Appendix I - Milestones on Normal Feeding, Clinical Clues of a Possible Feeding Problem, and Components of an Oral Motor Assessment

Motor Disorders Clinical Practice Guideline – Tables on Feeding90

Table IV-5 Milestones Relevant to Normal Feeding

Age (months) Progression of liquid and food Oral-motor skills Motor skills
Birth to 4 Liquid Suckle on nipple Head control develops
4 to 6 Purees Suckle off spoon
Suckle → suck
Sitting balance
Hands to midline
Hand-to-mouth play
6 to 9 Purees
Soft chewables
Assisted cup drinking
Vertical munching
Limited lateral
Reach, pincer grasp
Assists with spoon
Finger feeding begins
tongue movements
9 to 12 Ground
Lumpy purees
Cup drinking with assistance Refines pincer grasp
Finger feeding
Grasps spoon with whole hand
12 to 18 All textures Lateral tongue action
Diagonal chew
Straw drinking
Independent feeding increases
Scoops food, brings to mouth
18 to 24 More chewable food Rotary chewing
Decrease in food intake by 24 months
Increased control of utensils
24 + Tougher solids Increase in mature chewing for tougher solids Total self-feeding
Increased use of fork
Cup drinking, open cup and no spilling
Adapted from: Arvedson 1996

Table IV-6: Clinical Clues of a Possible Feeding Problem

  • Prolonged feeding times (>30 minutes)
  • Stress during or following feeding for child and/or parent
  • Poor suck, difficulty latching on to nipple
  • Loss of liquid or food around lips
  • Excessive tongue retraction or protrusion
  • Holding food in mouth or prolonged chewing before swallowing
  • Excessive drooling
  • Indication of respiratory distress during oral feeds (for example, arching back, turning away, eye widening, nasal flaring, difficulty catching breath)
  • Gurgly voice quality
  • Difficulty in making transition to a new texture at developmentally appropriate stages
  • Coughing or gagging while eating
  • Frequent vomiting or excessive spitting up during or after meals
  • Poor weight gain
  • Reduced interest in or negative response to oral presentation of food

Table IV-7: Components of an Initial Oral-Motor Assessment

  • Physical examination and comprehensive history:
    • Structure and function of oral, facial, pharyngeal, respiratory, and gastrointestinal systems
    • Other conditions that could affect the child's tolerance and stamina (such as cardiac conditions)
  • Observation of interaction patterns between the child and caregiver
  • Effects of muscle tone, posture, movement, and positioning
  • Oral-motor exam, to be performed prior to offering liquid or food, including:
    • Presence/absence of oral reflexes
    • Structure and coordination of movement of the lips, tongue, soft palate, and jaw
    • Oral sensation
    • Laryngeal function
    • Control of oral secretions (drooling)
    • Respiratory rate and effort
    • Oral postural control and voice quality
  • Feeding assessment including:
    • Feeding environment
    • Level of alertness and attention
    • Affect, temperament, and responsiveness
    • Ability to self-calm and self-regulate
    • Non-nutritive sucking (such as on a pacifier)
    • Observation of trial feeding
    • Swallowing
    • The effect of alternate positioning and modifications of the feeding process
  • Evaluation of the diet for adequate nutritional intake

90 Reproduced from the New York State Early Intervention Program Clinical Practice Guideline on Motor Disorders

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