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.
 

So, where does that leave SLPs treating children with feeding issues that have a clear oral-motor component? 

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.

Introducing the F-words of childhood disability

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:

1. Function. Functional interventions result in improvements in a child’s execution of daily tasks, and involvement in daily activities. Functional interventions don’t focus on “fixing” isolated impairments, and they don’t measure an individual child’s achievement against “typical or normal” development. Functional interventions account for the fact that children with disabilities may do things in their own way, and that there are many paths that lead to the same functional outcome. Functional interventions also make a distinction between what a child can do in their daily environment (performance) vs what they can do in a highly controlled clinical setting (capacity) and they prioritize performance.
2. Family. Family-centered care considers the entire family rather than focusing only on the client. It acknowledges the challenges inherent in supporting a disabled child in a hostile environment and prioritizes family support as well as interventions for the child.
3. Fitness. Fitness and physical recreation are less accessible to children with neurodisabilities but are important for helping them maintain their health and well-being.
4. Fun. Childhood should be fun! Children with neurodisabilities spend a lot of time in treatment and therapy and may have less time for free play and non-therapy recreational activities.
5. Friends. Children with neurodisability deserve age-appropriate friendships. Interventions to support and promote peer engagement and relationship building should be a priority.
6. Future. Consider the future to maintain perspective, and consider what is really important for kids.

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.
 

So, how do these new “F-words” apply to feeding therapy?

Using the ‘F-words’ as our guide, we might: 

• Set motor feeding goals that will improve functional outcomes, like mealtime efficiency, safety, and enjoyment—for example, providing opportunities to work on drinking from a sippy or straw cup, rather than an open cup, if it promotes the child’s independence for nutritional intake.
  • Avoid goals that focus on ‘fixing’ behavior that is functional, but not ‘normal’, ‘typical’, or ‘optimal’ by an able-bodied standard. For example, if a child prefers to chew on one side, and they do so in a safe, functional, and effective way, then don’t worry about pushing for them to masticate every bite bilaterally.
• Allow children to find their own unique path to functional outcomes, rather than trying to force them to comply with an arbitrary determination of typical or normal behavior. For example, the majority of people may place a drinking straw just inside their teeth to drink, but anchoring the straw on the tongue may result in the same outcome and be more achievable for others.
• Consider how you can best preserve family, fun, and friends at mealtimes. Mealtimes are important for socializing and bonding, and coaching families and peer groups to embrace connection and joy at mealtimes with children with neurodisability is particularly important given that mealtimes can be medicalized and stressful for these children. Consider modifications (like selecting specific equipment) that might allow a child to participate in the social aspects of mealtimes.
• Reconsider interventions that are burdensome for the family with uncertain functional benefits. For example, Millie’s exercise regime before each meal places undue stress on the family schedule and capacity for bonding and joy at mealtimes, with insufficient evidence of any functional benefit. Sometimes, less therapy may be more therapeutic if it reduces the ‘opportunity cost’ of taking time and resources away from family, fun, fitness, and friends.
• Look ahead to determine what skills are important for the child now and in the future and then select interventions that support growth in those areas. For example, working towards eating sandwiches may not be important for a toddler, but might become more important once the child starts school.

Feeding therapy and the principles of motor learning and neural plasticity

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:

• Limit NPO recommendations. As well as motor learning principles, remember that the size and strength of our muscles–even the small ones involved in swallowing–can reduce when the muscles are not used. Avoid disuse atrophy by engaging these muscles in swallowing tasks.
• Provide safe opportunities to engage in eating and drinking wherever possible.
• Ensure opportunities for learning are not unnecessarily delayed, e.g. late introduction of solids or textured foods for children with neurodisability.

Age Matters. People learn more easily when they are younger than when they are older. This may mean you should:

• Provide early intervention for motor feeding skills.
• Ensure opportunities for learning are not unnecessarily delayed. [See also: Use It or Lose It]

Salience Matters. People learn best when the task is rewarding and meaningful. This may mean you should:

• Make mealtimes enjoyable and interesting by finding preferred foods for children to engage with, encouraging play and exploration, and promoting positive and responsive social interactions at mealtimes.
• Use accessible, preferred foods to improve oral strength, endurance, and coordination.
• Use food, mealtime contexts, and natural environments (like home and school) to teach motor skills, with modifications for safety. Minimize use of equipment, isolated ‘exercises’, and clinical settings, and if these must be used, make them as specific as possible. If you are unable to treat in a more natural setting, provide families with home programming to promote carryover.

Attention and Motivation. People learn new movement skills best when they are focused on and enjoying the practice tasks. This may mean you should:

• Make mealtimes enjoyable and interesting. [See also: Salience Matters]
• Consider reducing distractions during the motor learning phase where appropriate.
• Modify meal/snack schedules where necessary to allow hunger to act as a motivator.
• Utilize regulation strategies to support attention and engagement in learning a new skill. Work with occupational therapists to optimize attention and sensory regulation.

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:

• Use food, mealtime contexts, and natural environments to teach motor skills. [See also: Salience Matters]

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:

• Use simplification when helpful very early in practice, but reduce its use as soon as possible.
• Avoid simulation, fractionalization, and segmentation, as they are unlikely to be useful in motor feeding because the steps in eating and drinking are strongly integrated and interdependent.
• Where possible, avoid simulating motor feeding (e.g. chewing on tools) or breaking an oral motor task into parts (e.g. working on tongue lateralization exercises in isolation).
• If a child’s motor feeding skills are very poor, consider temporarily simplifying the task, for example by slowing the rate at which boluses are presented, or modifying the size or texture of the bolus.

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:

• Avoid breaking an oral motor task into parts—for example, working on biting exercises in isolation. Instead, work on all the components of a motor task together wherever possible–for example, biting in the context of a real eating scenario. [See also: Rehearsal Strategies]

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:

• Use food, mealtime contexts, and natural environments to teach motor skills. [See also: Salience Matters]
• Provide modifications (e.g. bolus size and texture, pacing, postural support) to facilitate success.

Practice Amount Matters/Repetition Matters. People learn better if they practice a lot. This may mean you should:

• Provide caregiver coaching to allow for many opportunities to practice motor feeding skills outside of therapy sessions.
• Include caregiver input on supporting home programming that works for their routine and environment.

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:

• When a child is first learning a skill, give them lots of opportunities to practice all at once.
• Then, as they become more successful, encourage the caregivers to provide shorter opportunities to practice at multiple meal/snack times each day.

Random Practice. People learn best when multiple targets are worked on randomly. This may mean you should:

• Provide a variety of different target foods/fluids in random order. For example, if working on advancing mastication skills, offer variability with meltable solids, soft solids, and even alternating with purees or a drink intermittently.

Variable Practice. People learn best when the context of practice varies. This may mean you should:

• Coach caregivers to feed children and implement strategies in a variety of contexts—for example in different locations, with different companions, using different foods, utensils, or equipment.

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:

• When a child is first learning a skill, consider giving frequent knowledge-of-performance feedback—for example, “Wow, I saw you move that raisin onto your side teeth with your tongue! Great work!” 
• As a child acquires the skill, reduce the amount of feedback, introduce a delay, and focus on results—for example, “...Wow, looks like you ate that raisin all up.”

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:

• Coach the child’s caregivers to maximize practice in daily routines and environments, integrating random and variable practice to improve transfer. [See also: Random and Variable Practice]
• Select and use foods, liquids, utensils, and equipment that are easily accessible to the family.

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:

• When should I target a given skill? Refer to the principles of Use It or Lose It and Age Matters.
• Where should feeding therapy happen, and with which foods or tools? Refer to the principles of Salience Matters, Attention and Motivation, Variable Practice, and Transfer of Learning.
• What therapy tasks should I choose? Refer to the principles of Goal Complexity, Random Practice, and Specificity.
• What support or instruction should I provide? Refer to the principles of Implicit Learning, Rehearsal Strategies, and Extrinsic Feedback.
• How often should I target these skills? Refer to the principles of Repetition Matters and Intensity Matters

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!

What does this mean for oral motor exercises and tools?

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.)

Nothing worth doing comes easily

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.
 

So, what would you recommend for Millie? 

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:

• You discuss creating opportunities for learning by encouraging Millie to engage in self-directed exploration and play (fun) during social mealtimes (function, family, friends)—building her attention and motivation for motor learning.
• You offer to consult with Millie’s occupational therapist to find adaptive seating that may support her self-feeding and oral-motor function by improving her postural support, increasing her opportunity to succeed with implicit learning. (function)
• You can see that Millie has some challenges with chewing and bolus management, and so she often gags and seems distressed during meals. You suggest texture grading and lateral bolus placement to develop specific oral motor skills, using principles like salience, specificity, and goal complexity. (function)
• You provide the details for a support group for parents of children with neurodisabilities—maybe Millie’s parents would benefit from some social support from other parents. (family)

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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