The pleasure watching a child enjoying a favorite meal or birthday cake is familiar to all. Meals are a time for you to insure your child’s proper nutrition to promote health and development and a time for the whole family to share and connect with each other. However, it is not uncommon for mealtime to occasionally be a source of stress and frustration for parents and children alike. For children with Down syndrome, there may be additional circumstances that lead to more challenges with eating and swallowing. There are a variety of ways to improve the skills needed to safely enjoy mealtimes.

Children with Down syndrome may have similar patterns of oral motor challenges, attributable to a seemingly small mouth in contrast to a larger tongue (occasionally macroglossia), their underlying hypotonia, and tongue protrusion. Children with Down syndrome are predisposed to respiratory, cardiac and gastrointestinal problems in many cases, and these issues can greatly impact eating.

Feeding and Mealtimes: Stages

Infants

Infants with Down syndrome may have difficulty latching on to the nipple and initiating a strong suck pattern due to hypotonia. For children with respiratory and cardiac issues, it may be difficult to coordinate the suck-swallow-breathe process for feeding. If breastfeeding is difficult initially, mothers may want to give their infants expressed milk through a bottle or a supplementer, like a syringe or gavage, while the infant improves his latch and sucking for breastfeeding effectively. Proper positioning, special bottles if a bottle is being used, and some oral-stimulation techniques may be helpful for these infants.

Respiratory and cardiac issues often reduce a child’s stamina and if feeding takes more than thirty minutes, the baby may tire easily and be expending more calories than he is taking in. When a breastfeeding infant is not gaining sufficient weight, a mother may consider partial supplementation with formula or additional expressed breast milk. This can be done by bottle or a nursing supplementer so the infant can continue to breastfeed.

If the infant tends to sleep through feeding times or is difficult to rouse, feeding only on demand may be inadequate for his caloric and nutritional needs and stimulation of the mother’s milk supply. An infant may need to be awakened for breast or bottle feeding. If the infant falls back asleep without taking an adequate amount of milk, arousal techniques such as opening clothing, gentle movements such as tickling feet or stroking cheeks, talking, or patting may help the infant.

Lactation consultants, occupational therapists, speech therapists, and breastfeeding support groups often have valuable resources and with the guidance of the pediatrician will advise you regarding the safest and most appropriate feeding method for your baby.

Older Babies

As your child progresses toward sitting up and begins to show an interest in what you are eating, you look forward to introducing food. Introducing purees and later food with more texture or table foods may result in the child not accepting the food. Babies must learn to coordinate tongue and jaw movements and if he has a habit of protruding his tongue this may add to the problem of food being pushed back out. To address this:

• Consider if the baby is really ready for solids; you may want to try again in another month.
• Check positioning. The best position is sitting upright, with his legs, head, back, and feet supported.
• Start with small spoonfuls of food so that the child can learn to control tongue and jaw movements.
• If he thrusts his jaw or tongue forward, present the spoon firmly on the center-front of his tongue with gentle pressure. Resist scraping the spoon off on the child’s upper lip and let him clear the spoon himself.
• Let your baby lead the mealtime by respecting what he communicates. Has he finished his bite before you offer another? Is he turning his head away or leaning in toward you with an open mouth?

Toddlers

Your pediatrician may tell you to avoid certain foods, which may cause choking, until your child is one or two years of age. Because there may be a delay in mastering certain oral-motor skills, children with Down syndrome often need to be cautious with these foods until age five or beyond. If your child is not consistently using a mature rotary chew it is best not to offer these foods:

• Nuts
• Seeds
• Popcorn
• Raisins
• Hard candies
• Raw carrot sticks
• Chips
• Hot dogs
• Whole grapes
• Large pieces of meat

There are several techniques you can use to help your child develop more mature eating skills:

• Offer several choices of finger foods at each meal
• If your child shows a preference for chewing on one side of his mouth, place food on the opposite side whenever possible
• To encourage his rotary chewing, place small dabs of yogurt or similar food in the corners of his mouth to lick off so that his tongue can learn to move side-to-side.
• Offer food such as bread or cheese sticks at the molar level to encourage the child to chew with the molars and develop a rotary chew.
• When beginning with an open cup, start with thicker liquids which move more slowly and are easier to control (e.g. fruit smoothie, drinkable yogurt).

When to Seek Help

If at any stage you feel your child is not able to progress with eating, contact your pediatrician or gastroenterologist to discuss your concerns. You may be referred to early interventionists specializing in feeding such as occupational therapists, speech and language pathologists, or nutritionists. Interventionists should be experienced and/or credentialed in working with children with feeding issues. Your child may need help if he:

• continues to resist eating
• will only eat certain foods or textures and nothing else
• is not gaining weight appropriately
• frequently coughs or chokes on foods or liquids
• has frequent, unexplained fevers or pneumonia (signs of aspiration).

Mealtimes are about more than nutrition or developmental skills; mealtimes are a family time. Make the most of every mealtime to enjoy building family relationships through discussing the day’s activities, sharing the joys and challenges of everyday life, and appreciate the moments of being together.

References:

Satter, E. How to Get Your Kid to Eat… But Not Too Much. Bull Publishing, 1987.

Saenz M.D., Rebecca, B. Primary Care of Infants and Young Children with Down Syndrome. University of Mississippi Medical Center, Jackson, Mississippi American Family Physician

Medlen R.D., Joan E.From Milk to Table Foods: A Parent’s Guide to Introducing Food Textures. Disability SolutionsJanuary/February, 1999 Volume 3, Issue 3, p. 1, 3-9.