Question:

Hello Debra, I have been through your oral motor course twice. I know that you
will offer suggestions for tough cases so I hope you can assist with this one. I
started seeing a little one at 6 weeks of age because he would not take a
bottle. If the nipple was placed in his mouth he would gag significantly and
scream. He would breastfeed but it was not very productive. Because of a poor
suck-swallow- breathe it appears he has compensated with a chewing pattern on
the nipple. Because of this he ended up with 2 bottom teeth at 2 months of age.
This is very painful for his mother as he continues to bite.
Mom works and has to travel with her job. This little one is now 4 months old
and continues to not have a functional suck. He appears to have poor motor
planning skills and his tongue is all over his mouth during a bottle feed. It
seems it is getting worst instead of better.
He has good strength, muscle tone, endurance and appears to be developing age
appropriately with the exception of some atypical positioning of his UE's. I
have a slight concern but his pediatrician does not so my hands are tied on this
one. What do you suggest for a tongue that has a mind of its own, no purposeful
suck. I have never been able to elicit a suck reflex, even at 6 weeks of age.
I have been using exercises with an Infadent, Zvibe, Nuk exercises for tongue.
One other thing to mention and I have discuss with both the Pediatrician and
Mom, but she feeds the baby completely supine when she nurses. He will not nurse
in any other position. The few times he has had 2.5 ounces from a bottle at home
she reports he is also flat on his back. I have discussed aspiration and
importance of positioning to Mom.

Answer:

This little one sound like many of the children on my caseload.
To begin, I would need more information regarding reflux, bowel flow and early
birth history. The intake form we use at our clinic is on
www.beckmanandassociates.com
I also need the scores from the Beckman Oral Motor Protocol. If jaw movement is
less than 10 seconds on left and right, cheek strength less than 2 out of 5 left
and right and midblade tongue elevation less than 2 out of 3 on this baseline,
the child does not have the motor control for efficient oral intake. I would
begin by addressing those oral motor concerns first.
If feeding in supine is the only way that is successful at present, I would not
change anything until there is another position that works as well as supine. I
would begin trials, not at mealtime, but in therapy, for inclined sidelying with
bottle feeding. I would also assess the use of assisted flow using the Mead
Johnson bottle for pacing at 1-2-3, then present fluid by pressing the bottle,
1-2-3, present fluid, etc. If using assisted or faster flow bottles, work in
inclined sidelying so that excess fluid goes out the lower cheek, rather than
into the airway.
If you or the parent would like a Skype consultation, you can call to arrange
that with our office.
Or, if the family would like to travel to Central Florida, I can see them at the
clinic and Skype you in during the evaluation, or video for you to use when they
return home.