Do you have a child that:
- Chews on and on but doesn’t seem to swallow
- Will eat smooth foods but says they can’t swallow anything with lumps or solids
- Won’t swallow foods but hold it in their mouths to later spit out
- Won’t swallow foods but keeps filling their mouth with more food
- Avoids eating chewy foods or eating foods that are crunchy
- Won’t swallow the foods but seems to have food stored in their cheeks!
- Takes 10 swallows before on mouthful goes down!
Then you may have a child that is having “Oral Phase” swallowing difficulties. A difficulty to swallow is called dysphagia (dis-fay-ja) but there are many types and causes of dysphagia. To understand dysphagia, it helps to first understand how swallowing occurs.
Swallowing involves four stages. These stage are controlled by nerves that connect the digestive tract to the brain:
There are 4 main stages in the swallowing process:
- Oral Preparatory Stage, in which the food is chewed (masticated), mixed with saliva, and formed into a cohesive ball (bolus)
- Oral Stage, in which the food is moved back through the mouth with a front-to-back squeezing action, performed primarily by the tongue
- Pharyngeal Stage, which begins with the pharyngeal swallowing response:
- The food enters the upper throat area (above the voice box), the soft palate is lifted to block off the nose and the epiglottis blocks off the airway. These actions helps to direct and force the food downward to the esophagus.
- Esophageal Stage, in which the food bolus enters the esophagus (the tube that transports food directly to the stomach). The bolus is moved to the stomach by a squeezing action of the throat muscles.
This article is focused on the Oral stages of swallowing. It is a common issue for many children attending the SpeechNet Infant and Feeding Clinic. In the Oral stage children need to be able to bite, chew effectively and then the tongue forms the food into a “ball” (a bolus) and moves it into position ready for a swallow. This phase is voluntary meaning people have control over chewing and beginning to swallow. Some common problems at this stage of the swallow are:
- trouble initiating or wanting to take food into the mouth
- Trouble closing your lips to get food from a spoon or fork
- Difficulties keeping food in your mouth
- trouble chewing food effectively so it is not swallowed or attempted to be swallowed with large lumps in it causing gagging
- trouble moving food within the mouth
- trouble forming a ball with the food (bolus) so that it can be moved into the correct position ready for a swallow (less important with puree foods but this can be a key reason why lumpy foods are not swallowed). Food often remains scattered across the tongue and in the cheeks rather than being gathered into a ball (see photos below).
- Difficulties controlling foods in the mouth so that it goes into your throat too quickly often causing a gag or a vomit OR the food/bolus cannot be moved to the correct position on the tongue in order to initiate the swallow reflex.
- some food in the mouth remains after the swallow – or even after several attempts at swallowing. This is called
- Getting food stuck in your cheek and having insufficient tongue and oral control to be able to feel and re-collect the food – called pocketing
The role of the speech-language pathologist that has experience in paediatric dysphagia is to assess the factors that may be impacting on the swallow process and assist in developing a management plan.
Let’s look at just one example where the child was “chewing” and “chewing” but seemed to take forever to actually swallow the food. He often needed several effort-able swallows to get a single mouthful down.
1.First of all his bite was adequate however his chew was inefficient.
He used up and down jaw movements in attempt to chew foods such as carrots, meats or apple. However these types of foods really need a grinding or rotatory chew movement to get them ready for a swallow. Hence he was doing “lots of work” that made it look like he was chewing forever however the food was not actually being processed at all. He required assistance to learn a more mature form of chewing.
2 He had poor tongue movements which made it impossible for him to move food from his cheek pockets to his teeth and he could not use his tongue to form the food into a ball (bolus) for swallowing.
Food would fall into his cheek pocket and he could not sweep the food out and place it back on his teeth where he could chew it. The food was scattered all over his tongue and cheeks. As he could not gather the food into a ball (a bolus) he could not get a clear swallow and kept swallowing the tiniest amounts of food as they randomly moved to the back of the tongue. Food needs to be moved as a “small pile” so a swallow can be triggered. Consequently the swallowing was very ineffective with significant amount of residue being left on his tongue meaning each mouthful was taking such a long time making his meals go on and on. Even after 5-6 swallows per mouthful the tongue was still coated with food. Often he would drink so much water to try to “wash it down” he no longer felt hungry.
In the photos below you can see the food is all over his tongue. Using photos of his tongue and demonstrations of chewing and bolus formation he genuinely said “How do you do that! How do you get it all together in a ball like that?” The therapy involved using tongue exercise and techniques to assist him to learn how to form a bolus of food so that he could increase the efficiency of his swallow. The last picture clearly demonstrates the huge improvements he made!
Tongue movements and awareness of tongue movements within his mouth was a key element to helping him learn how to swallow effectively. Using resources such as the Online Mr Tongue Story greatly assisted him!
It is recommended that if you have concerns about your child’s swallowing skills that you should contact a speech-language pathologist experienced in paediatric dysphagia and feeding issues.
Inability to form a ball (bolus) of food – food is scattered and residue remains after swallow attempts
Formation of food into a ball (a bolus) allows an efficient swallow.
Mr Tongue Story encourages tongue movements important in eating and talking