A two-year-old in our setting has had trouble feeding himself and his language is delayed. Someone mentioned that he might have oral-motor problems. Is this a possible cause and how should we respond?
Messy eating and language delay are not uncommon in two-year-olds, so while oral-motor problems - of which more later - cannot be ruled out, the causes are just as likely to lie in the child's daily routines and normal patterns of development.
Start by considering mealtime routines, both in the nursery and at home, and ask yourself:
- Is the child being expected to eat more than he wants?
- Are the distractions in the nursery putting him off his food? Is he too tired to eat?
- Does he have toothache or pain in his mouth?
- Is he not hungry? Was his last snack too close to mealtime?
- Is he not accustomed to sitting at the table?
- Is he not used to having new foods introduced into his diet?
If the answer to any of these questions is 'yes', you could make appropriate adjustments to the way in which food is offered. If the child is too tired, you could feed him a little earlier than usual. If he is distracted by what is going on, he could sit with a smaller group of children and with one-to-one adult support to keep him on task. If snacks are offered cafeteria-style, you need to ensure he is not grazing throughout the morning and filling up on drinks of milk.
Many children come into a nursery setting unused to having to sit at a table to eat. Two-year-olds do not like being still for a long time so you need to ensure that the children do not have to sit and wait for too long for food to be served and cleared away.
Finally, if he has been offered a very limited choice of foods at home, it is likely that he will often refuse something new and different at nursery. Here, you will need to introduce things slowly, building on what he likes and allowing him to eat with his fingers if he wishes and progress in time to using cutlery.
NORMAL BEHAVIOUR?
Next, consider whether this little boy is asserting his normal 'two-year-old' self and doing it in a way that two-year-olds do, by refusing certain foods. Fussy eating is one of the most common feeding problems and a normal stage of development that all toddlers will pass through. Refusing some foods is a way of asserting themselves, so if the child has become fussy about what he eats, whereas before he would eat virtually anything, then take this as normal two-year-old behaviour.
As with introducing new foods, you will need to take things slowly. It is important not to try to hurry him along by trying to spoon food into his mouth. If food offered at mealtimes is rejected, it should be removed without comment, and don't allow more food before the next planned snack or meal time.
Another aspect of development to bear in mind for children of this age is mouth stuffing. Around the age of 24 months, children suddenly discover the size of their mouth cavity and experiment with seeing how much food they can pack into it and how, by keeping their lips closed, they can feel the pressure of the food against their cheeks and palate. Once they have experimented with this new sensory experience, the novelty will wear off and they will resume eating normally. Mouth stuffing which goes on for some time may, however, indicate oral-motor or sensory-control problems.
MOTOR AND SENSORY CONTROL
Oral-motor skills involve the use of tongue, cheeks, lips and jaw muscles - all critical for chewing, drinking and speaking well. Problems may stem from muscles in the mouth either not receiving or misinterpreting messages from the brain. Another reason may be poor muscle tone.
Poor jaw muscles may result in an open mouth, dribbling and difficulty chewing and swallowing. Poor tongue muscles may make moving the tongue from side to side and up and down difficult, while weak lip muscles may make lip-puckering hard and drinking from a cup or through a straw challenging.
Dribbling and mouth stuffing can occur in children described as being hypo-sensitive. They will often stuff their mouths full as they lack the normal sensation that they need to swallow before putting more in, and will only stop when they begin to gag or cough. Hypo-sensitive children will possibly have very rigid, tight lips and hate having their mouths touched or teeth brushed and may become very upset about certain food textures.
Then there are possible sensory problems to consider. A child with low levels of oral sensation and poor awareness of the size of his mouth cannot feel that there is something in it unless it is very full. A child with oral defensiveness finds the movement of food around their mouth and certain tastes and textures extremely unpleasant and uncomfortable. By overfilling the mouth, the movement of food is reduced.
NEXT STEPS
It is critical to have built up a good relationship with the child's parents/carers if you want to discuss any concerns that you have about their child's development. You need to find out if the child has always had problems feeding; for example:
- Did he choke or cough when being bottle or breast-fed? Often a child with oral-motor difficulties will have had problems of coughing and choking while being bottle or breast-fed
- Has he always disliked certain food textures?
If you and the parents believe that the child may have oral-motor difficulties or sensory defensiveness, it is very important to arrange a referral to a speech and language therapist who, after assessment, will make a diagnosis and provide guidelines for you and the parents to follow.
If a referral is seen as necessary for this child, experts may want to check for the motor disorder apraxia of speech - sometimes called verbal apraxia, developmental apraxia of speech, or verbal dyspraxia. Children with this condition have great difficulty planning and producing the precise, highly refined and specific series of movements of the tongue, lips, jaw and palate that are necessary for intelligible speech.
Even an experienced speech and language therapist will have difficulty making a diagnosis of verbal apraxia in a two-year-old and will have to carry out a series of tests to check whether the child does indeed have oral-motor problems, so do not try to make a diagnosis of that or any other communication difficulty yourself. It is sufficient to say to parents that you have concerns about the child's speech and eating skills and would like him to see an expert.
In the meantime continue doing all the things you would normally do to help the child to develop his communication skills and make sure you keep a record of his progress and difficulties. Through cooking activities you can introduce him to new tastes and textures and also help to develop the muscles in his chin, tongue and lips by playing games that involve blowing, licking and chewing.
Sue Chambers is a senior LEYF associate (www.leyf.org.uk).
