“The best practice for swallowing is swallowing” – Dysphagia in Children and Adults

Basia

Swallowing Evaluation and Rehabilitation

Check my other post:
Dysphagia - Feeding & Swallowing Disorders in Infants & Children

http://slpzone.blogspot.com/2012/05/feeding-and-swallowing-disorders-in.html    

Dysphagia and Swallowing Therapy and Treatment, Diet and Liquid Consistency

http://slpzone.blogspot.com/2012/04/dysphagia-and-swallowing-therapy-and.html

 

Basia

I refreshed my knowledge about Dysphagia by viewing ASHA webinars:

“Elements of a Comprehensive Clinical Dysphagia Evaluation presented” by Joseph Murray, PhD, CCC-SLP

“Impact of Impaired Antomy and Physiology on Treatment of Dysphagia in Adults” presented by Nancy B. Swigeret, MA CCC-SLP, BCS-S

“Dysphagia Intervention: Planning and Implementation” presented by Nancy B. Swigeret, MA CCC-SLP, BCS-S

“Theoretical Basis of Exercise and Treatment of Dysphagia” Nancy B. Swigeret, MA CCC-SLP, BCS-S

 

Basia

What is normal swallowing?

Normal swallowing consists of a set of physiologic behaviors which result in food, liquid or other substances moving from the mouth to the pharynx and esophagus while protecting and closing the airway to the stomach. Swallowing is an important part of eating and drinking.

What is swallowing dysfunction?

When the process fails and the bolus is aspirated, this is called swallowing dysfunction or dysphagia. Dysphagic patients may have difficulty with any one or more of the anatomic or physiologic components of the oral, pharyngeal or esophageal stages of the swallow.

Basia

What is a role of swallowing evaluation?

Evaluation of the patient with dysphagia should identify the anatomic or physiologic abnormalities characterizing the patient's swallow and include introduction and assessment of the efficacy of treatment strategies.

Basia

What is the primary goal in the management of swallowing disorders?

The primary goal in the management of swallowing disorders is to ensure safe swallowing. For determination of the appropriate rehabilitative approaches, clinicians should consider the assessment of all symptoms and problems causing dysphagia.

What are tree types of management?

The management of swallowing disorders:

• medical management
• surgical approaches
• rehabilitative approaches.

What are the types of treatment?

Treatment may involve:

• compensatory management, such as postural changes or enhancing sensory input
• rehabilitative management, such as active muscle exercise with or without the introduction of food.

Play with, Try and Enjoy Fruits and Vegetables

Many children eat few or preferable fruits and vegetables, don’t like or are reserved to try the new one. A very good way to break their habit is by letting them to explore the texture, smell and flavor when helping you in cooking. Preparing food for a surprise party, a play date or for someone who the child loves is the best time to push in the new ingredients to their diet.

Yesterday Basia made Dad's favorite Vegetable Salad with Mayonnaise.

Basia, 2012

“The origin of cooked vegetable salad goes back to 1864. Russian chef Lucien Olivier prepared this salad especially for Tsar Nicholas II. Oliver never gave this recipe to anyone. After his death, people tried to reconstruct the recipe, naming it Olivier salad. It was more sophisticated then present vegetable salad, which, after the war, was simplified and called Russian salad.”

Vegetable Salad with Mayonnaise - Recipe

Ingredients (for 8 servings)

3 large carrots
3 large potatoes
1 parsnip

5 hard boiled eggs
1 can of green peas
5 medium pickled sour cucumbers
2 apples, peeled, cored
1 small jar of mayonnaise
1 tsp of mustard

Preparation (time around 1hr)

Boil water in a large saucepan. Add and cook the carrot, potato and parsnip until tender. Remove them and drain. Set aside to cool. When cool, peel and chop into small cubes. Transfer to a serving bowl.

Chop the apples, pickled sour cucumbers and egg into small cubes. Mix with cooked vegetables. Add green peas. Season with salt and pepper.

Basia, 2012

Add mayonnaise and mustard.

Basia, 2012

Mix well. Add more salad and pepper if necessary.

Final Result, 2012

To learn more about picky eaters and ideas how to face the problem go to my old posts:

http://slpzone.blogspot.com/2012/04/picky-eater-and-new-food.html

Thanksgiving Pie and Other Ideas

Baking

The recipe is for 2 (two) 8-or 9-inch pie pan.

Pie Crust:
2 Cups of All-Purpose Flour
1 Cup of Confectioners Sugar
1 Yolk
2 teaspoons of Sour Cream
3 teaspoons of Baking Powder
4 oz of Soft Shortening/Butter

Filling:

16 to 20 oz chunky apple sauce for 1 (one) 8-or 9-inch pie pan + 8 crumbed baby biscuits
16 to 20 oz pumpkin pie mix for 1 (one) 8-or 9-inch pie pan
16 to 20 oz whole berry cranberry sauce for 1 (one) 8-or 9-inch pie pan

Sift together flour, sugar and baking powder. Cut in shortening. Add yolk and sour cream. Mix it all to make stiff dough. Divide dough into two equal portions to get 4 portions for 8-or 9-inch pie pan (2 portions for the bases and 2 for the tops.) Roll one portion on lightly floured surface into circle 1/8 -inch thick. Fit onto 8-9-inch pie pen. Now it’s time to preheat oven to 425 F (hot.) Add filling. (Attention! Chunky apple sauce mix with 8 crumbed baby biscuits. Whole-berry cranberry sauce and pumpkin pie mix are ready to use.) From the second ¼ portion make straps and place them on the filling to decorate it. Repeat the process for the second pie pan. Bake in reheated to 425 F oven for 20 minutes, lower the temperature to 375 F and bake 25 minutes longer or until gold. Let the pies cool on a rack for at least 1 hour before serving. You can sprinkle your pie with confectioners sugar.

Thanksgiving List

While waiting for the pies to cool down it’s a great time to make a Thanksgiving List, e.g.
I’m Thankful For:
You can also use the template. Click for the printable version http://www.dltk-holidays.com/t.asp?b=m&t=http://www.dltk-holidays.com/thanksgiving/images/b-givethanks-turkey.gif

You can play a Thanksgiving Alphabet Game. Click for the printable version https://docs.google.com/file/d/0B6QDkuYk8VqSSHhjTXlEcEVKY2M/edit?pli=1      

Thanksgiving Cards

First idea:
You need a piece of white paper, child’s hand to trace the fingers to make a turkey tail, markers, crayons or paints to color.
When finished place the wishes on the back of the turkey.

This isn't just a turkey as you can plainly see.

I made it with my hands which are a part of me.

It comes with lots of love especially to say,

I hope you have a very, Happy Thanksgiving Day!

Second idea:
Cat the template, glue and color with markers crayons or paints.
http://therapyfunzone.com/blog/wp-content/uploads/2010/11/cutting-turkey-white.pdf  
http://spoonful.com/sites/default/files/0606_thanksgiving_turkey_template.pdf
When finished place the wishes on the back of the turkey.

Joy, Happiness, Health

And many more

Are my wishes for you.

Happy Thanksgiving!

That’s a thank you card my daughter made early this morning.

That’s a thank you lunch she prepered for daddy.

Thanksgiving Book

  

You can also make a simple Thanksgiving book, ask wh- questions and practice reading.
http://www.dltk-teach.com/minibooks/thanksgiving/index.htm
Roll down for the printable version.

 

Dysphagia - Swallowing Treatments

Normal Larynx

Behavioral Therapy

Behavioral Therapy are postural maneuvers or compensatory strategies that are implemented to insure a safe swallow.

For example, a HEAD TURN is implemented when it is found that a patient is numb on one side of their throat during a FEESST exam. By having the patient turn their head to the numb side, the area of the throat that is numb becomes narrowed so that incoming food gets directed towards the sensate side of the throat.

Types of Swallowing Behavioral Therapy include:

A. Postural Techniques

• Head Rotation to Weak Side or Strong Side - By rotating the head to the side of either motor or sensory weakness, the patient can eliminate the injured side of the pharynx from the food bolus path.
• Shaker Exercises - Another way to open the upper esophageal sphincter by having the patient lay flat on their back and, in a precise manner, slowly lift their chin to their chest.
• Chin Tuck - By placing the chin downwards toward the chest the patient: 

1. widens the vallecula to prevent bolus from entering airway 
2. puts the epiglottis in a more protective position 
3. narrows the laryngeal entrance

• place bolus in swallow position
• swallow while holding breath 
• cough after swallowing before inhaling (this clears any residue that may have entered the larynx)

Dietary Therapy
Pharmacotherapy
Surgery

A) Zenker's Diverticulectomy Three procedures have been described to treat a Zenker's diverticulum: diverticulectomy, diverticulopexy, and peroral endoscopic division of the party wall between the diverticulum and the esophagus. Diverticulectomy is usually selected for treating large diverticula in otherwise healthy patients. It involves an open-neck operation where the(Zenker's) hernia sac is identified and isolated. The sac is then resected its neck, taking care not to compromise the esophageal lumen by resecting too much mucosa, and closing the pharyngotomy with a watertight closure. A cricopharyngeal myotomy is performed as close to the posterior midline as is possible to minimize risk to the recurrent laryngeal nerves; the myotomy consists of dividing the entire circular cricopharyngeus muscle. Diverticuloplexy, combined with cricopharyngeal myotomy, is preferred by some surgeons for dealing with small diverticula or large diverticula in high-risk patients. The sac is isolated and tacked with permanent suture to the prevertebral fascia, such that the mouth of the sac is in a dependent position. Diverticulopexy avoids a pharyngotomy, reducing the risk of a pharyngocutaneous fistula or injury to the recurrent laryngeal nerves. Endoscopic peroral division of the party wall between the sac and the esophagus was first described by Dohlman in 1960. He used a special double-lipped esophagoscope, inserting one lip into the sac and one lip into the esophagus. Electrocautery was used to divide the party wall, including the cricopharyngeus muscle. Dohlman's procedure fell into disfavor because of an unacceptably high complication rate and mortality from mediastinitis. More recently, with some modifications to Dohlman's original technique such as utilization of an operating microscope and a laser, the endoscopic approach has gained acceptance, especially for very ill patients in whom an open procedure might pose greater risks. B) Cricopharyngeal Myotomy Dysphagia as a result of abnormalities with the cricopharyngeus muscle may be ameliorated by selective use of cricopharyngeal myotomy. Cricopharyngeal myotomy may be either surgical or pharmacologic (botulinum toxin). In general, cricopharyngeal myotomy is primarily useful for true cricopharyngeal achalasia such as after vagus nerve injury at the base of the skull where pharyngeal motor function remains otherwise intact. Cricopharyngeal myotomy is contraindicated in conditions when there is impaired pharyngeal peristalsis or when significant reflux disease exists. Many disease entities where cricopharyngeal myotomy was thought to be useful in improving dysphagia, such as myopathy and brainstem stroke, may actually be of no benefit. C) Salivary Diversion Procedures Dysphagia severe enough to result in the threat or actual circumstance of food and saliva constantly soiling the airway typically requires aggressive management. Surgical procedures that divert or diminish the flow of food and saliva from the airway include vocal fold medialization, tracheostomy, laryngeal stents, reversible laryngeal closure procedures, laryngotracheal separation and total laryngectomy. The application of any one of these treatment modalities depends on several patient factors such as underlying disease process and overall health status of the patient. Patients who are aspirating regularly frequently become malnourished, which only exacerbates their underlying condition. Therefore, as measures are considered to prevent aspiration, alimentation through non-oral means should be implemented as well. Feeding gastrostomy or jejunostomy tubes, placed endoscopically (percutaneous endoscopic gastrostomy (PEG) or percutaneous endoscopic jejunostomy (PEJ), are excellent ways to aliment patients who are at high risk for aspiration as a result of severe dysphagia. Laccourreye O et al. Esophageal diverticulum: diverticulopexy versus diverticulectomy. Laryngoscope 1994.

B. Compensatory Strategies

• Effortfull Swallow - The patient is instructed to bear down, or to squeeze hard with all of their head and neck muscles while swallowing.
• The Supraglottic Swallow - Four step maneuver, inhale and hold breath (this closes the vocal folds)
• The Supra - Supraglottic Swallow - The patient follows the same procedure as with the supraglottic swallow but additionaly he/she  bears down while holding his/her breath. 
• Mendelsohn Maneuver - A technique that opens the upper esophageal sphincter. The patient is instructed to hold the thyroid cartilage up for several seconds. In this way, the larynx is kept tilted forward and elevated, thereby allowing the upper esophageal sphincter to relax.

You can learn more by watching a video with the swallowing strategies presented by a clinician-

http://www.youtube.com/watch?v=UgkRVD-LvjY&feature=endscreen&NR=1

During the FEESST test  it may become evident that certain types of food cause the patient to cough or choke, but other foods do not. During the FEESST exam the various food volumes and consistencies are used until it is determined which combinations allow the patient to swallow easily and safely.

Pharmacotherapy is therapy when certain medications may be prescribed which can help the patient swallow safely.

Depending on the results of the swallowing evaluation, certain medications may be prescribed which can help the patient swallow safely

A)  Mucolytic agents: Medications that thin-out thick secretions. Sometimes patients have very thick phlegm and mucus that makes it difficult for patients to swallow. Mucolytics can thin thick secretions so that they could be more readily expectorated and coughed.

B) Anti-acid medications: Swallowing problems are sometimes due to untreated, or insufficiently treated, acid reflux disease. The acid causes swelling in the throat which can contribute to swallowing difficulties. Under those circumstances, anti-acid medication is prescribed in order to help alleviate the throat swelling that may be contributing to the swallowing problem.

The surgical management of the patient with dysphagia primarily depends on the etiology of the dysphagia. The more common etiologies of dysphagia that lend themselves to surgical correction are described.

References:

1. Dohlman G, Mattsson O. The endoscopic operation for hypopharyngeal diverticulum. A roentgen cinematographic study. Arch Oto Head Neck Surg 1960. 
2. Ian Overbeek JJM. Meditation on the pathogenesis of hypopharyngeal (Zenker's) diverticulum and a report of endoscopic treatment in 545 patients. Ann Otol Rhinol Laryngol 1994.
3. Wisdom G, Blitzer A. Surgical therapy for swallowing disorders. Oto Clin NA 1998.
4. Pou AM. Surgical treatment of swallowing disorders: Cricopharyngeal myotomy in Carrau RL, Murray T (eds.) Comprehensive Management of Swallowing Disorders. Singular Publishing Group, Inc. San Diego, CA 1999.
5. Stevens KM, Newell RC. Cricopharyngeal myotomy in dysphagia. Laryngoscope 1971; 81: 1616-1620.
6. Lebo CP, Sang K, Norris FH. . Cricopharyngeal myotomy in amyotrophic lateral sclerosis. Laryngoscope 1976.
7. Calcaterra TC, Kadell BM, Ward PH. Dysphagia secondary to Cricopharyngeal muscle dysfunction: surgical management. Arch Otolaryngol Head Neck Surg 1975. 
8. Netterville JL, Stone RE, Luken ES, Civantos FJ, Ossoff RH. Silastic medialization and arytenoid adduction, a review of 116 procedures: the Vanderbilt experience. Ann Otol Rhinol Laryngol 1993.
9. Eliachar I, Nguyen D. Laryngotracheal stent for internal support and control of aspiration without loss of phonation. Otolaryngol Head Neck Surg 1990.
10. Castellanos PF. Method and clinical results of a new transthyrotomy closure of the supraglottic larynx for the treatment of intractable aspiration. Ann Otol Rhinol Laryngol 1997. 
11. Biller HF, Lawson W. Total glossectomy. Arch Otolaryngol Head Neck Surg 1983.
12. Lindeman RC, Yarington CT, Sutter D. Clinical experience with the tracheoesophageal anastomosis for intractable aspiration. Ann Otol Rhinol Laryngol 1976.
13. Cannon CR, McClean WC. Laryngectomy for chronic aspiration. Am J Otolaryngol 1982.

Dysphagia - Feeding & Swallowing Disorders in Infants & Children

Children with feeding and swallowing difficulties (also called dysphagia) are at risk for malnutrition, dehydration, and respiratory problems. Infants and children with feeding and swallowing problems are a diverse group, ranging from premature babies to teenagers. Parents are often the first to notice a feeding problem.

Check my other post:

Dysphagia and Swallowing Therapy and Treatment, Diet and Liquid Consistency

http://slpzone.blogspot.com/2012/04/dysphagia-and-swallowing-therapy-and.html

“The best practice for swallowing is swallowing” – Dysphagia in Children and Adults

https://slpzone.blogspot.com/2020/05/the-best-practice-for-swallowing-is.html

Causes of feeding and swallowing problems

• Prematurity
• Cerebral palsy
• Autism
• Head and neck abnormalities
• Muscle weakness in the face and neck
• Gastroesophageal reflux
• Multiple medical problems
• Respiratory difficulties
• Medications that may cause lethargy or decreased appetite
• Problems with parent-child interactions at mealtime

Symptoms

Children with feeding and swallowing problems present with a wide variety of symptoms, depending on the nature and cause of their disorder. Typical symptoms include:

• Poor feeding
• Difficulty chewing
• Difficulty drinking from a bottle or cup
• Difficulty breast feeding
• Refusing food or liquid
• Coughing or choking while eating or drinking
• Excessive drooling and food spilling from the mouth
• Liquid leaking out the nose
• Gagging
• Vomiting during meals
• Increased congestion during meals
• Increased fussiness or crying during meals
• Accepting only certain types of food (only pureed foods or only crunchy foods)
• Poor weight gain
• Frequent respiratory infections or pneumonia (may occur when food or liquid is aspirated into the airway, rather than swallowed effectively)

Evaluation and Diagnosis of Feeding and Swallowing Disorders

If you suspect that your child is having difficulty eating, contact your pediatrician right away. Your physician will examine your child and address any medical reasons for the feeding difficulties, including the presence of reflux or metabolic disorders. The pediatrician may refer you and your child to a feeding team or speech-language pathologist who specializes in treating children with feeding and swallowing disorders. The SLP will discuss your concerns and observe your child while they eat. The SLP may also conduct an instrumental assessment of your child's swallowing ability. This involves having your child eat and drink foods and liquids mixed with barium while watching them on an x-ray. This procedure is typically called a modified barium swallow (MBS) and is conducted in a radiology office. Sometimes a different instrumental assessment will be completed, which involves having a lighted scope inserted through the nose so your child's swallow can be observed.

If a feeding team is involved, which may include the speech language pathologist SLP, an occupational therapist OT, a physical therapist PT, a physician or nurse, and a dietitian, your child's posture, self-feeding abilities, medical status, and nutritional intake will also be examined. The team will then make recommendations on how to improve your child's feeding and swallowing.

You can watch 

normal swallow - animation

https://www.youtube.com/watch?v=4FMnXz6o2vI

X-Ray swallow -

http://www.youtube.com/watch?v=PwVreNrTKBw&feature=related

abnormal swallow

https://www.youtube.com/watch?v=mvAKyuI_nUE

Learn about basic of videofluoroscopy of swallowing

http://www.youtube.com/watch?v=-wmt6HlLduY&feature=related

Treatment

Based on the results of the feeding evaluation, the SLP or feeding team may recommend any of the following:

• Medical intervention, as needed
• Direct feeding therapy designed to meet your child's individual needs
• Nutritional changes
• Postural or positioning changes (different seating, etc.)
• Behavior management techniques
• Desensitization to new foods or textures
• Food temperature and texture changes
• Referral to other disciplines, such as psychology or a dentist

If feeding therapy with an SLP is recommended, the focus of intervention may include:

• Strengthening the muscles of the mouth
• Increasing tongue movement
• Improving chewing patterns
• Increasing tolerance of different foods or liquids
• Improving sucking /drinking ability
• Coordinating the suck-swallow-breathe pattern (for infants)
• Altering food textures and liquid viscosity to ensure safe swallowing
• Other interventions depending on your child's specific needs

Swallowing strategies for dysphagia 

A. Compensatory Strategies
- Supraglottic Swallow
- Effortfull Swallow
- Mendelsohn Maneuver
- The Supra-Supraglottic Swallow

B. Postural Techniques
- Head Rotation To Weak Side
- Head Rotation To Strong Side
- Head Back/ Chin Up
- Chin Tuck

Watch video with the swallowing strategies presented by a clinician - 

http://www.youtube.com/watch?v=UgkRVD-LvjY&feature=endscreen&NR=1

  

Management hints of gastro-oesophageal reflux 

1. Keep your baby upright for at least 30 minutes after a feed. 
2. Use a baby sling; which keeps your child upright, while your hands are free. Avoid baby slumping. 
3. Try elevating the head of the cot/bassinet. 
4.  Consider using a dumm. 
5. Avoid vigorous movements or bouncing a baby. 
6. The best time to lay your baby on the floor is when baby's tummy is empty, i.e. before feeding. 
7. Change nappy before feeding. Take care to elevate baby's head and shoulders. Avoid lifting legs too high. Turn to the side if possible. 
8. Avoid any tight clothing around the waist, such as tight nappies, elastic waistbands. 
9. Avoid overfeeding – if baby vomits, wait until the next feeding rather than feeding your baby again. 
10. If a baby is bottle-fed, it may be worthwhile to try AR (anti-reflux) or hypoallergenic formula.
11.  Offer a spoonful of thickened milk (formula or breastmilk) following the feed. 
12. If breastfeeding, in your diet avoid foods that can aggravate reflux, e.g. citrus, tomato, fatty foods, spicy foods, chocolate and carbonated drinks. 
13. Some reflux children may suffer from food sensitivities, and may need dietary restrictions (or the mother may consider an elimination diet). If you suspect foods may be responsible for your child's condition, it is essential to discuss this with your health care provider. Do not change your or your child's diet before seeking medical advice. 
14. Contact a reflux support organisation for further information and support. The support groups can offer the emotional support you may need.

Oral-Motor Exercises

Rules to follow for a success

Try to apply and look for a triumph. Good Luck!

Make exercises fun as much as possible!

Modify environment by minimizing distractions!

Sit behind a child, the way you both face a mirror!

Make sure your child is in comfortable, supported position!

Explain what you are doing in a simple, narrative way!

Provide exercises for short periods of time!

Don’t do all learned exercises at the same session!

Provide exercises before each meal not during a mealtime!

Pause to allow time to swallow any saliva that may have accumulated!

Don’t attempt swallowing if your child has a cold!

Stop if your child becomes distressed at any time!
Be patient!

 

Exercises to develop and improve oral sensitivity and muscle tone

1. First, before you approach the child’s face verbally explain what are you going to do and what for.
2. Use slow, firm strokes over the hands, arms, shoulders, neck with rough texture (e.g. towel, etc.)
3. Next start at the sides of the face, forehead, chin, gradually working towards the centre of the face.
4. Massage the cheeks using circular movements, particularly around the mouth.
5. Using thumb and index finger press the top and bottom lips firmly together. Hold for a while and release.
6. Stroke firmly downwards on the area between the nose and top lip while using your finger to push the bottom lip upwards.
7. Using 2 fingers pull the top lip down, starting under the nose and working towards the top of the lip (without touching the lip itself).
8. Do the same for the bottom lip, working from the chin to the lip. Support the jaw if necessary.
9. Gradually introduce stronger flavors at mealtimes:

a.       Using seasoning (curry, garlic, etc.)

b.      Introducing organic chips of different flavor (vinegar, pepper, etc.) and dips (mayonnaise, ketchup, etc.)

c.       Offering tangy, bitter flavored fruits or yoghurts (kiwi, lemon, grapefruit, cranberry, etc.)

10.  Introduce food of different temperature (ice-cream, popsicles, etc.)

11.  Gradually introduce sensory toys (textured teethers, etc.)

Exercises to develop and improve lip movements

 

1. Child will drink from a cup making very small sips.
2. Child will drink using straw (tight/round lip seal around the straw; straw has to be held just by lips, not deeply.)
3. Child will blow bubbles in the air, bubbles in the water using a straw, cotton wool balls across the table, whistles/party blowers, etc.
4. Child will make /oo/ sounds (imitating a ghost, owl, monkey, wind) and /ee/ sounds, like E-I-E-I-O in Old McDonald song, using exaggerated lip movements. You might need to gently push the lips from a tight stretched position (smile shape) to the round position (kiss shape).
5. Child will blow kisses. (You might need to gently push the lips from a tight stretched position  -smile shape to the round position - kiss shape. Put on some lip stick or face paint and make kiss marks on a mirror, tissue, paper etc.

Exercises to develop and improve jaw and tongue movements

1. When side-spoon-feeding your child, place spoon on the lower lip. Let the child to clean the spoon.
2. Over time place food at the sides of the mouth, between the teeth. This will encourage munching/sideward tongue movements.
3. To stimulate biting, munching and sideward tongue movements.

a.       Do exercises at times when your child is relaxed.

b.      Exercises should not be done at mealtimes.

c.       Place the item in the mouth, between the teeth, along the line of the jaw and ensure that it is not placed so as to stretch the lips. Do not place too far back in case your child gags.

d.      Place on the best side initially, than move to the other side.

e.       If the child is not munching, pull the item out slightly and gently or press down.

f.       When you feel your child is confident about biting skills, introduce food items. Initially use bite-and-dissolve foods (biscuits, snacks, etc.)

g.      If the child is not biting off the food, break it off for them while they are biting down on it. Do not force your child to take foods that their mouth is not ready.

h.      Over time, gradually introduce chewier foods in the same way.