Problem-Solving with Catherine: 15-month-old with TOTs and Difficulty Chewing

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What am I missing? 15m old, chewing crunchy things, meats and starches (muffins, toast, fruit breads) and swallowing without difficulty. Drinking juice (not water) from a straw. Eating dried fruits and snap pea crisps well. But fresh fruits and veggies, we are making almost no progress. Will put most trials in his mouth, chew then push out, then refuse further attempts. Likes yogurt but refuses all other purees. No trouble with getting hands messy. GI had no concerns, did an MBS with no notable findings. Frenectomy recommended by ped dentist to be done soon.

Catherine’s Answer:

Is he otherwise normally developing without any feeding history that sounds worrisome? What is his overall sensory system like? Any history of reflux? I wonder about the swallow study results and data that was obtained. While there apparently was no witnessed aspiration, did they describe swallowing physiology in the findings? That data can provide more information about muscular synergies and the multiple components that underpin chewing that might be problematic. It is not uncommon for swallowing physiology to be altered in the setting of tethered oral tissues, but there may be other findings from the swallow study that could shed light on the “bigger picture”.  The ability to recruit full ROM for chewing a full variety of foods may be sensory-based, motor-based, and/or due to the impact of the altered ROM of the check/lip/lingual muscles due to tethering, and/or a combination of any of these. Take a careful re-look at oral-motor control and preferential foods/liquids to help you peel apart what might be the “why”. The sensory “load” from the foods that child is successful with, and the bolus control required, and also the co-occurring muscular requirements for posterior bolus formation and full ROM for BOT retraction, are key considerations. It’s complex, so pause to sort it out and figure out the “what else” that might be impacting what you are seeing. The apparent need for a release is clearly a factor in your differential, but like a “detective,” now focus on if there is anything else that underpins function that might be aberrant. It may be that the release planned will not in and of itself promote normal eating patterns; I suspect that is unlikely. Whether there is perhaps also learned maladaptive oral-motor behavior and other reasons for his preferences will need to be sorted out and treated to support optimal feeding outcomes.




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