Signs of Feeding and Communication Delays

Communication and Feeding are activities that many of us take for granted, and realise how complicated they are, only when any one of ...

...these abilities are delayed or break down due to a variety of reasons.

As a parent, when the baby is born, the first and the foremost need that one looks at fulfilling is the feeding and nature has created for us a way to bond during this process, laying the foundations for later communication too!

Let us now examine the development of physical skills that support the development of feeding and swallowing

Age (months)

Development/Posture

Feeding/Oral Sensorimotor

Birth to 4 - 6

  • Neck and trunk with balanced flexor and extensor tone

  • Visual fixation and tracking
  • Learning to control body against gravity
  • Sitting with support near 6 months

  • Rolling over

  • Brings hands to mouth
  • Nipple feeding, breast, or bottle
  • Hand on bottle during feeding (2–4 months)
  • Maintains semiflexed posture during feeding
  • Promotion of infant–parent interaction

6 – 9 (transition feeding)

  • Sitting independently for short time

  • Self-oral stimulation (mouthing hands and toys)

  • Extended reach with pincer grasp

  • Visual interest in small objects

  • Object permanence
Stranger anxiety

  • Crawling on belly, creeping on all fours
  • Feeding more upright position
  • 
Spoon feeding for thin, smooth puree

  • Suckle pattern initially
  • Suckle → suck
  • 
Both hands to hold bottle

  • Finger feeding introduced

  • Vertical munching of easily dissolvable solids

  • Preference for parents to feed

9 - 12

  • Pulling to stand

  • Cruising along furniture

  • First steps by 12 months

  • Assisting with spoon; some become independent

  • Refining pincer grasp
  • Cup drinking

  • Eats lumpy, mashed food

  • Finger feeding for easily dissolvable solids

  • Chewing includes rotary jaw action

12 - 18

  • Refining all gross and fine motor skills
  • Walking independently
  • Climbing stairs
  • Running

  • Grasping and releasing with precision
  • Self-feeding: grasps spoon with whole hand

  • Holding cup with 2 hands

  • Drinking with 4–5 consecutive swallows

  • Holding and tipping bottle

18 – 24

  • Improving equilibrium with refinement of upper extremity coordination
  • Increasing attention and persistence in play activities

  • Parallel or imitative play
  • Independence from parents
  • Using tools
  • Swallowing with lip closure

  • Self-feeding predominates

  • Chewing broad range of food

  • Up–down tongue movements precise

24 - 36

  • Refining skills
  • Jumping in place
  • Pedalling tricycle
  • Using scissors
  • Circulatory jaw rotations
  • Chewing with lips closed
  • One-handed cup holding and open cup drinking with no spilling
  • Using fingers to fill spoon
  • Eating wide range of solid food

  • Total self-feeding, using fork

Source: Adapted from Arvedson and Brodsky (pp. 62–67)

As we can clearly see,

the ability to progress from suckling on the breast or bottle to feed as a neonate to self-feeding requires the development and maturation of the oral motor system which runs parallel to the development of other gross and fine motor skills.

At the same time, during the first three years, there is the psychosocial and language/cognitive development that happens alongside to support and complete the growth and development of the child.

Stage

Psychosocial milestones

Birth to 3 months

  • Cues for feeding: arousal, cry, rooting, sucking
  • Caregiver responds to cues (leads to self-regulation)

  • Infant quiets to voice
  • Hunger–satiety pattern develops

  • Infant smile promotes interaction with primary caregive
  • Pleasurable feeding experiences  greater environmental interaction

3 to 6 months

(attachment)

  • Primary interactions—"falling in love"

  • Reciprocity of positive infant and caregiver interactions

  • Consistent cues

  • Anticipation of feeding

  • Pauses likely socialisation, not necessarily for burping or to indicate satiety
  • Smiling, laughing, social, alert

  • Preferred feeders are parents
  • Calls for attention by 6 months

6 to 36 months

(Separation/individuation)

  • Responds to "no"
  • Imitates movements, and gradually imitation of speech

  • Play activity to explore environment (7–9 months)

  • Facial expression used to indicate likes and dislikes
  • Follows simple directions
  • Self-feeding emerges
  • Mealtimes become more predictable
  • Speech becomes important
  • Direction following—gradually 2–3 step commands
  • Mealtimes become part of whole family schedule
  • Rapid increase in language 24–36 months
  • Independent feeding by end of period

Source: Adapted from Chatoor et al

"When we understand the process of normal development of skills for feeding and communication as well as physical overall development, it becomes clear that a delay in the physical or gross motor development due to a variety of possible causes ranging from prematurity to congenital issues to trauma, can delay the development of skills for speech-language and feeding."

It also helps to bear in mind that if for any reason an infant is hospitalised during the early months or has a history of reflux or unpleasant initial feeding experiences, there is a huge probability that the child may develop sensory issues which may be presented as refusal to transition from milk to solids, picky with eating, poor eating and so on. In such cases the sensory based challenges need to be addressed first before skill building can happen to facilitate the intake of mature foods. For some children with  a physiological and or anatomical basis for swallowing difficulties ( such as absence of the swallowing reflex, removal of structures as a part of surgery, radiotherapy etc), apart from dealing with the sensory based issues, therapy will also have to be geared towards strength building using a variety of treatment modalities whenever warranted. One also needs to understand that how a child progresses with professional help and therapy is dependent on a host of factors including the child’s cognition and to understand and follow language and speech for the age.

So when should a parent seek help?

Seek professional guidance if your child 

  • Is slow to suck and swallow
  • Has limited intake
  • Needs a lot of time and unusual effort to feed 
  • Cries and fusses a lot during mealtimes
  • Gags and vomits during or after mealtimes
  • Has problems transitioning from milk feeds to solids
  • Refuses many foods and is picky about food types
  • Has obvious difficulties like biting and chewing
  • Is chesty has lots of secretions and gets chest infections often apart from being a poor eater

Feeding Specialists who could be Speech Language Therapists or even Occupational Therapists with special expertise and interest in Dysphagia (feeding and swallowing disorders) would be able to help you and your child go through the process of facilitating the development of skills to support eating and feeding.

Many-a-time, feeding tends to be the first and foremost concern parents wish to address. However, there could be a concurrent delay in the development of communication skills – specific delays or disorders. This could range from inability to make sounds or express themselves, to not being able to speak specific sounds or words and sentences including the inability to understand commands which may even manifest as learning difficulties at a much later stage.

How do We Know? 

Here are some tell-tale signs of a delay in communication, speech and language development:

By the first year

  • Is not babbling yet
  • Has not said the first meaningful  word
  • Does not use gestures like ‘bye’
  • Does not respond to her/his name when called
  • Not able to express needs

By 1.5 years

  • Is unable to follow simple instructions
  • Does not identify 2-3 major body parts
  • Does not respond to WH questions (eg, what’s this ? where is the bottle?) with a word or gesture

By 2 years 

  • Does not pretend play
  • Has less than 100 words
  • Is not using two word sentences like ‘daddy go’
  • Unable to imitate words and actions

By 3 years

  • Unable to ask questions
  • Is not using sentences to speak and express 

By 4 - 5 years

  • Is lagging in preschool;
  • Unable to narrate events / stories

These are just major milestones to look out for. When you see a Speech Language Therapist, the professional will be able to evaluate the various aspects of communication and work with you and the child in facilitating the speech and language skills.

The grandmother tales of ‘wait and see’ are no longer relevant today.

There is nothing to lose in seeking a consult to get a professional opinion if you, as a parent, feel or have an inkling that something is amiss with your child’s development!   

The reassuring factor is that, sometimes it just takes the extra push and commitment to nudge and nurture the developing system in a child!


References

  1. Arvedson JC, Brodsky L. Pediatric Swallowing and Feeding: Assessment and Management, 2nd ed. Albany, NY: Singular–Thomson Learning, 2002.
  2. Chatoor I, Schaefer S, Dickson L, Egan J. Non–organic failure to thrive: a developmental perspective. Pediatr Ann 1984;13:829–843. | PubMed | ChemPort |
  3. Sussman, F. (1999). More Than Words: Helping parents promote communication and social skills in children with autism spectrum disorder. Toronto: The Hanen Centre.
  4. Pika Sen, Radika Vasudeva. No more baby Talk: A parent’s guide to speech and Language development. Pearson Malaysia Sdn Bhd (2002).

 

Dr Radika Vasudeva

Director, Consultant Speech Language Therapist
Stravantis Pte Ltd, Singapore

She can be reached at radika@stravantis.com

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Question of the Month

  • Q: What are the various compressive suits available and in what way do they help a child with special needs?

    A: There are various compressive suits available worldwide, just do a google search on compressive suits for therapy and a long list will appear. Each suit has different properties, is made of different materials and claims to have certain benefits. For example: compressive suits for children with autism are supposed to improve sensory input. Compressive suits have also been used for children with poor balance and proprioception (knowing where your limbs are in space). However, not all suits are suitable for all children. Compressive suits can cause increased difficulty in breathing, worsen scoliosis or hip dysplasia if not fitted properly.

    Please consult your therapist for an assessment before use.


    Janell Lee
    Paediatric Physiotherapist

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