Activities of daily living (ADLs) constitute one of the areas of occupation described in the American Occupational Therapy Association’s (AOTA’s) Occupational Therapy Practice Framework.² The ADLs listed in Box 8-1 are the most basic tasks that children learn as they grow and mature.³⁴ Basic self-care skills include feeding and eating, dressing and undressing, and grooming and hygiene.² Because eating is a critical daily living skill essential to the child’s survival, growth, health, and well-being, it falls within the OT practitioner’s domain of concern.³ A child with sufficient eating skills is able to actively bring food to the mouth without assistance. A child who requires feeding must receive assistance in the activity of eating.³ Oral motor control relates to the child’s ability to use the lips, cheeks, jaw, tongue, and palate.³⁶ Oral motor development refers to feeding, sound play, and oral exploration.²⁸ Feeding is an oral motor skill, but some oral motor skills, such as oral motor awareness and exploration, do not involve food at all.¹⁴

The normal development of oral motor skills related to eating and feeding involves sucking from a nipple, coordinating the suck–swallow–breathe sequence, drinking from a cup, and munching and chewing solid foods.^12,24,25 The maturation of these skills is closely tied to the physical maturation of the infant.

Feeding and eating skills

Oral motor development

The infant’s oral mechanisms differ anatomically from those of the adult; the oral cavity of the infant appears to be filled by the tongue. The small oral cavity, coupled with sucking fat pads that stabilize the infant’s cheeks, allows the infant to compress and suck on a nipple placed in the mouth. The limited mobility of the tongue results in the back and forth movement of the tongue known as suckling.^24,28,29 As the size ratios in the mouth change with the infant’s growth, a more mature oral motor pattern emerges. By 4 to 6 months of age, the area inside the infant’s mouth increases as the jaw grows and the sucking fat pads decrease. These changes allow increased movement of the infant’s cheeks and lips. A “true sucking” pattern develops, as the infant’s tongue can move up and down as well as forward and backward. Increased control of the jaw, lips, cheeks, and tongue allows the infant to move food and liquid toward the back of the mouth and prepares the infant to accept and control strained baby food.^28,30

Full-term infants are born with reflexes that allow them to locate the source of food, suck, and then swallow. The following describes these reflexes in relation to oral motor development.³⁰

• Rooting reflex: When the infant’s cheeks or lips are stroked, he or she turns toward the stimulus. This reflex, which allows the infant to search for food, is maintained for a longer period in breast-fed infants.

• Suck–swallow reflex: When the infant’s lips are touched, the mouth opens, and sucking movements begin.

• Gag reflex: The gag reflex protects the infant from swallowing anything that may block the airway.²⁸ At birth, the gag reflex is highly sensitive and elicited by stimulation to the back three fourths of the tongue. This reflex gradually moves to the back one fourth of the tongue as the infant matures and engages in oral play.

• Phasic bite–release reflex: When the infant’s gums are stimulated, he or she responds with a rhythmic up-and-down movement of the jaw. This reflex forms the basis for munching and chewing.

• Grasp reflex: When a finger is pressed into the infant’s palm, he or she grasps the finger. As the infant sucks, the grasp tightens, indicating a connection between sucking and the grasp reflex. Most of these early reflexive patterns begin to change or disappear between 4 and 6 months of age, when the cortex develops.^28,30

Infancy

Oral skills develop concurrently and are closely related to the overall development of sensorimotor skills. Table 8-1 presents a brief overview of the development of normal sensorimotor, oral motor, and feeding skills during the first 3 years of life. Feeding initially requires that the adult provide head support and head–trunk alignment to enable the infant to coordinate the suck–swallow–breathe sequence. The infant’s first suckling pattern predominates for the first 3 to 4 months of life.¹² Beginning at 4 months, a “true sucking” pattern—an up-and-down tongue movement—develops as head and jaw stability appears.

TABLE 8-1

Normal Development of Sensorimotor, Oral Motor, and Feeding Skills

AGE	SENSORIMOTOR SKILLS	ORAL-MOTOR SKILLS	FEEDING SKILLS
BIRTH/37–40 WK GESTATION	Is dominated by physiologic flexion Moves total body into extension or flexion Turns head side to side in prone position (a protective response) Keeps head mostly on side in supine position Tends to keep hands fisted and flexed across chest during feeding Has strong grasp reflex	Possesses strong gag reflex Possesses rooting reflex Possesses autonomic phasic bite–release pattern Sucks and suckles when hand or object comes into contact with mouth Shows minimal drooling in supine position and increased drooling in other positions	Begins bottle- or breast-feeding with total sucking pattern Uses mixture of suckling and sucking on bottle (dependent on head position) Possesses incomplete lip closure Is unable to release nipple
1–2 MO	Appears hypotonic as physiologic flexion diminishes Practices extension and flexion Continues to gain control of head Moves elbows forward toward shoulders in prone position Possesses ATNR, with head to side in supine position Experiences weakening grasp reflex Does not possess voluntary release skills	Continues to show strong gag reflex Continues to show rooting reflex Continues to show automatic phasic bite–release pattern Continues to suck and suckle when hand or object comes in contact with mouth Drools more as jaw and tongue move in wider excursions	May lose coordination of sucking–swallowing–breathing pattern with increased head movements Opens mouth and waits for food Has better lip closure Uses active lip movement when sucking
3–5 MO	Experiences diminishing ATNR and grasp reflex Possesses more balance between extension and flexion Has good head control (centered and upright) Brings hands to mouth constantly Supports on extended arms and props on forearms in prone position Brings hand to feet and feet to mouth in supine position Props on arms, with little support in sitting position Develops tactile awareness in hands Reaches more accurately, usually with both hands Begins transfer of objects from hand to hand Does not possess controlled release skills; may use mouth to assist	Experiences diminished rooting reflex and autonomic phasic bite–release pattern Experiences diminished strong gag reflex at 5 months Drools less in positions with greater postural stability Uses mouth to explore objects Begins to show new oral movements in association with increased head and body control	Anticipates feeding; recognizes bottle and readies mouth for nipple Demonstrates voluntary control of mouth during bottle-feeding or breast-feeding Loses liquid from lip corners Is able to receive solid food from a spoon at 5 months Uses suckling during spoon feeding; gags on new textures Shows tongue reversal after spoon is removed; ejects food involuntarily
6 MO	Has total head control Shifts weight and reaches with one hand in prone position Begins shifting weight in quadruped position Transfers objects from hand to hand in supine position Reaches with one hand while supporting with other in sitting position Reaches to be picked up Begins to use thumb in grasp Begins to hold objects in one hand Shows visual interest in small things	No longer has rooting reflex or autonomic phasic bite–release pattern Experiences decrease in strength of gag reflex Maintains lip closure longer in supine, prone, and sitting positions Drools when babbling, reaching, and teething; drools less during feeding	Sucks from bottle or breast with no liquid loss and long sequences of coordinated sucking–swallowing–breathing Suckles liquid from a cup with liquid loss Coughs and chokes when drinking too much liquid from cup Moves upper lip down to scrape food from spoon and uses suckling with some sucking to move food back Gags on new textures Opens mouth when spoon approaches Uses phasic up-and-down jaw movements, suckling, or sucking when presented with solids Moves tongue laterally when solids placed on side biting surfaces Begins finger feeding Plays with spoon
7–9 MO	Shifts weight and reaches in quadruped position Creeps Develops extension, flexion, and rotation; expands movement options in sitting position May pull to stand and hold on to support Reaches with supination Uses index finger to poke Develops voluntary release skills	Experiences diminishing gag reflex; becomes more similar to an adult protective gag reflex Uses facial expressions to convey likes and dislikes Uses mouth in combination with visual examination and hand manipulation to investigate new objects Bites on fingers and objects to reduce teething discomfort Produces more coordinated jaw, tongue, and lip movements in supine, prone, sitting, and standing positions; rarely drools except when teething	Suckles liquid in cup; loses liquid when cup is removed Takes fewer sucks and suckles before pulling away from cup to breathe Independently holds bottle Feeds self cracker using fingers Holds jaw closed on soft solids to break off pieces Uses variable up-and-down movement while chewing; moves tongue laterally and jaw diagonally when solids placed on biting surfaces Assists with cup and spoon feeding
10–12 MO	Creeps with good coordination Cruises holding on to support with one hand Stands independently Learns to walk independently Uses superior pincer grasp with finger tip and thumb Smoothly releases large objects	Produces more coordinated jaw, tongue, and lip movements when sitting, standing, and creeping on hands and knees; rarely drools except when teething	Easily closes lips on spoon; uses upper and lower lips to remove food from spoon Uses controlled, sustained biting motion on soft cookies or crackers Chews with mixture of up-and-down and diagonal rotary movements Feeds self independently using fingers Likes to feed self but needs assistance with using spoon; inverts spoon before putting in mouth
13–18 MO	Walks alone Learns to go up and down stairs Has more precise grasp and release	Moves upper and lower lips By 15 to 18 months, has excellent coordination of sucking, swallowing, and breathing	Uses an up-and-down sucking pattern to obtain liquid from a cup Shows well-coordinated rotary chewing movements by 18 months Has well controlled and sustained biting movements Practices self-feeding; becomes neater Holds cup and puts cup down without spilling liquid
19–24 MO	Demonstrates equilibrium reactions while standing and walking Runs with more narrow base of support	Uses up-and-down tongue movements and tip elevation Develops internal jaw stabilization Swallows with easy lip closure	Efficiently drinks from cup Has well graded and sustained bite
24-36 MO	Jumps in place* Pedals tricycle* Scribbles* Snips with scissors*	Uses tongue humping rather than tongue protrusion to initiate swallow	Possesses circular rotary jaw movements* Closes lips while chewing* Holds cup in one hand* Handles spoon more accurately* Uses fingers to fill spoon* Begins to drink from straws*

ATNR, asymmetrical tonic neck reflex.

^*From this point on, skills learned during the first 24 months are further refined.

Adapted from Alexander R, Boehme R, Cupps B: Normal development of functional motor skills, Tucson, AR, 1993, Therapy Skill Builders; Bly L: Motor skills acquisition in the first year: An illustrated guide to normal development, Tucson, AR, 1994, Therapy Skill Builders; Case-Smith J, Humphrey R: Feeding and oral motor skills. In Case-Smith J, Allen AS, Pratt PN, editors: Occupational therapy for children, ed 2, St Louis, 1995, Mosby; Clark GF: Oral-motor and feeding issues. In Royeen CB, editor: AOTA self-study series: Classroom applications for school-based practice, Rockville, MD, 1993, American Occupational Therapy Association; Glass RP, Wolf LS: Feeding and oral-motor skills. In Case-Smith J, editor: Pediatric occupational therapy and early intervention, Boston, MA, 1993, Andover Medical; Lowman DK, Murphy SM: The educator’s guide to feeding children with disabilities, Baltimore, MD, 1999, Paul H Brookes; Lowman DK, Lane SJ: Children with feeding and nutritional problems. In Porr S, Rainville, EB, editors: Pediatric therapy: A systems approach, Philadelphia, 1999, FA Davis; Morris SE, Klein MD: Pre-feeding skills: A comprehensive resource for feeding development, Tucson, AR, 1987, Therapy Skill Builders.

At 6 months, the infant has complete head control and more jaw stability, allowing for better control of tongue movements. This stability allows the infant to effectively suck from a bottle and take in soft food from a spoon.²⁴ At 4 to 5 months, the infant demonstrates a reflexive phasic bite–release pattern when given a soft cracker. With practice, the rhythm progresses into a munching pattern, which involves an up-and-down jaw movement. The munching pattern is effective for eating baby food or other dissolvable foods.^12,24 By 7 to 8 months, some diagonal jaw movements are added to the munching pattern. Infants use their fingers to eat soft crackers and cookies.^12,24

Around 12 months, infants enjoy and prefer eating with their fingers. Rotary chewing movements and a well-graded bite are observed. At this time, many infants transition from drinking from a bottle to drinking from a cup. While learning to drink from a cup, the infant’s jaw initially continues to move in the up-and-down sucking pattern. In addition, the infant bites the rim of the cup to stabilize the jaw. By 15 months, the infant demonstrates some diagonal rotary movements of the tongue and jaw while chewing food. Between 15 and 18 months, the infant begins to independently eat with a spoon.¹²

Early childhood

By 24 months of age, the foundation has been established for all adult eating patterns.²⁷ At age 2, children eat independently, consuming most meats and raw vegetables (Figure 8-1). Circular rotary chewing develops between the second and third year of life and allows toddlers to eat almost all adult foods.^24,30

By 24 months, children can hold a spoon and bring it to the mouth with the wrist supinated into the palm-up position.²⁸ At 30 to 36 months, children experiment with forks to stab at food. A variety of spoons are available for children learning to use utensils.²¹ The size of the spoon’s bowl should match the size of the child’s mouth. Children learning to use spoons typically use ones with shallow bowls; they have to work harder to eat food from spoons with deeper bowls. Child-size spoons and forks are easier for children to hold and manipulate, and bowls and plates with raised edges also make it easier for children to scoop the food.^21,28

By 24 months, toddlers can also efficiently drink from cups. Children may begin drinking through straws between 2 and 3 years of age, especially if they have been exposed early to the use of straws. Given the variety of playful long, short, and decorated straws that are available on the market, children are happy to independently use their own straws.²¹ By 30 to 36 months, children try to serve themselves liquids and family-style servings of food.²⁸

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