the airway, such as chronic neonatal lung disease
o Heart disease
o Cleft lip or palate
o Nervous system disorders
 Cerebral palsy
 Meningitis
 Encephalopathy
o Developmental delays
o Abnormal oral structures such as a large tongue
o Prenatal malformations of the digestive tract, such as esophageal atresia
o Oral sensitivity that can occur in very ill children who have been on a
ventilator for a prolonged period of time
o Irritation of the vocal cords after being on a ventilator for long period of
time
o Paralysis of the vocal cords
o Having a tracheostomy (artificial opening in the throat for breathing)
irritation or scarring of the esophagus or vocal cords by acid in
gastroesophageal reflux disease (GERD)
o Compression of the esophagus by other body parts, such as the heart,
thyroid gland, blood vessels, or lymph nodes

(Adapted from Penn State University Children's Hospital; Arvedson, 2006; & Rudolph, 2002)

35
 The Treatment Team

Every child will have a team made up of different professionals, and depending on the
needs of the child, this team may change over time as the child's needs change. The team
members possess different roles dependent on their profession. Listed below are
professionals that commonly work with children who have feeding disorders.

Pediatrician
o The pediatrician is the medical leader who examines the child to
determine if there is a specific diagnosis or problem that is having an
impact on the child’s eating and feeding
o They may prescribe or administer treatments necessary for the individual
child's case
o Pediatricians may also refer the child to other medical professionals such
as occupational therapists for treatment of the feeding and/or eating
difficulty

Psychologist
o Identifies and treats psychological and behavioral problems. Examples of
these behaviors during eating are gagging, vomiting, and spitting.
o Psychologists examine the parent-child relationship interactions during
mealtimes

Speech language pathologist

o Evaluates the child's oral-motor functions required for eating
o Evaluates the child's communicative signals during feeding and eating

Dietitian
o Looks at past and current diets of the child to determine nutritional needs
o The dietitian may design specific meals to meet the nutritional needs of
the child
o Ongoing monitoring of the child's diet will be necessary to make sure the
child is receiving the nutrition needed to support healthy growth and
development

36
 The Treatment Team (continued)

Nurse
o The nurse is often the main coordinator for the treatment team
o The nurse reviews and records information gathered by the parents and/or
caregiver prior, during, and after clinic visits.
o Nurses are seen more in an acute inpatient or clinical setting and not in an
outpatient setting

Occupational Therapist
o The occupational therapist treats problems related to abnormal posture,
tone, motor function, oral motor structures, and self-feeding.
o The occupational therapist’s role often overlaps with the speech language
pathologist

Parents/caregivers
o Parent's and/or caregivers are part of the treatment team
o They offer knowledge and share observations of their child's feeding and
or eating difficulties to assist the medical professional with the treatment
process.

(Adapted from Miller, Burklow, Santor, Kirby, Mason, & Rudolph, 2001; Arvedson, 2006 )

37
 Occupational Therapist Role

All team members are important for treatment of an eating and/or feeding disorder, but
the role of the occupational therapist during the treatment process will be the main focus
for this manual.

Feeding and eating are activities referred to as occupations, which are various kinds of
life activities that individuals engage in. An occupational therapist’s main goal for
treatment is to increase engagement in occupations that are disrupted; this is the case with
infants and toddlers who have feeding and eating difficulties. Occupational therapists
offer a wide range of skills to evaluate and treat these children.

THE TREATMENT PROCESS

Referral
o A referral comes from a physician or other medical professional
recommending further evaluation of your child's feeding and eating
conditions.

Evaluation
o The occupational therapist will conduct a formal evaluation to gather
information about your child. This may include clinical observation and
the use of assessment tools that focus on identifying your child's abilities
and limitations in their daily feeding and eating.

Determine if there is a need for occupational therapy

o Based on the findings of the evaluation, the therapist may or may not
recommend further occupational therapy services for your child. If further
services are recommended, the therapist will help you to set up a treatment
schedule.

38
 Occupational Therapist Role (continued)

Interventions to achieve your child's set goals for feeding and eating
o Occupational therapy interventions, based on the findings of the initial
evaluation, will be implemented to help reach the goals set for your child
by you and your therapist.

Re-evaluation to determine the child's progress

o Throughout the treatment process, the occupational therapist will re-
evaluate your child to document their progress in feeding and eating. The
re-evaluation findings will be used to revise and/or set new goals for your
child.
(Adapted from Willard & Spackman, 2003; AOTA, 2002)

(Microsoft Office Online, 2006)

39
 Preparing for Occupational Therapy

During the initial evaluation, it is important to share as much information as possible

about your child; this includes a feeding and eating history. It is easiest to keep a journal
or notebook of this information for organizational purposes. Information gathered for the
journal/notebook should include:

Medical history
o Diagnostic testing
o Surgeries with dates
o Previous and current medications
o Previous therapy received

Feeding and eating journal

o A journal is kept to write down observations noticed during eating and/or
feeding
o Observations may include:
o Types of food your child eats or drinks
o Amounts of food your child eats and drinks
o Mealtime behaviors
o Mealtime interactions with others
o Frequency of vomiting, gagging, or coughing episodes

Film of a mealtime
o This is a 30 minute videotape of your child during a mealtime
o The video captures the child's typical responses at home and offers the
occupational therapist with an understanding of mealtimes at home
o The video is used to compare behaviors and problems in different settings;
children may act differently in a new setting with unfamiliar individuals.

(Adapted from McNally, & Evans Morris, 2002)

40
 Medical History

The following pages are designed to help you record this information in preparation for
the initial evaluation with an occupational therapist.

Please fill in the blanks prior to the initial evaluation with the occupational therapist.

CHILD'S NAME:__________________________________________________________________

DATE OF BIRTH:_________________________________________________________________

DOCTOR'S NAME:________________________________________________________________

CURRENT HEIGHT AND WEIGHT:________________________________________________

DIAGNOSTIC TESTING/RESULTS:
Diagnostic tests are procedures which gives a rapid and convenient indication of whether
a patient has a certain disease.
__________________________________________________________________________________

__________________________________________________________________________________

__________________________________________________________________________________

__________________________________________________________________________________

__________________________________________________________________________________

__________________________________________________________________________________

SURGERIES AND DATES:

__________________________________________________________________________________

__________________________________________________________________________________

__________________________________________________________________________________

__________________________________________________________________________________

__________________________________________________________________________________

__________________________________________________________________________________

__________________________________________________________________________________

__________________________________________________________________________________

41
 Medical History (continued)

CURRENT MEDICATIONS:
__________________________________________________________________________________

__________________________________________________________________________________

__________________________________________________________________________________

__________________________________________________________________________________

__________________________________________________________________________________

__________________________________________________________________________________

__________________________________________________________________________________

__________________________________________________________________________________

PREVIOUS THERAPY RECEIEVED:

__________________________________________________________________________________

__________________________________________________________________________________

__________________________________________________________________________________

__________________________________________________________________________________

__________________________________________________________________________________

__________________________________________________________________________________

__________________________________________________________________________________

__________________________________________________________________________________

__________________________________________________________________________________

ALLERGIES:
__________________________________________________________________________________

__________________________________________________________________________________

__________________________________________________________________________________

42
 Feeding/Eating History

Is your child still nursing or using a bottle (if no, how old was your child when he/she

stopped)?_________________________________________________________________________

In your opinion, were there any problems with early nursing or bottle feeding?

__________________________________________________________________________________

__________________________________________________________________________________

When were solid foods started (age) & what was given first?_______________________________

__________________________________________________________________________________

__________________________________________________________________________________

In your opinion, how did your child do with his/her first solid food?________________________

__________________________________________________________________________________

__________________________________________________________________________________

How often does your child drink or eat?________________________________________________

__________________________________________________________________________________

__________________________________________________________________________________

__________________________________________________________________________________

How long does it take your child to complete a meal or snack?_____________________________

__________________________________________________________________________________

__________________________________________________________________________________

What foods or liquid does your child have for:

Snack:____________________________________________________________________________

__________________________________________________________________________________

__________________________________________________________________________________

43
 Feeding/Eating History
Breakfast:_________________________________________________________________________

__________________________________________________________________________________

__________________________________________________________________________________

__________________________________________________________________________________

Lunch:____________________________________________________________________________

__________________________________________________________________________________

__________________________________________________________________________________

__________________________________________________________________________________

Dinner:___________________________________________________________________________

__________________________________________________________________________________

__________________________________________________________________________________

__________________________________________________________________________________

Who feeds or is with your child during meals or snacks?__________________________________

__________________________________________________________________________________

__________________________________________________________________________________

Where is your child fed or where does your child eat (in a lap, highchair, etc)?

__________________________________________________________________________________

__________________________________________________________________________________

Is your child able to drink from a cup? If so, what kind?__________________________________

__________________________________________________________________________________

__________________________________________________________________________________

Is your child able to feed him/herself?__________________________________________________

Is your child able to use any feeding utensils? If so, what kind?____________________________

__________________________________________________________________________________

44
 Feeding/Eating History
Are you using any special equipment with your child? (special bottles, nipples, spoons, plate,

etc)_______________________________________________________________________________

__________________________________________________________________________________

__________________________________________________________________________________

Does your child eat/drink in settings other than at home, and if so, where?___________________

__________________________________________________________________________________

__________________________________________________________________________________

__________________________________________________________________________________

__________________________________________________________________________________

Does your child's feeding behaviors change if he/she is somewhere other that at home?

__________________________________________________________________________________

__________________________________________________________________________________

__________________________________________________________________________________

__________________________________________________________________________________

Does anything make your child's feeding behavior:

Better:____________________________________________________________________________

__________________________________________________________________________________

__________________________________________________________________________________

__________________________________________________________________________________

Worse:____________________________________________________________________________

__________________________________________________________________________________

__________________________________________________________________________________

__________________________________________________________________________________

45
 Feeding/Eating History

What are your concerns about your child's ability to eat and/or drink?______________________

__________________________________________________________________________________

__________________________________________________________________________________

__________________________________________________________________________________

__________________________________________________________________________________

__________________________________________________________________________________

__________________________________________________________________________________

__________________________________________________________________________________

During feeding and drinking:

What has worked for you and your child?______________________________________________

__________________________________________________________________________________

__________________________________________________________________________________

__________________________________________________________________________________

__________________________________________________________________________________

__________________________________________________________________________________

__________________________________________________________________________________

What has not worked for you and your child?___________________________________________

__________________________________________________________________________________

__________________________________________________________________________________

__________________________________________________________________________________

__________________________________________________________________________________

__________________________________________________________________________________

__________________________________________________________________________________

46
 Feeding and Eating Journal

While completing this journal, please note any abnormal observations you have noticed
during eating and feeding. Please include a description and date of the observation.

Types of food and liquid your child prefers to eat or drink

Date Observation
Ex: 8/ Ex: 8/25Applesj Applesauce , yogurt, pudding, etc.

Types of food and liquid your child refuses to eat or drink

Date Observation
Ex: Ex: 8/25Ap Applesauce, yogurt, pudding, etc.

47
 Feeding and Eating Journal (continued)

Amounts of food and liquid your child eats or drinks

Date Observation
Ex: 8/25 ½ glass of milk, ½ cup of Fruit Loops, 2 chicken fingers, etc.

Mealtime behaviors

Date Observation
Ex: 8/25 Cries When forced to eat yogurt, pushes plate away, is distracted by other people
eating, etc.

48
 Feeding and Eating Journal (continued)

Vomiting, gagging, or coughing episodes

Date Observation
Ex Ex: 8/25 Gags when eating peanut butter, coughs being fed by bottle, etc.

Mealtime interactions with others

Date Observation
Ex: 8/25 T Throws food at others, gets distressed when others join mealtime, etc.
8/25

49
 Feeding and Eating Journal (continued)

Other
Date Observation

(Microsoft Office Online, 2006)

50
 The Initial Evaluation

Prior to the visit the registered occupational therapist will review past medical history
that is important to the treatment process.

The initial evaluation may include assessing a variety of feeding and eating components.
These components may include:
o Oral motor function
o Muscle tone
o Posture
o Sensory response
o Behavior
o Self-feeding ability
o Parent-child interactions
o Social and environmental components
o The child's physical abilities (including fine and gross motor)

These components may be evaluated with:

o A clinical observation of feeding and/or eating
o A formal or informal assessment
o Diagnostic testing

CLINICAL OBSERVATION
The clinical observation is when the therapist observes your child feeding and/or eating
to determine strengths, weaknesses, and deficits.

DIAGNOSTIC TESTS
Diagnostic tests are instruments or tools used by the occupational therapist to determine
strengths, weaknesses, and deficits. A description of diagnostic tests that may be used for
ongoing evaluation are on the following pages.

51
 Diagnostic tests for swallowing

Diagnostic tests may be recommended beyond the initial evaluation with the occupational
therapist. Below are descriptions of diagnostic tests used with the pediatric population.

Videofluoroscopic study (VFSS)

o VFSS is the most common instrumental assessment used

o The VFSS is used to evaluate your child's swallow
o Helps determine the safety of the swallow during eating

The VFSS is an x-ray that lets the professionals observe the structures and muscles your
child uses when eating a variety of foods and liquids. The x-rays shows where the food
goes once your child swallows. Specifically the professionals are looking for the presence
or absence of aspiration (which is when the food enters the airway), how much energy is
needed, and how long it takes for your child to eat.

During the study your child will eat different consistencies of food and liquids. The
professional observing will be able to see how your child manages these different
consistencies.

(Adapted from Miller, Wilging, 2003; DeMatteo, Matovich, & Hjartarson, 2005)

52
 Diagnostic tests for swallowing (continued)

Fiberoptic endoscopic (FEES)

o Examines the inside part of the digestive tract

FEES is a test that uses a small, flexible tube with an endoscope at the end of it. The
endoscope is a light and a camera lens used to take pictures of the surrounding area. to
examine the inside of part of the digestive tract. An endoscopy is performed while your
child is under anesthesia. Pictures may be taken inside the throat, the esophagus, and the
stomach to look for abnormalities in the digestive tract. There is also a possibility to take
biopsies to look for problems. Biopsies are small tissue samples.

( Adapted from Miller, Wilging, 2003; Mayo Clinic Online,)

(Microsoft Office Online, 2006)

53
 Initial Evaluation Summary

The initial evaluation may be a brief process or it may be extensive and time consuming,
based on your child’s strengths and deficits. The occupational therapy will interpret the
initial evaluation results to guide the treatment process.

Below is space to write notes of the occupational therapist recommendations and

information presented during the initial evaluation.

NOTES

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54
 Treatment/ Intervention

The occupational therapist will determine what types of treatment/interventions your

child needs to improve feeding and eating function. Below are explanations of common
treatments/interventions used by occupational therapists. At the end of this manual there
is space for notes to write down additional information learned through the treatment
process. This may include observations, instructions for home programs given by the
occupational therapist, etc.

Oral Massage

Oral massage is used to increase the child's awareness of oral motor structures, or to
decrease atypical responses by the child, such as gagging or bite reflexes. Massage may
be done with a finger, if the child’s mouth is very small, a nuk brush, which is a small
rubber brush with soft bristles on the end, or a washcloth may be used. The therapist will
begin by massaging an area on the child that is not sensitive to get the child used to the
therapist’s touch. The therapist will then work their way to the child’s mouth. The
therapist will provide gentle but firm pressure to the areas around and in the child’s
mouth.

Oral Exploration

Oral exploration is a normal phase for an infant or toddler to go through in order to

explore different objects. Most infants start to mouth hands, feet, and other objects
around 5-7 months of age. When infants skip this step, it can produce hypersensitivity or
other deficits in oral motor functioning. Therapists may have infants or toddlers who do
not mouth objects on their own practice in the clinic. This can be done by lying the infant
or toddler on their side where they can easily reach their hands or feet, or may be done by
providing toys, food, or other objects for the child to mouth. The therapist may physically
assist the child to mouth and explore objects and foods.

55
 Treatment/ Intervention (continued)

Positioning

Different positions that a child is placed in can have an impact on the functioning of their
oral motor movements. A therapist may work on positioning with your child to determine
the best position for the child to maximize oral motor functioning. The therapist may use
different chairs, cushions, and bolsters to position your child. The therapist will both
encourage and discourage specific positions to use when feeding your child at home. The
therapist will also work with you on different ways to hold your child, in order to
maximize comfort and functioning for the child.

Handling Techniques

Based on your child's oral motor strengths and deficits the occupational therapist may use
different handling techniques on your child's jaw and throat. Handling techniques are
when the therapist supports the jaw or mouth with their fingers or hands to facilitate
normal eating patterns. The therapist may support the child's jaw to encourage normal
chewing patterns. Support to the jaw also helps if your child does not have the muscle
strength or oral motor control to perform eating tasks independently. The therapist may
put pressure on the front of the chin to facilitate chin tuck, which in turn facilitates
normal swallowing. Handling may also include using utensils in a certain way, placing
them in a certain position to facilitate normal eating.

56
 Treatment/ Intervention (continued)

Feeding equipment

To promote oral motor function the occupational therapist may recommend different
bottles or feeding utensils to best fit your child's needs. For example they may
recommend a different nipple size or shape, or a special spoon, cup, or plate. Different
utensils may be recommended in order to maximize independence for the child during
feeding and eating.
(Case-Smith, & Humphry, Ch 14, 2005; Chapman Bahr, 2001)

(Microsoft Office Online, 2006)

57
 Parent Role

o Write down as much information as you can about the observations you
make at home before and during the treatment process.

o Ask questions. There is no such thing as a stupid question.

o When you are ready, there are additional resources you can use to help
you and your child. Don't be afraid to bring resources into occupational
therapy treatment sessions for clarification.

o Complying with home programming suggestions given to you by the

therapist will ensure your child's feeding and eating treatments will carry
over into all environments. Therapy sessions are only a few hours a week,
and to maximize benefits from services suggestions should be
implemented at home.

o If you are having difficulty implementing interventions at home, be sure to

talk to your therapist, and together you may be able to work out a routine
that fits your family schedule.

o Voice your concerns; your therapist is there to help you and your child.
Every parent has good times and stressful times, and it is important to
keep your therapist informed about how you are doing.

58
 Definitions

Aspiration
When the food enters the airway

Assessment
A specific strategy or tool occupational therapists use to gather the evaluation
information

Biopsies
Small tissue samples

Dysphagia
Difficulty in swallowing

Informal assessment
A procedure for obtaining information that can be used to make judgments about
characteristics of the child by using means other than standardized instruments.

Endoscope
A flexible tube with a light and a camera lens on the end used to take pictures of the
surrounding area

Evaluation
The entire process of gathering information

Fine motor skills

Small movements (such as grabbing something with your thumb and forefinger ) that use
the small muscles of the fingers, toes, wrists, lips, and tongue

59
 Definitions

Formal assessment
Assessment instruments which are standardized and norm-referenced and are
administered under controlled conditions

Gross motor
Gross motor skills are the bigger movements (such as running and jumping) that use the
large muscles in the arms, legs, torso, and feet

Hypertonia
Excessive muscle tone or tension resulting in slow, rigid, movements and sometimes
limited range of movement

Hypotonia
Low muscle tone, floppiness, or lack of tension, in the muscles when a body part is
moved

Intervention
The term used for the processes and methods that occupational therapists use to help their
clients achieve desired occupational performance in their valued activities

Muscle tone
Mild continuous contraction of the muscle tissue in its resting state; resistance to stretch

Oral-motor
Relating to the muscles of the mouth and/or mouth movements.

(Adapted from Willard & Spackman, 2003; AOTA, 2002; Case-Smith, & Humphry, Ch 14, 2005)

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 Additional Resources

BOOKS

o Child of Mine, Feeding with Love and Good Sense (2000)

By Ellyn Satter
o Ellyn Satter's Nutrition and Feeding for Infants and Children,
Handout Masters (1995, with 1997 updates)
By Ellyn Satter
o Feeding Your Child: The Braelton Way.
By Berry Brazelton and Joshua Sparrow
o Secrets of Feeding a Healthy Family (1999)
By Ellyn Satter
o Just Take a Bite: Easy, Effective Answers to Food Aversions and
Eating Challenges
By Lori Ernsperger, PH. D and Tania Stegen-Hanson, OTR/L

(Microsoft Office Online, 2006)

61
 Additional Resources (continued)

WEBSITES

o American Speech-Language-Hearing Association

 www.asha.org
o Additional medical terminology
 www.medterms.com
o Dysphagia Factsheet
 http://www.nidcd.nih.gov/health/voice/dysph.asp
 Overview of dysphagia - definition, causes, and
research
o Magic Foundation for Children's Growth
 http://www.magicfoundation.org/
 Support for growth hormone therapy. Online
brochures on a number of disorders related to growth,
including premature puberty, intrauterine growth
retardation, etc.
o Mailing Lists for Feeding Issues of Children
 http://www.comeunity.com/disability/speclists.html#f
eeding
 Recommended parent discussion lists about feeding
difficulties in young children.
o Marcus Institute, Emory University
 http://www.marcus.org
 Information on feeding disorder programs for young
children, and several articles.

62
 Additional Resources (continued)

o Mayo Clinic
 www.mayoclinic.org
o New Visions
 http://www.new-vis.com
 Articles by Suzanne Evans Morris, Ph.D., an speech
pathologist specializing in feeding therapy. List of
articles.
o Small Wonders - A Preemie Place
 http://hometown.aol.com/Lmwill262/index.html
 Laura Williams' website has feeding tips and stories for
parents of children born premature.

(Microsoft Office Online, 2006)

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 Intervention Notes
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 Intervention Notes
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 Intervention Notes
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 Intervention Notes
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 Intervention Notes
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 Intervention Notes
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 Intervention Notes
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 Intervention Notes
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 Intervention Notes
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 Intervention Notes
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 References

American Occupational Therapy Association. (2002). Occupational therapy practice framework:

Domain and process. American Journal of Occupational Therapy, 56, 609-639.

Arevedson, J. (2006). Swallowing and feeding in infants and young children. Goyal & Shaker GI Motility
Online. Retrieved September, 9, 2006 from
http://www.nature.com/gimo/contents/pt1/full/gimo17.html

Chapman Bahr, D. (2001). Oral motor assessment and treatment: Ages and stages. Needham Heights, MA:
Allyn & Bacon.

Case-Smith, J. & Humphrey, R. (2005). Feeding Interventions. In J. Case-Smith, Occupational therapy for
children (pp. 481-519). St. Louis, Missouri: Elsevier Mosby.

DeMatteo, C., Matovich, D., & Hjartarson, A. (2005). Comparison of clinical and videofluoroscopic
evaluation of children with feeding and swallowing difficulties. Developmental Medicine & Child
Neurology, 47, 149-157.

Evans Morris, S., & Dunn Klein, M. (2000). Mealtime Assessment. In S. Evan Morris & M. Dunn Klein,
Pre-feeding Skills ( pp. 175-183). San Antonio, TX: Therapy Skill Builders.

McNally, K., Morris, S.E.. (2006). Finding an appropriate treatment program for children with feeding
difficulties: a guide for parents. Retrieved September 9, 2006.

Miscrosot Office Online (2006). Clip Art retrieved November 28, 2006 from ttp://office.microsoft.com

Miller, C., Burklow, K., Santoro, K., Kirby, E., Mason, D., & Rudolph, C. (2001). An
interdisciplinary team approach to the management of pediatric feeding and swallowing disorders.
Children's Health Care, 30(3), 201-218.

Miller, C.K., Willging, J.P. (2003). Advances in the evaluation and management of pediatric
dysphagia. Current Opinion on Otolaryngology & Head and Neck Surgery, 11, 442-446.

Penn State Milton S. Hershey Medical Center (2004). Feeding Disorders, retrieved November 18,
2006 from http://www.hmc.psu.edu/childrens/healthinfo/f/feeding.htm

Rudolph, C., & Thompson Link, D. (2002). Feeding disorders in infants and children. Pediatric
Gastroenterology and Nutrition, 49 (1), 112.

80
 CHAPTER V

SUMMARY

The purpose of this scholarly project was to develop a manual for parents of

children with oral motor deficits that prepares and guides them through the occupational

therapy evaluation and treatment process. An exhaustive review of current literature and

research was conducted in order to provide a basis of validity for the manual. The

literature supports the need for parent-friendly occupational therapy services and

educational preparation for parents.

The parent manual includes information on feeding disorder facts, descriptions of

the professionals that provide treatment for feeding disorders, and a detailed description

of the occupational therapist’s role. This manual also includes the following: parent

activities to prepare for occupational therapy evaluation and services, an overview of

occupational therapy treatment/interventions for children with feeding and eating

disorders, a description of instrumental assessments commonly used, and a description of

the parents role during occupational therapy services. The final section of the manual

includes a word bank, additional resources, and treatment/intervention notes pages for

parents to use during the occupational treatment process.

The product is designed for use by the occupational therapist in a clinic or

hospital outpatient setting. The occupational therapist should have knowledge and skills

in the area of feeding and eating deficits. The product is designed to give to parents prior

81
to the first occupational therapy session. The manual may be given to the parents by the

referring physician or when parents set-up an appointment for the initial occupational

therapy evaluation at the facility. Use of the manual will help them prepare for

occupational therapy evaluation and treatment. Occupational therapists may also use this

manual as a parent resource during treatment to provide parents with educational material

on occupational therapy evaluation and treatment for feeding and eating oral motor

deficits. Parents can refer to the manual for definitions and explanations of therapy

techniques. The additional notes pages provide the parent or therapist with space to

record treatment or home programming notes; parents will be able to keep information

organized in one manual to alleviate potential stressors.

A limitation of the product is that it has not been used clinically by an

occupational therapist to determine the effectiveness. It is recommended that research be

done to determine the effectiveness of the manual when used in a clinical setting. In

addition, more evidence-based research in the area of evaluation and treatment of feeding

and eating disorders for children should be completed. The use of evidence-based

practice will optimize the child's experience by using researched evaluation and treatment

strategies to increase feeding and eating function.

According to literature reviewed in Chapter II, parent participation and

compliance is directly correlated with their understanding of feeding disorders; when the

parents do not understand information presented by the occupational therapist it is

difficult to comply with recommendations. Attending occupational therapy services for

their child is a disruption in their daily lives. Treatment and home programming

82
recommendations given to parents by the occupational therapist takes up additional time

during the day, and parents are required to adjust their schedules to meet the needs of

their child with feeding and eating disorders. The literature indicates that parents

appreciate guidance from professionals throughout the treatment process, and that printed

information should be written in parent-friendly terms. It is hoped that these needs can be

addressed through the use of this manual.

83
 REFERENCES

American Occupational Therapy Association. (2000). Specialized knowledge and

skills in eating and feeding for occupational therapy practice. American Journal of
Occupational Therapy, 54, 629-640.

American Occupational Therapy Association. (2002). Occupational therapy practice

framework: Domain and process. American Journal of Occupational Therapy, 56,
609-639.

Arevedson, J. (2006). Swallowing and feeding in infants and young children. Goyal &
Shaker GI Motility Online. Retrieved September, 9, 2006 from
http://www.nature.com/gimo/contents/pt1/full/gimo17.html

Burklow, K., Phelps, A., Schultz, J., McConnell, K., & Ruldolph, C. (1998). Classifying
complex pediatric feeding disorders. Journal of Pediatric Gastroenterology and
Nutrition, 27 (2), 143- 147.

Chapman Bahr, D. (2001). Oral motor assessment and treatment: Ages and stages.
Needham Heights, MA: Allyn & Bacon.

Case-Smith, J. & Humphrey, R. (2005). Feeding Interventions. In J. Case-Smith (Ed.),

Occupational therapy for children (pp. 481-519). St. Louis, Missouri: Elsevier
Mosby.

DeMatteo, C., Matovich, D., & Hjartarson, A. (2005). Comparison of clinical and
videofluoroscopic evaluation of children with feeding and swallowing difficulties.
Developmental Medicine & Child Neurology, 47, 149-157.

Ernsperger, L., &Stegen-Hanson, T. (2004). Just take a bite: Easy effective answers to
food aversions and eating challenges. Arlington, TX: Future Horizons Inc.

Evans Morris, S., & Dunn Klein, M. (2000). Mealtime Assessment. In S. Evans Morris &
M. Dunn Klein, Pre-feeding Skills (pp. 175-183). San Antonio, TX: Therapy
Skill Builders.

84
Franklin, L., & Rodger, S. (2003). Parents perspectives on feeding medically
compromised children: Implications for occupational therapy. Australian
Occupational Therapy Journal, 50, 137-147.

Hanna, K., & Rodger, S. (2002). Towards family-centered practice in paediatric

occupational therapy: review of the literature on parent-therapist collaboration.
Australia Occupational Therapy Journal, 49, 14-24.
Linscheid, T. (2006). Behavioral treatments for pediatric feeding disorders. Behavior
Modification, 30 (1), 6-23.

McNally, K., Morris, S.E.. (2006). Finding an appropriate treatment program for children
with feeding difficulties: a guide for parents. Retrieved September 9, 2006

Manikam, R., & Pesrman, J. A. (2000). Pediatric feeding disorders. Journal of Clinical
Gastroenterology, 30,1:34-46.

McCurtin, A. (1997). The manual of pediatric feeding practice. Bicester Oxon, United
Kingtdom: Winslow Press Ltd.

McNally, K., Morris, S.E.. (2006). Finding an appropriate treatment program for children
with feeding difficulties: a guide for parents. Retrieved September 9, 2006.

Miscrosot Office Online (2006). Clip Art retrieved November 28, 2006 from
http://office.microsoft.com

Miller, C., Burklow, K., Santoro, K., Kirby, E., Mason, D., & Rudolph, C. (2001). An
interdisciplinary team approach to the management of pediatric feeding and
swallowing disorders. Children's Health Care, 30(3), 201-218.

Miller, C.K., Willging, J.P. (2003). Advances in the evaluation and management of
pediatric dysphagia. Current Opinion on Otolaryngology & Head and Neck
Surgery, 11, 442-446.

Penn State Milton S. Hershey Medical Center (2004). Feeding Disorders, retrieved
November 18, 2006 from
http://www.hmc.psu.edu/childrens/healthinfo/f/feeding.htm

Rommel, N., De Meyer, A., Feenstra, L., Veereman-Wauters, G. (2003). The complexity
of feeding problems in 700 infants and young children presenting to a tertiary care
institution. Journal of Pediatric Gastroenterology and Nutrition, 37, 75-84.

Rudolph, C., & Thompson Link, D. (2002). Feeding Disorders in Infants and Children.
Pediatric Gastroenterology and Nutrition, 49 (1), 112.

85
Schkade, J.K., & Schultz, S. (2003). Occupational Adaptation. In P. Kramer, J. Hinojosa,
& C. Brasic Royeen (Eds.), Perspectives in human occupation: Participation in
life. Philadelphia, PA: J.B. Lippincott.

Schuktz-Krohn. (2006). Feeding and eating for infants and toddlers. OT Practice, 11 (9),
16-20.

Woolston, J. (1991). Eating and growth disorders in infants and children. Developmental
Clinical Psychology and Psychiatry, 24, 1-85.

86