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If there are facial muscle tone issues, the use of tapping, pressure, vibration and speed of input can change tone (Morris & Klein, 2000). Figure 2 depicts a diagram of the facial muscles. Fast tapping, light touch, vibration and a fast pace alerts the system and can increase tone while slow tapping, deep pressure, vibration and a slowed pace tends to decrease tone. When the facial muscles are shortened or inactive, such as in children who are defensive about foods and utensils entering the mouth, stretching these muscles will improve the muscle length to enable a more mature movement patterns. For example, many children who refuse food will hold the upper lip in retraction showing their top teeth. The lips are in extension and there is tension throughout the face. In this position the child will not be able to use the upper lip actively to remove food from a spoon, drink from a cup without spillage, or place the tongue behind the teeth to receive the food.

I started attending UTA RN to BSN online program in 2021. At the time I started the program I was a Texas resident, halfway through my program in 2021 I relocated to Washington State I continued to take courses through 2021. I then had to take time off due to family/financial matters, little did I know I had taken too much time off and if I wanted to continue in the program I would have to apply for readmission. At this point I only had two courses left to complete to earn my BSN. I went through the admission process for readmit and paid my application fee only to be told that the state I currently reside in (Washington) is not eligible to participate in the program.


Oral stimulation should be viewed as preparation for eating; therefore, oral-motor practice with food should follow oral stimulation so that the movements facilitated during oral stimulation can be coordinated to practice food manipulation, transport and swallow. In other words, oral stimulation is a means to an end, and should not typically be done in isolation.

A relatively new type of intervention for oral-motor difficulties in children with neuromotor impairments is an intraoral appliance, Innsbruck Sensorimotor Activator and Regulator (ISMAR; Gisel, Schwartz, & Haberfellner, 1999). The ISMAR was designed to achieve two goals: 1) jaw stabilization, and 2) activation/mobilization of the oral and pharyngeal structures. Although there were some difficulties in achieving tolerance and compliance with ISMAR (see Johnson et al, 2004), children with neuromotor disorders demonstrate significant improvements in spoon-feeding, biting, chewing, cup drinking, swallowing, and drooling after one year of ISMAR (Haberfellner, Schwartz, & Gisel, 2001; Johnson et al, 2004). These functional changes in feeding skills appear to be a function of jaw stabilization. Furthermore, these improvements in feeding were maintained for one year after ISMAR therapy was stopped (Gisel, Haberfellner, & Schwartz, 2001). Finally, use of ISMAR was associated with significant improvements in sitting and ambulation providing preliminary evidence for the dynamic interplay among oral-motor, postural, and ambulatory functions (Gisel et al, 2000).

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Some children have difficulty grading the amount of mouth opening and closing needed for a variety of foods. When a child demonstrates wide jaw excursions, he will have difficulty using his tongue to manage the food. Providing jaw stability by placing your hand under the jaw will help the child to take bites and to keep the mouth closed while the tongue does the work of manipulating the food. As the child practices, thinner foods can be placed between the molars to chew using minimal jaw excursions.


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At this point, the oral-motor pattern Joey has practiced dictates what foods he will accept; they all have to be able to be transported like a liquid. Foods that do not flow like a liquid are refused resulting in his food refusal. He can’t advance texture because he doesn’t let pieces of food into his mouth, and doesn’t have the tongue pattern necessary to manipulate them resulting in failure to advance texture. In addition, he has no experience eating in an upright position, which influences appropriate alignment and the muscle groups necessary to eat and swallow. Thus Joey now has multiple feeding problems resulting from medical and sensorimotor issues that initially prevented normal spoon practice. His lack of practice with normal patterns and increased experience with abnormal compensatory patterns in turn resulted in his food selectivity, failure to advance texture and ultimately food refusal.

Shifting from a sequential swallowing pattern to a single bolus swallow in spoonfeeding can be practiced using the spoon. Many therapists are taught to use Nuk brushes and other similar implements to present tastes and foods to children that refuse foods. Since we use a spoon to eat with, practicing the oral-motor pattern needed with the appropriate utensil will lead to more efficient learning.


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In summary, the child’s feeding experience and practice directly influence oral-motor pattern and oral-motor pattern directly influences feeding response (Bosma, 1986). If the utensils or food taste and texture do not change, the child does not learn to accept new foods and does not practice the new patterns necessary to manipulate the new food and transport it through the pharynx safely and efficiently (Gisel et al, 2000). Lack of appropriate and successful practice may result in the loss of previously acquired oralmotor skills and/or failure to acquire more advanced skills.

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Oral-motor ontogeny follows a stepwise progression building on the suckle reflex to acquire the more complex oral-motor milestones suck, munch, and chew (Bosma, 1986; Ogg, 1975). Just as with gross motor skill development, milestone acquisition is not driven by maturation alone. Rather, the emergence of each oral-motor milestone is also dependent upon successful practice (Eicher, 2002; Illingworth & Lister, 1964; Pinnington & Hegarty, 2000). Infants are born with a biologically driven suckle reflex which fades around four months of age (Ingram, 1962). When the infant uses the reflex successfully with breast or bottle feedings, they master suckling and its coordination with breathing (Herbst, 1983). In addition, this practice occurs contemporaneously with neuronal growth and development that together enable the infant to acquire volitional control over the suckle response (Arvedson & Lefton-Greif, 1996; Bosma, 1986; Miller, 1993). If an infant does not experience successful practice with the suckle reflex before the reflex fades at four months of age, the suckle pattern may not be mastered (Illingworth & Lister, 1964).

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Using a two-group design, Gaebler and Hanzlik (1996) compared 5 minutes of pre-feeding stroking to 5 minutes of pre-feeding stroking and introral prefeeding stimulation in a sample of 18 premature infants. Assessments occurred on days 1, 3 and 5; the group that received oral stimulation fed significantly better than the control group on day 3 only. A more recent study has demonstrated that those preterm infants who received daily 15-minute oral stimulation program consisting of stroking the peri- and intraoral structures for 10 days before the start of oral feedings, achieved full oral feedings seven days sooner than the infants in the control group (Fucile, Gisel, & Lau, 2005). In addition, infants in the experimental group demonstrated greater overall intake, rate of milk transfer, and amplitude of the expression component of sucking. In contrast, there were no differences between experimental and control infants on sucking stage maturation, sucking frequency, amplitude of the suction component of sucking or endurance of sucking.


As a result, the child becomes more protective of the airway and mouth; s/he may pull the tongue up or back to minimize entry into the mouth, and tongue movement is restricted (Mendell & Logemann, 2002). These changes may result in the use of more immature tongue movement patterns, less efficient tongue transport, and increased residual after the swallow (Mendell & Logemann, 2002). This can lead to preference for purees and foods that do not require increased tongue manipulation.

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Oral motor skills develop within a system that changes rapidly both in structural growth and neurological control during the first three years of life (Arvedson & Lefton-Greif, 1996; Bosma, 1986). During this period, children engage in a great variety of oral motor experiences as they satisfy their basic needs for food and comfort and begin to explore their world. Developmentally, a feeding problem exists when a child is “stuck” in their feeding pattern and cannot progress (Eicher, 2002; Kerwin, 2003; Palmer & Horn, 1977). Because oral motor skills represent a sequential progression of increasingly complex movement patterns, any disruption in practice can interfere with or limit positive oral motor practice, resulting in the loss of advancement in skill development and the learned behaviors that ensue (Illingworth & Lister, 1964). The challenge of treating children with feeding problems comes in identifying the specific areas that interfere with skill advancement for the individual child (Rudolph & Link, 2002; Stevenson & Allaire, 1991).

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He may not be able to move the food laterally to the molars to grind down the food in preparation for swallowing. This will lead to the child learning to swallow foods whole or partially chewed. If the tongue movements are not altered, the child will continue to practice this less efficient movement and will not be able to advance to higher textured foods. The use of pressure on the middle of the tongue or the lateral sides of the tongue can facilitate the intrinsic and extrinsic lingual muscles to widen, thin out, narrow, elongate and flatten. Pressure on the lateral borders of the tongue can thin out the muscle and the tongue will move to that side. Stimulation to the anterior part of the tongue will facilitate a tongue tip. This serves to facilitate movement, increase acceptance of tactile sensation and acceptance of implements in the mouth.

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Oral-motor problems in children are easy to recognize when the child coughs and chokes while eating. However, the majority of feeding problems present initially in more subtle ways, such as difficulty introducing spoon feedings or advancing texture, or limited variety of foods accepted (Kerwin, 1999). For some children, these more common feeding problems may reflect a specific oral-motor problem, such as uncoordinated tongue movement during lateralization or dysfunctional oral transport of the food bolus to the back of the mouth to initiate the swallowing reflex. Children with neurological disorders, or those born prematurely often exhibit oral-motor problems (Gisel, Alphonce, & Ramsay, 2000; Lau & Hurst, 1999; Sullivan, Lambert, Ford-Adams, Griffiths, & Johnson, 2000). Increasing evidence suggests that oral-motor problems are under-recognized in children with problems other than cerebral palsy (Ramsay, Gisel, McCusker, Bellavance, & Platt, 2002; Reilly, Skuse, Wolke, & Stevenson, 1999), including children with autism disorders (Amato & Slavin, 1998).

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Successful eating requires effective oral-motor patterns. The behavior analyst can be instrumental in assisting members of other disciplines in teaching children these skills. Because behavior analysts are skilled in task analyses, they can also help members of the other disciplines task analyze their interventions and learn to look for and document specific responses that they expect from each procedure (see Kumin et al, 2001 for example of task analysis of oral-motor treatment). Perhaps an ideal avenue for future investigation is combining the best of both approaches together to maximize the child’s benefit from systematic, gradual steps with clear instruction and consequences in the context of meaningful oralmotor facilitation and therapy (Bailey & Angell, 2005). Peterson and Ottenbacher (1986) demonstrated this combined approach in teaching lip closure to three children with mental retardation.

Treatment is most successful when the history of the child’s feeding progression is understood and a thorough assessment of the contributing factors has been done. Oral motor treatment should not start until medical issues are identified and controlled or stabilized, and issues of postural alignment and support have been addressed. To be most successful in providing oral motor stimulation, any medical issues need to be stable. This will help the child be more amenable to accepting any stimulation in the oral cavity and practice the oral-motor patterns that are needed. Since oral movements are refined motor movements, and they are distal to the pelvis and trunk, trunk alignment must be obtained to gain the best practice. Improving neck elongation and jaw stability will set the other oral structures in the correct alignment for active acceptance, manipulation and transport of food through the pharynx.


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Stimulation of the orbicularis oris muscle improves flexion of the lips for mouth closure and puckering. Active use of this muscle assists in food containment, straw drinking and closure to provide the negative pressure necessary for transporting food through the oral cavity and swallowing.