Hypotonia or low tone is common for individuals with Down syndrome. It affects their overall development from walking later to eating. With low oral-motor tone, a more intense oral sensory input is required to "wake-up" the muscles in and around the mouth in order for oral motor skills to develop. Matthew's Occupational Therapist (OT) had several suggestions for helping him transition including oral alerting activities, offering Matthew high flavor food, thickening food to increase texture, and practicing chewing.
Oral Alerting Activities
Oral alerting is done to help increase sensory awareness of the face and mouth muscles before a meal, in effect, encouraging more coordinated use of the mouth (jaw, lips, cheeks, and tongue) and developing a more efficient biting, chewing, and swallowing pattern. Some oral alerting techniques are: a cool-cold washcloth wake-up, finger tapping on the face, and vibration using a NUK brush, z-vibe, or jiggler. I'm sure any OT would be more than willing to discuss these in more detail. We have the z-vibe and elephant jiggler pictured here.
Offering High Flavor Food
Did you know that hypotonia affects taste too? Sara Rosenfeld Johnson, a renowned speech and language pathologist (SLP), affirms this in Low Tone Affects Taste as well as Movement on her blog Sara's Feeding and Speech Thoughts. Here's an excerpt:
"...when children are diagnosed with Low Tone/Hypotonicity it also means they may have Hypo-sensitivity/Hypo-responsivity to touch, taste and smell. He likes foods that are highly flavored because he can "taste" them. Kids with hypo-sensitivity like foods they can taste so increasing flavor for these kids is essential."Matthew does like the tartness of blueberry pomegranate flavored applesauce (Musselman brand). But on the other hand, he also likes bland jarred baby food. Go figure!
To this day, Matthew eats jarred 2nd (baby) food. Occasionally, he'll eat home-made pureed food mixed with jarred baby food. He also eats jarred 3rd foods - pears and squash only - which do not have the chunks of food like the other 3rd foods do but they have a thicker consistency than 2nd foods. Sometimes I thicken the 2nd foods with rice or oatmeal cereal to add texture. The thicker texture encourages learning to coordinate the tongue and jaw movements to handle the food differently than if it were runny, therefore helping improve oral motor skills.
A teething feeder filled with fruit is great for Matthew to practice chewing and biting solid food without the risk of choking. His OT says that not all kids like this feeder, probably because of the texture of the feeder in their mouths. Matthew didn't care for it initally but he warmed up to it after several attempts of offering it to him. He also eats cheerios, goldfish crackers, small chunks of fresh pear, nutrigrain blueberry toaster waffles, and cinnamon graham crackers. I try to offer one of these after every other meal so he can practice chewing often.
In the last four or five months, I have been trying to step-up my efforts in transitioning Matthew from baby food to table (non-pureed) food. I fed him small pieces of Gerber pasta pick-ups, which caused him to gag and throw up. I fed him 3rd foods Lasagna, which also caused him to gag and throw up. I fed him buttered steamed carrots. He cried a little, tolerated a few pieces then he was done. I tried feeding him some green beans from a Gerber Graduates - Lil' Entrees for Toddlers meal but after getting one piece in his mouth, he cried and refused more.
I recently stumbled upon "Food Progressions for Biting and Chewing" by Suzanne Evans Morris, Ph.D, who is a Speech-Language Pathologist and author of a few books on pre-feeding skills and pre-speech. She identifies 8 sensory features of food (sensory input, size, shape, texture scatter, consistency, placement, and need for transfer during chewing) that help determine the degree of ease or difficulty for biting and chewing, how these require different sensorimotor strategies, and that a high level of success is important.
After reading Suzanne Evans Morris' work, I had an epiphany. MAYBE I sabotaged my own efforts to transition him from baby food to non-pureed food by giving him food that he was not developmentally ready for, triggering his sensitive gag reflex and causing him to gag and throw-up. Because of these unpleasant experiences, I might have created a certain level of fear and distrust of new table food, thereby making the transition more difficult. So it seems I need to re-evaluate my transition efforts and understand the different sensory features that each food presents in order to offer more appropriate choices that match his current level of oral-motor skills. I need to take a closer look at the chart of guidelines for matching oral motor skills with food textures in "Chapter 7: Successful Eating" of The Down Syndrome Nutrition Handbook by Joan Guthrie Medlen, RD, LD.
Despite these few bumps on the road, I'd like to think we are headed in the right direction and employing the right strategies to help him overcome his minor feeding difficulties. Over time, with frequent exposure to different foods and practice chewing, I hope he will eat a wide variety of table food when he's older... unless his Daddy's picky-eater gene has the last say.