1. Eating and Drinking problems
Observations and Possible Solutions
Handicap International Henk Willemsen

2. Observation: What do you see?
the child often chokes when swallowing
food is pushed out of the mouth with the tongue
fluids or bits of food run out of the mouth before swallowing
child eats slow and very little
the child is unable to eat solid foods

3. Possible causes Cleft lip: nose and mouth are not separated.
Cerebral palsy; abnormal postures and movements, hyper- or hyposensitivity, old “babytime” reflexes preventing the child from eating in a easy way
Mental retardation: slow development, behavioural problems
A cleft lip/palate makes it very difficult for the child to eat or drink: food and fluids can come out through the nose because there is no separation between the nasal cavity and mouth. An operation is the best solution. Before that: put the nipple as for back in the mouth as possible.
For cp: sometimes the child has difficulties in sitting up, it may be bent backwards or forward, maybe there are old “babytime” reflexes preventing the child from eating in a easy way, (head bending to the side when you touch the cheek, sucklingreflex instead of chewing, ATNR, bite-reflex. Movements of muscles in face and arms can be difficult, so self-feeding or chewing and swallowing may be difficult.
Hypersensitivity may cause the reflex that makes you gag when you`re eating something you shouldn`t (what`s that called in English!) to be more in front of the mouth: so the child gags very easily. Sensitivity problems also causes difficulties because the child doesn`t feel what its doing, or it`s feeling too much (like a mouth full of living cockroaches! Or things are sensed as very hot, very cold, very sweet, very sour: unpleasant, with more gagging and tonguethrusting as a result)
Especially children with atthtosis will be effected by these problems.

4. Observation: what do you see?
Posture when feeding:
Lying down?
Body stretched, arm
back, head tilted back?

5. Better feeding positions:
Sitting up:
Use a pillow, you're lap, a wedge, a special chair, you're hand or arm.
Helps preventing the abnormal postures reactions.
Head slightly forward, arms and shoulders too, hips bent.
Use you're shoulder and arm for control

6. Better feeding positions:
A little pressure on the chest helps keeping the
right posture

7. Better feeding positions:
not like this: but like this:

8. Better feeding positions:
Use you're fingers to
push the food slightly
into the cheek, that
prevents it from being
pushed out again and
encourages chewing.
A baby sucks by moving her tongue forward and backward. For this reason, when the child begins to eat from a spoon, her tongue will at first push part of the food out of her mouth. She has to learn to use her tongue differently-pushing the food between the gums to chew, and to the back of her mouth to swallow. Children with developmental delay or cerebral palsy may have trouble learning to do this, and continue to push or 'thrust' the tongue forward for some time. Do not mistake this for meaning she does not like the food.

9. Encouraging to chew getting used to solid foods
biting bits of food of.
putting food between the teeth.
Normally a child's feeding skills gradually increase without any special training. She learns first to use her lips and tongue to suck and swallow liquids. Later she learns to bite and chew solid foods, and to take food to her mouth with her hands . If the child has trouble eating solid foods, do not keep giving only milk or formula or 'rice water'. Even mother's milk alone is not enough after 6 months. Normal babies also have to get used to solid food!
Mash or grind up other foods to form a drink or mush. By 8 months to 1 year of age the child should be eating the same food as the rest of the family - even if it has to be mashed or turned into liquids.
To help the child learn to chew, put a bit of firm food in the side of her mouth between her teeth. Use very small pieces of bread crust, tortilla, or chapati. Help her close her mouth using jaw control.
Biting off can be encouraged by pulling slightly on a long thin piece of food.
Or rub the piece of food against the teeth before putting it between them.
CAUTION: Do NOT open and close the child's jaw or help her chew. After she bites the food, her jaw must stay closed or almost closed to chew. To help her do this, apply steady firm pressure with jaw control. This should lead the child to make chewing motions. Let the jaw move some on its own. But do NOT make chewing motions for the child! This will only encourage abnormal movements.

10. Giving Jaw-Control If you sit beside the child
If the child is facing you
At first the child may push against your hand, but after she gets used to it, it should help her control the movement of her mouth and tongue. Be sure not to push her head back, but keep it bent forward slightly.
While you feed the child, apply gentle, firm steady pressure - not off and on.
Good positioning together with jaw control will help with several problems common in cerebral palsy, such as pushing the tongue forward, choking, and drooling (dribbling). As mouth control improves, gradually lessen and finally stop jaw control. CAUTION: Jaw control helps in many children with developmental delay and cerebral palsy-but not all. After trying it for 2 or 3 weeks, if the child still resists it or shows increased problems, stop using jaw control.

11. Drinking not head backward but head forward
At first you may need to apply jaw control to help the child close her lips on the rim of the cup. Tilt the cup so that the liquid touches the upper lip and let the child do the rest. Do NOT take away the cup after each swallow as this may trigger pushing the head back or tongue out. It helps to start with thick liquids-like cooked cereals, maize mush, or yogurt

12. Drinking also make sure the cup has a protecting rim.
if you use a plastic cup with a piece cut out, he can drink without bending his head back (see Werner H36)

13. Good to know!
Thicker liquids are easier to swallow: thicken liquids with corn meal , gelatin or mashed food.
Hardest for the child to eat are combinations of liquids and solids-such as vegetable soup or juicy fruits.
Use food and drinks the child likes a lot to practise!
Tough or leathery foods are harder to chew than crunchy or soft (biscuits, breads, vegetables)
also remember that the child can experience things have extra strong taste or sensation: sweet, sour, hot, cold.
Sweet or sour things can make a child drewl more than usual.

14. Self-feeding Do encourage the child to feed itself.
Make a special, good fitting chair, and special eating / drinking equipment when necessary.
Give help when needed.
To be able to feed itself, a child needs more than control of the mouth, lips, and tongue. it also needs to be able to sit with the head up, to pick things up, and to take them to the mouth
Try to make mealtime a happy time. Remember that it takes time for any child to learn new skills, and that a child learns best when he plays. When any child first learns to eat for himself, he makes a mess. Be patient, help the child to become more skilful at eating, praise him when he does well, but at the same time let him enjoy himself and his food. Remember, even normal children often do not learn to eat cleanly and politely until they are 5 or 6 years old-or even older.
Many suggestions in the book Disabled Village children (may be nice for another workshop?)