How can your child progress beyond purees?
Today’s episode is part 2 in the series on Feeding Disorders in Down Syndrome – we are continuing on from Episode 92 with Dr. Kay Toomey who leads us through a beautifully detailed explanation of the hierarchy of what feeding should be like, especially in children with Down syndrome.
This particular episode comes with several handouts that Dr. Kay Toomey references. I recommend that you have all of these open while listening to the podcast – to give you the best experience.
You can go to www.functionalnutritionforkids.com/feedingsos to get these handouts and my own set of notes that you can print out.
You can find Dr. Toomey at www.sosapproachtofeeding.com
Audio Transcript:
Vaish:
How can you track progress beyond race? Today’s episode is part two in the series on feeding disorders in Down syndrome is continuing on from Episode 92. That’s where you’ll find part one with Dr. K two, again leading us through a beautifully detailed explanation of the hierarchy of what feedings should look like, especially in children with Down syndrome. You are listening to functional nutrition and learning for kids where we learn to overcome nutritional, physical, and educational hurdles to optimal learning and equal education. I’m your host Vaish.
This particular podcast episode comes with several handouts that Dr. Toomey references. They’re all in the show notes. There’s a link there and I recommend that you have these open while listening to the podcast because Dr. Toomey references these over and over again. Now if you want the link here, it’s functional nutrition for kids.com/feeding.
SOS, yes, /feeding so as you can get these handouts there. And I’m sure you’re all familiar with Dr. To me if you’ve listened to Episode 92, or maybe even before, for those of you who are new to her work, she’s a pediatric psychologist who has worked with children who don’t eat for almost 35 years.
She developed the SOS approach to feeding as a family-centered program for assessing and treating children with feeding problems. She speaks nationally and internationally about her approach. She helped to form the Children’s Hospital Denver’s pediatric oral feeding clinic as well as the Ross Medical Center’s pediatric feeding center.
She co-chaired the pediatric therapy services department at Rose Medical Center prior to entering private practice, she has been the Clinical Director for Toomey and Associates feeding clinic, and then the SOS feeding solutions, before shifting into clinical consultation to focus on her teaching. She is currently the president of me and Associates.
Now if you want to know more about Dr. Toomey, or the SOS approach to feeding, the link is the SOS approach to feeding dot coms. Like me, I’m sure you’re also going to be amazed by Dr. Toomey his breadth of knowledge and depth of knowledge. There is a lot to unpack in this podcast, which is why I highly recommend you go to functionalnutritionforkids.com/feedingSOS. Okay. And that’s where we have Dr. Toomey’s notes and my notes because I had to take a lot of notes during this podcast.
Welcome back. Dr. Toomey, this is so exciting to have part two of the conversation we were having last time. So if at least to me, one of the mind-blowing things that you shared last time is that the number one priority of the body is not eating, but it’s breathing. And even though it is you know, common, it seems like common sense now that you’ve said it, but I never thought about it like that.
The number two priority is postural stability. So I know we’re saying into a further deeper conversation. But do you want to share with us anything so we can like maybe like a quick recap of that so we can move on?
Dr. Kay Toomey:
Absolutely, absolutely. What we’re going to talk about today is oral motor skills for children who have Down Syndrome and as well as children who are on the autism spectrum, that really this applies to typically developing children as well. But we’re going to talk specifically about why children with Down syndrome end up staying on purees so long, and how we can help them begin to master the skills they need to transition from purees to textured foods, we know that the foundation of all eating is going to be the breathing as you brought up. And then the next foundational piece that everyone needs is that postural stability.
We talked about last time, that’s because you only have so much motor brain power available to you at any one point in time. And so that if you’re using up all your motor brainpower to make sure you’re not going to fall over a fall on your head. That’s why postural stability is so important. It’s to protect the body protect the brain, so you’re not falling over while you’re trying to eat. If you’re using up all of your motor brainpower to make sure that you’re stable, you’re not going to have the motor brain power leftover that you need to make your mouth work correctly.
Vaish:
And when I was just like last time, I remember say repeating the sentence twice when you talked about the motor brain power because it’s such it’s it’s so important to me, but I just want to intervene and ask I’m guessing this becomes even more important when you have apraxia because the motor brain power is is is struggling even more.
Dr. Kay Toomey:
That’s actually a really good point. That wasn’t exactly where it was gonna go. I was gonna talk about its especially important postural stability for children with Down syndrome because they have low muscle tone. But for children, for example, on the autism spectrum, we know that those children have a much higher percentage of apraxia or difficulties with motor planning is, you know, I guess a more generic term to use and you are absolutely correct if you have a difficult time using your muscles either because you have low tone, or using your motor system and your muscles, because you have motor planning difficulties and you can’t coordinate the muscles and the motor movements very well, you are already taxing your motor brain.
And so that you are coming into every feeding with less motor brain available, to begin with, because you’re going to have to set aside a certain amount of motor brain just to take care of those issues, either the effort that’s going to be required for the low tone or the effort that’s going to be required because you have motor planning difficulties. So you’re going to be starting with less motor brain power in the first place. So postural stability is absolutely key.
For these children, and especially for the children with Down syndrome, we need to be thinking about postural stability that not only gets them in that 9090 90 positions, 90 degrees at the hips, 90 degrees at the knees, 90 degrees at the feet. So that means they must have a footrest, that their foot can, you know be flat, they are also typically going to need some kind of site support. And we talked about last time that their preferred chair is the fully adjustable wooden chairs like the trip trap chair, the height right chair, there is a chair called an abbey.
That’s a pretty good one as well. And unfortunately, those adjustable wooden chairs don’t have side supports. And so you’re going to need to build in some kind of side support for the kids to help them with making that transition from purees. To texture table foods because purees don’t take as many oral motor skills as texture table foods do. And, and so postural stability, we have to really put in those extra supports. If we want our children to transition to a more difficult oral motor task, then puree. So the easiest thing to do to create side supports in your child’s chair is to actually go buy a set of yoga blocks.
They were not very expensive, they’re but they’re very hard. They’re very hardy, they’re durable. And then depending on you know how crafty you are, I guess that one thing to do is to go to a craft store and buy the double stick Velcro and strip it on the sides of the chair, put a strip on the bottom of the yoga lock, and you just attach the yoga blocks to the side of the chair. Now if you’re like me, and you’re not very clever, duct tape is wonderful. But just duct tape the yoga blocks onto the chairs well that it comes like an arm is that what you’re saying?
Dr. Kay Toomey:
So it becomes essentially an armrest correct? And, and so that’s what we’re looking for, we’re looking for better side support, we’re looking for better hip stability. And then it’s nice for the children to have someplace to rest their arms if they need to. But you really want those yoga blocks right up against the hips. So you kind of potential has to squeeze the child in just a little bit.
You don’t want to squish them, you know too much. But you do really want those side, yoga blocks the side support to actually be touching the child’s hips and thighs so that they have that really good side support, then what they will be able to do is sit up very straight. But if they need to wing a little bit or Prop A little bit, they can put their elbows on those side arms, instead of having to lean forward on the table.
When you lean forward, what happens is that you put your head and neck in an incorrect position for chewing. And if your listeners want to prop their elbows on the table or their desk, they are going to get themselves in that position where their head and neck are kind of forward. And then if you try to chew, you’re going to see it’s much more difficult than if you sit upright with your head balanced on your neck.
How much easier is it to chew when you sit upright with good posture? Obviously, the big challenge for children to transition from purees to texture table food is the skill of chewing.
Now everybody thinks that chewing is the end-all and be-all skill, but it’s actually tongue-in-movement. That is the foundation for chewing. And so I am going to bring up a handout that we’re going to go ahead and sin and let your readers look at. And it is a handout that’s called the developmental food continuum. It actually thought I had the handout up and I apologize, it looks like I have too many things open on my computer right now.
Vaish:
I nobodies. And for those of you who are listening to the podcast, there will be a link. So you can watch this on YouTube if you want to see the handout.
Dr. Kay Toomey:
Excellent. Excellent. So I’m going to bring up two handouts that we are going to hopefully be able to use you know what I am. Let’s see if I can. There we go. So there are going to be two handouts that go together. This first one is called beginning food exploration. I’m going to have people read through this when they get the biggest reason why we need this handout is because of the notification on the bottom, we’re going to use a very specific type of food texture, to help develop the tongue movements that children need to learn in order to transition from purees on textured tables. And it’s something that we call an SOS a hard module.
Vaish:
We can use a hard munchable. Right?
Dr. Kay Toomey:
Yeah. And the term means specifically to use a long, hard, very hard stick shape food. The job of this food is for the child to only Munch up and down on it, to not actually break a piece of it free, so that they can learn the tongue movement first before they have to learn how to chew. And so let’s see if I can bring up the developmental food continuum.
Vaish:
Tell me to flash if you can see this. I can see it okay, yes.
Dr. Kay Toomey:
Judge the developmental food continue. So knowing about how children learn from an oral motor standpoint is obviously we begin with breast and bottle feeding. And initially, breast and bottle feeding has a reflexive oral motor movement that’s sometimes referred to as a suck sometimes is referred to as a suckle. It more or less means the same thing. It’s where you cut your tongue around the base of the breast nipple, or the bottle nipple, and you the tongue forward and back to draw the fluid into the mouth.
This is a reflexive movement at first, but your reflexes for eating actually go away between four and six months of age. And between four and six months of age is typically when some kind of puree or spoon feeding is introduced. And for children with Down syndrome, we are going to actively encourage families to use the spoon and to use purees with these children.
There is another approach out there that’s referred to as baby lead weaning where parents just put adult table food on the tray in front of children. And research shows that children with Down syndrome do not do well. With that approach. I say baby-led weaning actually skips the full left-hand side of this page. And baby-led weaning starts in children at about the nine-and-a-half month age range. That is a challenge. If you are very typically developing.
Many kids will have already acquired some of these earlier skills, even if they don’t practice with a spoon. That is not what happens with children who are at risk for feeding challenges. And we know children with Down Syndrome have a much higher percentage of risk for feeding difficulties.
For example, we know that 60% of children with Down syndrome are actually going to struggle with aspiration. So that 60% of children with Down syndrome, right from the beginning of breast and bottle feeding, are going to be struggling with the coordination of sucking, swallowing, and breathing, so that they can get the food down correctly and not spray.
We know that because of the low tone, these children are much more at risk when you have a child present risk or developmental delays, you don’t get the luxury of skipping steps, you have to do every step because your child needs to master and practice every step along the way. Because the steps are not going to just happen for these kids.
We need to start with the student feed. And we are going to start with spoon-feeding somewhere. At four and six months of age, typically, the biggest readiness signal for starting purees is if you put your child in a seated upright position, that they can hold their body and their head upright for five to 10 seconds before they follow. So they don’t have to get into a seated position. If you put them in a seated position, you can give them some side support. If you put them in a seated position, can they hold their head and neck upright and keep their body upright, for between five and 10 seconds?
Vaish:
So this is an indicator that your child is ready for spoon feeding, that is an indicator that they’re ready to begin the spoon feeding.
Dr. Kay Toomey:
Now from our last talk, we talked about the fact that with little bitty babies, between four to as much as six to eight months of age, we’re actually going to support their stability by letting them lean back a little bit. Yeah, Infant Feeding chair. And that would be what I recommend for your families with children with Down syndrome is that they purchase an infant feeding chair, like the first year’s chair that we talked about last time and that you begin the spoon feeding where the chair is doing a lot of support work for them until they’re really and truly able to sit upright by themselves for long periods of time, that’s when you would move them into one of those adjustable seats.
You’re going to begin with them in a slightly reclined back position when you start the spoon feeding. But they have to have the ability to hold their head up and some core strength. And that’s why you test this by putting them in a seated position. See how long can they stay before they tip over. And we’re looking for only five to 10 seconds. And so once you start the baby foods, what you’re going to see if they’re going to reflexively try to suck on a spoon, right?
That’s the reflex that’s in place. This is why when you first start spoon-feeding your baby, a lot of the food comes out at you. Because what the babies are doing in that cycle is forward back. Because they’re trying to stop along the spoon. Some of it’s going to get pushed down, and some of it’s going to get pushed back. And what your child has to do in this stage is they have to shift from that reflexive cycling motion to voluntarily controlling the cycle to only moving the tongue backward. And that’s why we start with very thin baby food cereals.
We also start with thin baby food cereals. Because around six months of age, children are going to lose what leftover iron and zinc they have from their mother and the pregnancy. And you now need to supplement their iron and zinc with fortified baby cereals. So around typically for a child with Down syndrome, I would say six months you would be introducing thin baby food cereal usually mixed with some formula or mixed with some breast milk. And those early feedings are not about trying to get volume in your child.
Those early feedings are about trying to support your child in learning how to move from a reflexive cycle where they actually can control that cycle and they can slow Them on and try to move the tongue forward, but then slowly move the tongue back so that more of the food comes into the mouth, instead of going forward, back forward, back, forward-back, and pushing most of it out. When you see your child low dam, and really start pulling the cereal backward into the mouth, that’s when you would introduce that thin baby food puree. So typically what most baby food manufacturers call is stage one. And we really want families of children with Down syndrome to be practicing this with the spoon. Many families because of the pouches are going to give their children the pouches.
The problem with the pouches is that you suck the pouch like you do the breast or bottle. So the pouches are not going to teach the babies any new skills. And so if families of children with Down syndrome are starting their children on the pouch, they may get some volume of puree in their child, but their child is perpetuating old oral motor movement that we don’t want to be perpetuating.
Vaish:
So this food continuum you’re making the point of this is not just nourishment, it’s you’re planning both, you know, the oral motor skills that the child needs to go to the next step. And this is maybe even more progression of oral motor skills than the nourishment itself.
Dr. Kay Toomey:
Exactly. Actually, you are absolutely right. In the first couple of months of practicing on the spoon, it is not about the volume on the spoon, the child is still going to get the majority of their calories from the breast and bottle. The first couple of months of using the spoon is about practicing learning new oral motor skills, about learning new flavors of things.
One of the other challenges with the pouches is they typically add all of the things together. And so the baby food pouches taste very similar to one another. And, and that we don’t want that either. Because boom, texture table food tastes really different. And if your child is only getting one flavor, because they’re eating pouches, and all the pouches more or less taste the same. Many of the pouches are mixed with Apple and apple sauce. So the apple becomes the overriding flavor. Or many of them are mixed potentially with carrots or so your childhood, like
Vaish:
A taste intelligence that we’re developing in detail.
Dr. Kay Toomey:
Yes, you have to build their flavor palette.
Vaish:
Right? That’s a nice word. Because it because food tastes really different.
Dr. Kay Toomey:
Whereas, you know, if you’re mixing all the flavors together, you only have one flavor. Most of us do not just eat one flavor at a meal, we have several flavors at a meal. So it’s the first two months of working with the spoon are not about volume or nutrition. It’s a little bit about nutrition. Because we need that extra zinc, we need that extra iron.
We need those extra vitamins and minerals. But it’s really about learning about developing the flavor palate, and about learning how to move the tongue differently. And one of the questions you asked me is, the parents of children with Down Syndrome have asked you why did these children stay on puree so long? Well, one reason is that if parents are using pouches, and not practicing on the spoon, their child isn’t learning any new skills. And these children have to practice with the spoon to learn some new skills.
Vaish:
And I may be jumping many steps here and asking you this question. Feel free to come back to it later. Uh, one of these things was now perhaps we all know like, you know, 18-year-olds and 20-year-olds were still on fully pureed foods, can they come back to this continuum?
Dr. Kay Toomey:
Ah, you know, 1820 years is a long time to be doing the wrong or motor patterns. And I would say try it. And, and, and see where you can get how I feel about working with any child who has any kind of development is that we’re going to go into teaching them a new skill with the belief that they can learn And then and that the child is going to tell us and show us how far in the process of learning the new skill that they can actually get. But I like to teach them the new skill, we have to have the right steps in place. Because as I said earlier, these children are not going to be able to skip steps and learn the skill. These children have to master each step one at a time before they can go to the next higher part of the skill.
Vaish:
We can try it, but also with the understanding that some patterns have been very deeply ingrained. So it may, it may take a long time, but it may be worth trying.
Dr. Kay Toomey:
Yes, I think it’s worth trying. Absolutely. So So once the child loses their reflexes for eating around six months of age, they are now going to have to voluntarily move their tongue in a way that’s going to support their eating. And they’re going to do that by instead of going fast back and forth, back and forth, slowly drawing the tongue just backward to pull the food into the mouth, and keep it in the mouth. And as I said, that happens usually around six, or seven months. And they do that within baby foods, what you’re going to start seeing around seven, or eight months, is you want to see, the tongue actually starts to cut under the spoon, and the lips closed down on the spoon.
I don’t have a spoon on me, but I’m gonna borrow my pen. So we want to see the tongue cut the lips close. So another unfortunate error that parents will sometimes make in trying to feed their children is they are putting the spoon in and scraping it up against the teeth or the palate, or they’re dumping the food on the child’s tongue. Neither of those two things is going to encourage the child to learn this skill.
When you scrape the food into the roof of their mouth, or you dump it on top of the tongue, you as the adult are doing all the work. And so the child doesn’t learn the skill. So when you feed the child, and what you want to do is you actually want to stop with the food right in the front of the mouth. Just dive straight in right in the front and wait and give your child a chance to cut their tongue around the spoon and close their lips on the spoon.
Vaish:
And I feel like this add in another way you’re giving the child some control over their own intake and not forcing food on them. So at least I mean, it sets the stage so much for like future decisions your child is making.
Dr. Kay Toomey:
Absolutely. And you want them to be in control. Because when they are in control, they’re going to be safer than when the grown-ups are trying to just dump food in their mouth, right? Actually, put accidentally put it back too far. And then we could cause a choking episode and aspiration episode. Whereas when the child is doing it under their own voluntary control, they’re going to be much more cautious than we are as the grown-ups.
Vaish:
Not to mention feeding right?
Dr. Kay Toomey:
Well, exactly. For children with down syndrome, right, yeah. So so once you see that your child can actually close their lips on the spoon, and cut their tongue on the spoon, then you can go to the thicker baby foods. So we start usually with like peaches and apples and sweet potatoes and carrots because they’re thinner. And by the way, it’s a myth out there that if you start your baby with fruits that they’ll only eat fruits and they’ll become sweeter holics and they won’t ever eat vegetables. We know that innately human beings a predisposition to not eat vegetables, vegetables are bitter. And we are genetically predisposed to not eat bitter things because they are things that can be poisonous.
Typically things that are bitter are poisonous. And so there’s a genetic predisposition to not actually eat vegetables. And so it’s actually better if you start with fruit first to make the first experience pleasant, happy, and exciting for them. Then the second food you introduce is one of the sweeter vegetables like sweet potatoes or In pure carrots, and then over time, you know, so we recommend you alternate, a fruit for three days and new fruit for three days, then a new vegetable for three days, then a new fruit for three days and new vegetable for three days. And over time, you can start building on the fruits and vegetables that are a little less sweet.
Hopefully, as they gain these oral motor skills, you can shift into the ones that aren’t so thin. And you can go more to the stage of baby foods. And things like peas, not only are peas kind of bitter, but they’re pretty thick as well. And you have to have good skills to be able to manage the thickness and to slowly get used to different flavors. And so what you’re going to see then, is that people think we move from thin purees to thicker purees to purees that have Funston what people call the stage three baby foods, we actually do not progress that way. And that’s why there’s a little stop sign. Before stage three, I see. Yeah, on the page, we actually have to go from the thicker purees, or the really evenly matched table food purees to the opposite end of the texture continuum. to that group of foods.
Vaish:
We call that so counterintuitive, I would never have thought that.
Dr. Kay Toomey:
We learned that you can do what’s called a mixed texture that has a thin puree background with chunks and bumps in it until you’ve learned to chew is this
Vaish:
For kids with a risk of like you said oral developmental delay every child on the planet.
Dr. Kay Toomey:
I see. And, and so going from stage one to stage three baby foods is not developmentally appropriate, you actually have to shift over to the right-hand side of the page and get tongue control first.
Vaish:
So if the listener is not watching this on YouTube, what I’m gonna say right now is go to functional nutrition for kids.com/feeding. SOS, where I have Dr. To me you can download everything she sent. And there you can pull this up and just pause this video or audio, for now, if it’s video, you’re probably seeing it but if it’s audio, pause it pull it up, because you can see the STOP sign that she’s put in. I was very surprised to see that stop sign because it was like what’s going on there? How are we going in a very counterintuitive way. And that’s what he’s talking about now.
Dr. Kay Toomey:
Yeah, exactly, exactly. So what we want to do is with this boom, once you see the lips close on the spoon, and the tongue cup under the spoon, we want to on purpose begin to give fairly thick, either table food purees, like a pudding, you could even do or most people will introduce is a custard style of yogurt. Custard style, like Greek yogurt, tends to be very thick. Or you can mash up table food like a very ripe banana into a very thick but even mash, we don’t want lumps and bumps in it.
So it needs to be super evenly matched or you really cook up some carrots, and you evenly mash those. So you’re going to get a little more texture, a little more thickness. And what that bigger texture and bigger thickness do when it comes to the spoon is it draws the tongue to do what we call a tongue wave. And so with the soft mesh table foods and the table food smooth purees, we’re building on the early skill of moving, closing the lips moving the tongue back to now actually doing a wave. So I want you to think about if you were going to eat a spoonful of cheesecake.
When you put that cheesecake in your mouth, what most of us do is we cut our tongue around the base of the spoon, and then we kind of pull it into our mouth and squish it into the palate we call this what we do. And that’s what that tongue wave is that tongue wave squishes those thicker textures into the palate and draws the food back and there’s usually some suction involved too.
So the and that’s what you want to see that tongue wave and the tongue wave is what we want to be practicing on the spoon. But at the same time, we now need to introduce a texture group called Hard munchables. And the hard munchables are going to be explained in that other handout I showed you called beginning food exploration. And a hard munchable is a long hard stick shape food that’s so big and hard that your child’s not going to get a piece of it off. It needs to obviously be small enough to fit in their mouth. It needs to be big enough, they can’t get a piece off. So we’re not going to use baby carrots. We’re not going to use a carrot stick, we’re going to peel the whole entire carrot. We’re going to use stock to use a raw asparagus stem.
Vaish:
Oh, that’s hard enough as well. Okay,
Dr. Kay Toomey:
yes, yes, we’re going to use something like raw lemon grass stems, you could use something like a very hard, hard beef jerky, you could use a big, really fat sphere, at least the size and shape of a big fat marker of something like Hichem you could potentially use, you could use the stem of broccoli raw, and make it about the size and shape of a really big fat marker.
The goal of heart munchables is for the child to put this stick shaped food in their mouth, and we get to begin to move it around with their tongue. So the heart munchable needs to be long enough that the child can get their hand fully on one end, and the other end all the way to the back molar. And exactly, so about the size and shape of a pen, or a big fat Mark pens will be to them a big fat mark. And what the child is going to do is that first, when they put it in with their hands, their hands, their hands will move it back and forth.
When you put something in the side of your mouth, you are going to actually activate a reflex called the transverse tongue reflex. And your transverse tongue reflex is a reflex that happens to notify your mouth that you just put something hard in the mouth, and the tongue automatically goes over to figure out what you’ve put in your mouth.
We have to get control over this reflex in order to advance to table foods textured staple foods. And the way you get control over this reflex is by putting long stick-shaped things in your mouth. And so at first, you stick it in your mouth, the reflex happens but as you move your hand that your mouth at first your tongue follows what their where the hand is moving to hard munchable. But over time, in practice, the tongue will start moving in the opposite direction of where the food is.
The purpose of the hard munchable is when you see the child can put something in their mouth and actually move their tongue freely all over the inside of the mouth versus getting stuck up against the food. You know they have voluntary control over this reflex. Now I’m going to stop sharing, oh no, I don’t need to stop sharing, let me know VOSH. If you can see this new handout that I just I
Vaish:
can I can see the two bins?
Dr. Kay Toomey:
So you can also work on developing this skill by practicing with teething toys. And so that’s what this handout is that I’m making available to people we want parents during meals to actually be using true food. Outside of mealtimes. We want parents to create a shoe bin of Big Stick shape things that are kinds of examples of stick-shaped teething toys that you might put in your shoe band.
Vaish:
For those who are listening again, this is another handout it’s called Cubans and this is also if you click on that link you will also get a sender.
Dr. Kay Toomey:
Similar to twitch but you don’t have to use oral stimulation choice may be spoon is a great thing to put in a tube in children Toothbrushes are great to put in a tube in a rubber snake would be a great thing to put in a tube in massagers, the three prong massagers that have the three little legs. Yeah, I like them. Any, those are great because they vibrate as well. So anything that’s a long, hard stick shaped thing, is what we want to be having the child use outside of mealtimes. during mealtimes, we want to use actual food.
This is how children learn when I’m quite a bit older than probably many of your listeners. And, and back in my day, when we were very young infants, what we used to do is we used to give children things like steak bones to not, we used to give kids, the rinds of watermelon, to not use to do this naturally. And the issue became that people weren’t watching their children carefully enough. And so children had choking episodes.
That’s why this beginning food expiration out, hopefully, you can see this says on the bottom of it, they ever leave a child who’s learning how to eat unsupervised, because any child who’s learning how to eat, especially if you’re using a hard Punchbowl of some sort, is potentially at risk if they’re not supervised for having some kind of a choking episode. So when you choose your hard munchables, during your meal times, you want to make sure they’re long enough that your child really and truly can’t get a piece off. And at the bottom of the developmental food continuum handout. There are other examples of hard modules.
For example, a whole dill pickle is a marvelous word munchable frozen french toast deck, you have to carefully watch your child as they’re working with the hard munchable to make sure that a piece doesn’t get loose, right? If your child is, you know, got enough strings or enough tea, that they can get a piece loose of one of the hard munchables you’re using during meals, you have to stop using that food as a hard Lunchable. And you have to find a different card munchable to use.
So this is this food group, the hard munchables are how we help especially children on the autism spectrum, advanced with their eating by practicing with the hard Munch bowls, because they’re a single uniform texture, but they have different flavors. And so it’s a safe texture for kids on the autism spectrum to explore and get new flavors that are used to new flavors. And the goal is to get this voluntary, side-to-side tongue movement that is what we’re looking for.
Yeah, once you can see that they have voluntary side-to-side tongue movement, then you’re going to work on something we call meltable hard solids and multiple hard solids are going to be things that would dissolve very quickly in your saliva. And at first with kids with Down Syndrome and children on the autism spectrum that are stick shaped again. Because when you give a child a stick shape food and they put it in their mouth, the leading edge of the stick is going to land on the back molars, which is food needs to be transferred to in order to learn to chew it properly. So things like graham cracker sticks, veggie straws, snap pea crisps, baby.
Those are all great stick shape mountable, right and as the child practices with that stick shape mountable. Then you can move to the small meltable pieces, like the baby cereal puffs that are out there. Little you know, pieces of something like pirate booty, you know, a small piece of some veggie straw. You could use So, the skill we’re learning with those meltable hard solids is something called tongue tip lateralization.
If you put the tip of your tongue on your very last molar. That movement that you just did is called tongue tip lateralization when we have a small piece of food in the front of our mouth. From the front of our tongue, we have to transfer that food to the back molar. In order to chew it correctly. The foundation of chewy is first getting voluntary control over the tongue reflex. So that you can move your whole tongue voluntarily from side to side. And then the next skill is to move the food from the side to the back. Molar. Because in order to texture table food, you have to get the food onto the back molar. So what we call tongue lateralization, voluntary tongue lateralization movement of the tongue side to side, we bring on board with the hard munchables. And then we work on tongue tip lateralization with the meltable hard solids.
When you see that your child can voluntarily transfer a piece of food from the front lips to the back molars, then you can introduce cubes of table food, because, in order to chew food, it has to start on the back molars. And we start this process with very meltable foods. Because when children are learning to eat, they’re not good at the skill. And if they don’t get it to the back molar, we want the food to melt away in your mouth, right, and not accidentally fall backward and cause them to choke.
Right. And then we go to what we call soft cubes. Soft cubes are things that are so soft, that if your child doesn’t get it to the back molar, and the food accidentally falls on top of the tongue, like the middle of the tongue, they can just squish it into the roof of their mouth and still swallow down. Right. So a stock cube would be like a very right piece of avocado, a piece of peach that’s been soaked in peach juice, a very soft piece of boiled potato. Once they can manage stock cubes, then you can go to what we call soft mechanical food. And the soft mechanical foods have to go to the back molars because they actually require some chewing or reading. So things like pasta is a soft bread is if stuff mechanical, very, very soft meat.
Vaish:
Now I understand why those foods are so the horse so hard to chew. I’ve observed it in my son and I still wonder how come he can have a crisper like, you know, like a Preseli texture thing. But now if he has broccoli, he’s following the whole broccoli and what’s going on here. So I see that now.
Dr. Kay Toomey:
Yes. So a lot of kids can do those crunchy foods because you can do what we call rabbit munching on your front teeth. Right. And you can break them into little enough pieces, that when you mix them with saliva, you can squish them into the roof of your mouth and still get them down. And that is not a correct oral motor movement pattern. We don’t want to be teaching children that pattern. So, so the hard munchables get voluntary control over the reflex. So you can move your tongue laterally from side to side.
The multiple foods next are going to work on that hung tip lateralization to the back molars. The soft cubes are going to practice actually, up and down munching on the back molars. The soft mechanicals practice shifting the job side to side on the back molars. And then you can move on to mixed textures where you actually have a true chewing motion. So this is going to be the process that families with children with Down Syndrome and Autism who are not transitioning or purees need to go through the children to learn each skill at a time before they can progress to those harder bigger. Yeah.
Vaish:
And that is so so thorough. So thank you, doctor, to me that is so thorough, and as people, I’m hoping we’ll look at the handouts while listening to the talk. That is when you really I mean it’s kind of beyond thorough. You’ve really broken it down pretty much into every step that people have to do. Like I was actually thinking of my son some of the clients that I work with, with I could see like some many of the holes that we’ve kind of fallen into eating one food at a different like, you know, maybe developmental stage when they’re not really an eye.
I’ve heard people talk about developmental stages of crawling, you know how sometimes people will forcibly make people sit or walk, kids, sit or walk in walkers with Down syndrome. And that conversation I’ve been privy to, and it was very obvious to me that, you know, a kid should not be on a walker until they’re ready to walk or a kid should not be forced to sit for long periods of time in our in car seats because you’re like missing developmental stages, you kind of like you have, it would be ideally people would crawl, kids would crawl before they walk then by army crawl all of that. But, you know, you brought that same thing to the oral motor part where now these are the steps that you need to go through and we’re doing so much jumping, we’re in such a hurry. Right?
So Right. Yeah. And understandably so because we want our kids to eat good food and, you know, be able to outsource the food a little bit, maybe for some people.
Dr. Kay Toomey:
Yeah, right. It’s very much about that. One of the reasons why children stay on purees for too long is because people are trying to jump those developmental steps, and the children can’t do it. And so the children resist. And, and if we teach them each of the skills individually, then they will progress on to more textured tables. And we work with children with Down Syndrome and Autism every day. And we teach them how to do the skills and transition them off their purees.
Vaish:
And as always, they can reach you at SOS feeding.com. Correct. Absolutely. And if you want to work with Dr. Tony, enter the team, you can, you can return.
Dr. Kay Toomey:
Yeah, as we talked about the older the child is, the harder it is to teach those new skills, but it’s still worth trying. And it’s still worth connecting as is true for any skill.
Vaish:
I mean, I can’t learn languages now as much as I did when I was a kid. I think that’s just universally true for everybody. But Right.
Dr. Kay Toomey:
Right. Yeah, it gets harder as we get older, doesn’t it?
Vaish:
Well, thank you so much. I mean, you’re such a wealth of information. There’s just like every time we talk I can think of like five other topics I’d love to talk to you about. So maybe I get one talk again sometime. But thank you so much.
Dr. Kay Toomey:
Thank you and your listeners for their time.
Vaish:
I have put together everything that Dr. Tony references plus my own set of handy notes on functional nutrition for kids.com/feeding SOS, I noticed the episode was so full of information that a list of action items would probably be super helpful to you. I found myself taking furious notes while listening to Dr. To me. I went back over and over again and deleted and redid the notes so as to just keep it simple for you. And for me.
This is episode 98 of functional nutrition and learning for kids. For those of you wondering yes, I did remove the episode on vegan diets, it’s going to be back because I wanted to give you a more complete picture by adding in a lot more research. So look forward to that in the next few weeks or so that we’re going to get a more complete picture of the pros and cons of a vegan diet, where it should be used, and where it should not be used. Until next week. Bye.
