Monday, February 8, 2010

Oral Motor Myths

Myths... a high-arched narrow palatal vault (that would be the “roof” of the mouth), tongue protrusion, mild to moderate conductive hearing loss, chronic upper respiratory infections, mouth breathing, habitual open mouth posture, and the impression that a child's tongue is too big for his mouth... all myths.

Speech and language pathology expert, Sara Rosenfeld-Johnson published an article back in 1997 titled, The Oral Motor Myths of Down Syndrome. In the article she lists seven structural/functional disorders (the myths above) that she feels can be prevented.

In other words, infants with Down syndrome are not born with these oral motor differences; instead they develop them based on inappropriate therapeutic approaches to feeding difficulties present at birth due to low tone.

Rosenfeld-Johnson writes, “Orally, these children look pretty much like any other infant with the exception that they have a weak suckle. This critical observation draws us to the connection between feeding muscles and muscles of speech. In quick order, a cascade of events unfolds for these babies with weak suckle.”

The events she refers to begin with making it as easy as possible for the newborn to eat which sets in motion a downward spiral of circumstances that lead to the development of the above-named oral motor irregularities.

There is an assumption in the medical community that babies with Down syndrome do not eat well, and that they inevitably demonstrate all or most of the seven structural/functional disorders seen in many people who have Down syndrome. Because successful nutritional intake is one of the primary goals that needs to be reached ASAP with a newborn, nurses and doctors often push solutions that may be in direct conflict with the best oral-motor therapy techniques for improving a baby’s oral motor skills.

I can tell you from experience that this is true. I had a baby with severe heart defects that could not eat enough on her own to survive. She could not successfully nurse, nor would she drink well from a bottle. I did not know about Sara Rosenfeld-Johnson’s theories. If I had known, I would have used them as support for my stubborn ideas about feeding and continuous oral motor stimulation.

So what are SRJ’s recommendations?
1. When a baby is being fed, his mouth must always be lower than his ears.

2. A breastfeeding mom should stimulate the mammary glands while her baby is nursing to increase milk flow. Over time, as the baby’s strength increases, gland stim will no longer be necessary.

3. A bottle-feeding parent should use bottles with disposable liners. This allows the air to be pushed out of the bottle causing a vacuum and making it possible to feed in a position where the bottle nipple is presented from below the mouth. The caregiver can push gently against the liner if necessary to facilitate the flow. Rosenfeld-Johnson explains, “This position encourages a slight chin tuck and the child draws the milk up the nipple predominately with tongue retraction. This position and retractive action prevents milk from flowing freely into the child's mouth. The child no longer needs strong tongue protrusion to enable swallowing. It is also important not to make the hole in the nipple larger.”

The article clearly explains how feeding approaches can alter your baby’s future both positively and negatively, making it a valuable read.

Your Turn
Can following these fairly simple suggestions have a significant effect on your baby’s future oral motor structural and functional formation? My child’s oral motor development has been consistent with what was presented in the article, so based on that (and the fact that the points in the article made sense) I would say give it a try.

What about you? Did you by chance feed from birth according to SRJ’s method? Did you not? Does your child exhibit any of the mythical characteristics, or not?


  1. I didn't know anything about oral issues when we adopted our now 10 month old little guy. I have yet to find a food he won't eat or a texture he won't try. He never sticks out his tongue either. I don't know if that's because he didn't have any "issues", or if they are just that - mythical.

  2. Let's see. I would lightly tap Marissa tongue & verbally tell her to put her tongue in. She will now pull it back in when I say, "tongue". I did use a method similar to SRJ. Marissa was breast and bottle fed since she, too, had feeding issues associated with low tone and a heart defect. When breast feeding I always held my breast to maintain an steady flow of milk. Bottle feeding, we just did what we were taught & I don't think that followed her "rule". In a nutshell, Marissa's tongue protrusion is limited and she is great about self-monitoring, even at 16 months old!

  3. My son has a high-arched narrow palatal vault since birth. He had an evaluation when he was baby and the a high-arched narrow palatal vault was there. I bottle fed my son following Sara Rosenfeld-Johnson bottle feeding techniques. When my son is sleeping the tongue tip is out a little bit and I noticed since he was born. There are other issues that may cause this oral behavior as Tongue trust and enlarge tonsils. My son has tongue trust because to factors, trisomy 21 and heritage genes. Hypothyroidism is very common in kids with Trisomy 21, therefore it could be possible that kids with thyroid issues may have enlarge tonsils, causing an open mouth posture. We will check this with the Endocrinologist in our next appointment.

  4. I love that article! I found it when Goldie was about 2 months, her OT also gave me a copy. We have used her strategies since birth. I used a finger feeder instead of bottles. Goldie does not exhibit the mythical characteristics. Sleep apnea did cause her to breathe through her mouth before her T&A surgery. Great post!

  5. Hm. I'm trying to not allow the mama guilt. We have always used glass bottles because we felt they were the safest material, and we use the small silicone gerber nipples because he got the best latch on them.

    He definitely sucks on that bottle when I feed him, not just letting it fill his mouth.

    So my question would be... can one switch a year into the game, or should I be thinking more about which sippy cup would be most appropriate instead?

  6. Hey,

    Hope all is well.

    Just went to Talk Tools and ordered - I don't know - like 5 products after reading this post.

    Gotta have the Honey Bear with Flexible Straw.

    Ahhh!!! xox :)))

  7. We were lucky to have found an OT who prays to SRJ, unlucky in that we didn't find her until Abby was 5.5 mos old. Abby is in the process of learning to switch to the Honey bear- it's been a long process for us. I so wish we had found this therapist earlier- but we are glad to have her for now. We are actually getting a SRJ evaluation in May. I was thrilled to get to meet her last fall when she came to the clinic we go to.
    Thanks for this post Sandra- there were a few things in there we hadn't gone over yet!

    Jen- we were told by our OT that sippy cups wouldn't be in Abby's future b/c of the increased risk of aspiration. When a kid drinks from them they have to tip their head back- this also falls into the same category as her comment that when a baby feeds their chin should be lower then there ears. She recommends her honeybear with the flex straw. The difference in the HB vs just a straw sippy cup would be that you can squeeze the liquid into their mouth until they get the concept of sucking the liquid up the straw. At least to start out. In the same respect- I think we will probably try the disposable liners. We use the nipples from those bottles with vent air bottles. Any tips to cue your child to suck on the straw would be appreciated. We seem to be at a standstill with this. We are just now getting lip closure.

    I also definitely notice a difference in her mouth posture when we are consistent about jaw strengthening excercises.

    One other tip with the honey bears- we use 1/2 a packet of gerber mangos stirred in with the breastmilk for it. Our OT said you need something with a strong flavor to capture her attention and that she is only getting in the HB- so she'll be motivated to drink from it. She suggests cinnamon but Abby had no preference for it- the mango seems to be what she digs.

  8. We have followed SRJ therapies since my son was a baby. I found her advice to be very helpful and it really helped with early feeding. We still follow these therapies with Cameron who is now 4 and I can personally tell you that it does a lot to help with the open mouth posture and speech.

  9. I've never looked in to SRJ's techniques for my little guy (now 2). He does have a high arch in the roof of his mouth, but no tongue thrust or seemingly long tongue or any feeding issues. He was able to nurse exclusively after about 2 weeks of serious trying and supplementing with bottle feeding. Each kid is unique to their specific feeding issues. We use sippy cups and straw cups, depending on how much mess we can tolerate at the moment. I recently read that one line of thought in the medical community is to "correct" the high arch so their tongue has a better place to rest for word formation and speech clarity. Interesting, but I don't want anything invasive done... he's managing just fine. Thanks for the post. Many of my friends think SRJ is wonderful.

  10. My son refused to nurse after he was born. I was admit about nursing after reading this very article and after weeks he finally started nursing. It took about 5 months for him to be really good at it but he is almost 11 months now and still going strong. I used to pump after every feeding to keep my supply up until he was efficient enough on his own. He still has a tongue thrust though and has an open mouth position. We are working on it with a z-vibe.

  11. So what bottles are recommended? Any with liners, or is there a specific brand? Thank you for sharing! I am getting new bottles today :)

  12. Keeping MaKenna's mouth below her ears above her mouth definitely helped with breastfeeding. I had nursed my son (2.5 years older than MaKenna) over 2 years, so I knew I would figure out a way to get her to successfully breast feed eventually. But until we had cranial sacral therapy work done, she didn't have an efficient suck that would give her enough milk to gain weight. After having her head adjusted, so to speak, MaKenna had a much better suck and hasn't stopped breastfeeding for over 2 years now!

    Great post! My daughter's speech therapist gave us a copy of this article when MaKenna was first born, over 2 years ago. And today I'm passing it on to a new parent. Thanks for the information, what a great blog you have created, thank you!

  13. This is a great article. Claire doesn't really have feeding issues, but it still gives me things to think about. I will work on keeping her mouth below her ears, but am unsure of changing bottles as she is eating well and gaining lots of weight. I hate to change what isn't broken. Claire has some tongue thrust but sucks well. The tip of her tongue will protrude sometimes, but not always. Her dr mentioned she does have a high arched palate, but all her drs have remarked on her strong suck too.

  14. I think SRJ is great! We have seen improvements with Brennan since starting to use the straw cup and using some other feeding strategies SRJ suggested (supporting his jaw while spoon feeding, doing chewing exercises, etc.). A little over a year ago (before we met with SRJ) we took Brennan to the dentist and were told he had a high palatal arch. A couple of weeks ago, the same dentist told us he no longer has a high palatal arch. Interesting, isn't it??? It has also improved his tongue retraction.

    And as for the breastfeeding, I was told by the doctors and nurses soon after Brennan was born that I would most likely not be able to breastfeed him due to his Down syndrome diagnosis. If he were my first child, I may beleived them and not even tried to breastfeed him. But, since he was my 4th, I figured I'd at least try as I had with my others - and it worked! And last year at the NDSC convention, you should have seen all the breastfeeding moms!

  15. Maybe Liam was just lucky. He doesn't have the protruding tongue, etc. We did feed him with his mouth above his ears, and we didn't have the plastic liners (but my wife did have to pump). But we're happy for the tips, and will tell any newcomers at our local DS parents' society what to watch for.

  16. I must admit your article is very much informatative and useful. I am now ready to try these simple instruction to improve oral-motor skill levels.

  17. i would like to say something about the sarah johnson article. i read it almost two years ago, and i bought the program and am currently using it with my 3 year old boy with DS. i breastfed my son from the moment he was born until he was 1.5 years old. he never drank from bottles of any kind.. i did everything by the book when it came to feeding and oral motor stimulation.. he had an excellent (privately hired) speech pathologist and another excellent occupational therapist (also privately hired) since he was about 4-5 months old.. yet, he has low muscle tone in his tongue and nothing could take that away. we are currently using the sarah johnson's program because i believe in the program (have been using it for over 6 months now).. but i have to disagree with her that those simple feeding instructions will make the problem go away.. he still has his tongue protruding sometimes.. so i guess its a combination of things, but in our case, he was born with this low muscle tone.. exercises can help , but will not make it go away completely.


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