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PEDIATRIC FEEDING · BIRTH THROUGH HIGH SCHOOL
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Something to chew on: Motor learning and neural plasticity principles in oral motor feeding therapy
Oral motor feeding problems are real, but oral motor feeding interventions are tricky to navigate. We discuss 14 principles and 6 ideas to help you get started with evidence-based therapy for these children, plus a free download!
February 11, 2023
Millie is 10 months old and has a genetic syndrome that affects her motor development. She and her parents, Trish and Mike, present to your clinic for support with eating and drinking after a history of tube feeding, possible aspiration on thin fluids, and difficulty transitioning to solids. The family has recently attended an intensive therapy block where they were instructed in oral motor exercises and stretches to complete before each mealtime. Millie used to cry when Trish did the exercises, but now she just seems ‘tuned out.’ Trish is completing these exercises as instructed, but she confides that it’s hard to fit them in amongst Millie’s other therapies and medical procedures. Nonetheless, she and Mike are determined to leave no stone unturned. If it might help Millie, they’ll do it. They want to know what you recommend to progress Millie’s eating and drinking.
The oral motor world can be a scary place for caregivers and clinicians alike. The move away from non-speech oral motor exercises (NSOMEs) in the speech world left many SLPs unsure of how to provide evidence-based assessment and treatment for motor speech and feeding difficulties. Commercial interests have jumped in to fill the gap, offering tools and trainings that claim to improve oral motor function; and while many SLPs are (rightfully) skeptical of these claims, it can be hard to find reliable information about what to do instead. Despite many decades of research, systematic reviews by Arvedson et al., Arvedson et al., Morgan et al., and Shortland et al. reported that there was little consistent, high-level evidence for any oral motor feeding intervention, aside from non-nutritive sucking for young infants.
In recent years, new ideas in neuromotor intervention (for example, physical and occupational therapy research) have gained scientific support. Now, scientists and clinicians are beginning to apply these concepts to motor feeding, creating a rich source of inspiration for some of our trickiest clients. Below, we summarize some exciting ideas in neuromotor intervention and discuss how you can apply this to your work with children who have motor feeding challenges.
In 2011, Professor Peter Rosenbaum proposed the F-Words of Childhood Disability, a move away from trying to “fix” a child’s neurodisability, and towards an ICF-influenced set of 6 other “f-words” that should drive our intervention decisions. These new(ish) f-words are:
If these ideas feel familiar, it might be because they are similar to principles from the anti-ableism and neurodiversity-affirming movements. While we’re moving away from setting language and social goals for autistic children based on “normal or typical” development, it remains common for “normal or typical” feeding to be the aim for children with oral motor feeding challenges.
Using the ‘F-words’ as our guide, we might:
Researchers like Sheppard, Zimmerman et al., and Khamis et al. have recognized the value of motor learning and neural plasticity principles in pediatric feeding. Yet, in our experience, many clinicians aren’t aware of these principles or don’t know how to apply them. While there are many useful principles (and we recommend the linked papers above for clinicians who are interested in diving deeper) some of the most applicable principles are:
Use It or Lose It. People who have no opportunity to learn a skill may lose the capacity to use it. This may mean you should:
Age Matters. People learn more easily when they are younger than when they are older. This may mean you should:
Salience Matters. People learn best when the task is rewarding and meaningful. This may mean you should:
Attention and Motivation. People learn new movement skills best when they are focused on and enjoying the practice tasks. This may mean you should:
Specificity. People learn faster and retain better if they practice a task that is similar to the goal, as opposed to a task that is modified compared to the goal. This may mean you should:
Rehearsal Strategies. People learn best when the practice is functional. Rehearsal tasks are ways of practicing that are not functional. Simulation is pretending to complete the task; fractionalization means practicing part of the task in isolation; segmentation means working on sequential parts of the task separately and then joining them together; and simplification means reducing the difficulty of the task. This may mean you should:
Goal Complexity. People learn most efficiently when the practice task is as complex as the child is able to achieve with support. Practicing a whole task rather than breaking it into parts is likely to be most effective. This may mean you should:
Implicit Learning. People learn more effectively when they learn a skill by doing it (with modifications as needed) and experience the outcome for themselves rather than being explicitly taught the movements required for a task. This may mean you should:
Practice Amount Matters/Repetition Matters. People learn better if they practice a lot. This may mean you should:
Massed vs. Distributed Practice/Intensity Matters. People acquire a skill better if they first practice many times all in a row, and then generalize it better if they practice spread over a longer time period. This may mean you should:
Random Practice. People learn best when multiple targets are worked on randomly. This may mean you should:
Variable Practice. People learn best when the context of practice varies. This may mean you should:
Extrinsic feedback. People learn better when they receive external feedback that is intermittent (not constant), delayed (not immediate), and focused on the results (not the performance). A brief period of more frequent, knowledge-of-performance feedback might be helpful in the early stages of learning a new skill. This may mean you should:
Transfer of Learning. People’s learning is most useful when they can take a skill and apply it to their daily lives. This is also referred to as generalization. This may mean you should:
Phew! We know this might feel overwhelming, especially if you're new to shaping your therapy around these principles. To *ahem* simplify the task of applying these principles, you might begin by considering only the principles specific to different clinical questions, like this:
And if you don't have it all memorized yet, don't worry! You can download our printable chart to help you apply the principles of neuroplasticity to these clinical questions mid-session. Just be sure to laminate it to protect it from enthusiastic clients!
A common theme across multiple principles of motor learning and neural plasticity is that children will likely learn best when their practice involves real food and mealtimes, especially when those mealtimes are enjoyable and interesting. Attempting to build skills or strength using tools or exercises divorced from functional eating/drinking scenarios may not result in efficient or effective motor learning in comparison, and is likely to be harder to transfer into functional activities.
A common question is whether tools and exercises should be used if children are extremely aversive or not safe for oral intake. For children that are extremely aversive, using motor learning principles around attention and motivation might mean starting with goals that optimize the child’s comfort and enjoyment around mealtimes rather than a goal, for example, of increasing jaw strength. After all, if a child has an extreme aversion to foods or mealtimes, is the primary concern how strong they are? An aspiring acrobat might build up their body strength in the gym, but as long as they’re petrified of heights, their strength can’t do them any good on the high wire. Building mealtime comfort also has functional implications—it may allow a child to join their family and friends at mealtimes or celebrations, even if they don’t eat yet.
For the very small minority of children not safe for any oral intake, mouthing and chewing on non-food objects may be helpful (as it is for a typically-developing child), but motor learning principles suggest that we should encourage intrinsic motivation and attention—for example, by supporting mouthing in child-directed play and exploration. There is no evidence that purpose-sold ‘special needs’ products are superior to mainstream teethers, toys, or child-safe tableware and household items for this purpose. These products may, however, be reasonably used for children who are oral sensory seekers, and who are intrinsically motivated to seek and enjoy the specific types of sensory input provided by different mouthing toys.
It is unlikely, based on motor learning research, that passive stretches, massage, or ‘stimulation’ will improve motor skills or oral musculature in children who eat and/or drink. Further, forcing or coercing children to accept unwanted and non-functional oral stimuli, such as intra-oral massage, undercuts intrinsic motivation and violates bodily autonomy. Claims that these activities ‘wake up the mouth’ do not have a strong scientific premise. (There is some evidence that oral sensorimotor stimulation may be helpful for preterm infants in the NICU, possibly because it provides sensory input in an environment of relative sensory deprivation. The same mechanism does not make sense for older children with oral motor difficulties, who are in a similar sensory environment to their same-age peers.)
These principles don’t provide a ‘program’ or ‘manual’ for treatment of motor feeding issues—but since when did any client come with a manual? If there were a cookbook approach to treating clients, our job wouldn’t require a master's degree. It takes careful clinical reasoning and critical thinking to apply concepts from neurodisability research to our assessment, goal-setting, and intervention. But in the hands of a skilled and thoughtful SLP, these principles could result in motor feeding interventions that are more efficient, effective, meaningful, and client- and family-centered. Now, that’s something to chew on.
First, you validate the commitment that Millie’s family has shown in seeking out feeding therapy and following through so assiduously on home practice tasks. You explain that there isn’t yet adequate scientific evidence to demonstrate an effect of passive exercises on feeding function (but acknowledge that some families want to try them out, and that’s reasonable). You then explain that evidence from motor intervention research suggests that motor therapies are most likely to be effective when they are meaningful, specific, and contextualized. So, you want to focus on developing fun and family bonding at mealtimes and then set other goals based on feeding functions that are important to Millie and her family—like drinking safely and enjoying family foods. To start with:
When you ask for Trish and Mike’s thoughts, Trish smiles. “It doesn’t sound that different from how my sister feeds her kids.” Mike leans forward. “Do you think Millie could be part of my family’s Sunday dinners?” “Let’s work out how to make that happen,” you reply. (future)
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Arvedson, J., Clark, H., Lazarus, C., Schooling, T., & Frymark, T. (2010). The effects of oral-motor exercises on swallowing in children: an evidence-based systematic review. Developmental Medicine & Child Neurology. https://doi.org/10.1111/j.1469-8749.2010.03707.x [open access]
Arvedson, J., Clark, H., Lazarus, C., Schooling, T., & Frymark, T. (2010). Evidence-based systematic review: Effects of oral motor interventions on feeding and swallowing in preterm infants. American Journal of Speech-Language Pathology. http://doi.org/10.1044/1058-0360(2010/09-0067) [available to ASHA members]
Greene, Z., O’Donnell, C. P. F., & Walshe, M. (2016). Oral stimulation for promoting oral feeding in preterm infants. Cochrane Database of Systematic Reviews. https://doi.org/10.1002/14651858.CD009720.pub2 [open access]
Khamis, A., Novak, I., Morgan, C., Tzannes, G., Pettigrew, J., Cowell, J., & Badawi, N. (2019). Motor learning feeding interventions for infants at risk of cerebral palsy: A systematic review. Dysphagia. https://doi.org/10.1007/s00455-019-10016-x [open access]
Kleim, J. A., & Jones, T. A. (2008). Principles of experience-dependent neural plasticity: Implications for rehabilitation after brain damage. Journal of Speech, Language, and Hearing Research. https://doi.org/10.1044/1092-4388(2008/018) [available to ASHA members]
Morgan, A. T., Dodrill, P., & Ward, E. C. (2012). Interventions for oropharyngeal dysphagia in children with neurological impairment. The Cochrane Database of Systematic Reviews. https://doi.org/10.1002/14651858.CD009456.pub2
Pineda, R., Guth, R., Herring, A., Reynolds, L., Oberle, S., & Smith, J. (2017). Enhancing sensory experiences for very preterm infants in the NICU: an integrative review. Journal of Perinatology. https://doi.org/10.1038/jp.2016.179 [open access]
Rosenbaum, P., & Gorter, J. W. (2012). The ‘F-words’ in childhood disability: I swear this is how we should think! Child: Care, Health and Development. https://doi.org/10.1111/j.1365-2214.2011.01338.x [open access]
Sheppard, J. J. (2008). Using motor learning approaches for treating swallowing and feeding disorders: A review. Language, Speech, and Hearing Services in Schools. https://doi.org/10.1044/0161-1461(2008/022) [available to ASHA members]
Shortland, H.-A. L., Hewat, S., Vertigan, A., & Webb, G. (2021). Orofacial myofunctional therapy and myofunctional devices used in speech pathology treatment: A systematic quantitative review of the literature. American Journal of Speech-Language Pathology. https://doi.org/10.1044/2020_AJSLP-20-00245 [available to ASHA members]
Zimmerman, E., Carnaby, G., Lazarus, C. L., & Malandraki, G. A. (2020). Motor learning, neuroplasticity, and strength and skill training: Moving from compensation to retraining in behavioral management of dysphagia. American Journal of Speech-Language Pathology. https://doi.org/10.1044/2019_AJSLP-19-00088 [available to ASHA members]
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