Oral eversion

 

Conversations around feeding a baby are common parts of anticipating the introduction of a new baby into a family be it through birth, adoption, foster care or otherwise. There are discussions about  bottle versus breast, breast milk storage, formula brands, mixing instructions and feeding schedules . There is something immensely satisfying in feeding a baby to contentment. One of the most common parental responses to comfort a baby who wakes up in frenzy involves some form of touching and feeding. What happens when the feeding mechanism goes wrong? What happens when the slightest touch of the baby’s mouth sends them to more frenzy and inconsolable crying? What if the mere sight of the bottle triggers gagging and vomiting? How about if baby arches their back to try and move away instead of accepting the cuddling around the breast or breast?  
A baby with oral aversion has a sensitivity to food or drink taken by mouth. The sensitivity causes them to associate feeding to be unpleasant, unwelcome, painful and a fearful experience. Oral aversion can cause a lot of parental stress due to feelings of inadequacy, frustration, fear of malnutrition, grief of the loss of the “perfect baby”. 
 The dangers to the baby include
  • Dependence of supplemental feeding methods such as G-tubes and NG tubes 
  • Low weight due to inadequate calorie intake 
  • Nutritional deficiency due to low volumes and fewer selections 
  • Poor development of social skills that would normally be enhanced at family mealtimes, and social settings such as birthday parties. 
Premature babies are more likely to develop oral eversion than babies born at term gestation according to the Journal of Pediatric Gastroenterology and nutrition. Babies who spent time in the Neonatal Intensive Care Unit (NICU) may have needed lifesaving procedures such as intubation, suctioning, nasal gastric (NG), oral gastric (OG) tubes. These procedures cause mouth trauma, pain and discomfort. Factors such as low muscle tone and insufficiently developed suck/ swallow/ breath coordination as well as illness and low stamina can all contribute to lack of appropriate and timely oral stimulation to allow development of the natural feeding mechanism. Gastroesophageal reflux disease is common in babies especially premature ones. The acidic gastric contents push up through the esophagus and cause a burning sensation. Repeat of these experiences lead to babies associating food intake with the burning sensation, a factor that contributes to oral aversion over time. 

 Untreated oral aversion will lead to avoidant/restrictive food intake disorder (ARFID) in the older child. A child with ARFID is not a typical picky eater. The child is not concerned about body image but will complain certain foods taste, smell or feel bad. They have no appetite and will eat only small amounts of food. They associate food with trauma and may exhibit choking, vomiting, upset stomach and/or abdominal pain. 

 Studies shows that children do not “outgrow”. A child who continues to gag, choke, has difficulties swallowing, has tantrums or refuses to eat during mealtimes will need professional support. The concerns should be discussed with pediatrician to facilitate referral to trained occupational or speech therapists. Thorough feeding evaluation provides the therapist with the data needed to develop a treatment plan. Treatment approaches include sensory, motor and behavioral models. 

There are basic feeding guidelines suggested for children with feeding difficulties 
  • Maintain appropriate boundaries such as meals at designated eating areas
  • Avoid distractions such as TV watching 
  • Feed the child at intervals of 3-4 hours to encourage appetite and avoid snacks
  • Maintain a pleasant neutral attitude by avoiding becoming anxious, angry or too excited 
  • Limit mealtime durations to no longer than 20-30 minutes 
  • Serve age-appropriate foods according to the child’s oral motor development 
  • Systematically introduce one food at a time and step by step 
  • Offer a food repetitively 5-15 times before giving up 
  • Encourage independent feeding in toddlers ensuring they have their own spoon 
  • Allow age-appropriate messes during mealtimes by using a bib and not wiping the mouth with each bite.

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