Pocketing of food in the cheeks can stem from under-development of oral-motor skills in the jaw, mouth and/or tongue which can make chewing difficult, especially with tougher foods (like meat). Such issues would be addressed by a Speech and Language Therapist.

Pocketing can also occur when a child tries to avoid eating certain foods due to an aversion to tastes or textures, whilst overstuffing itself may involve a variety of factors including behavioural issues, extreme hunger, sensory cravings and/or a lack of sensory awareness. If hunger and sensory cravings can be ruled out, the child may simply be overstuffing his/her mouth with favourite foods.

However, if there are indications that your child has sensory-processing difficulties it is more likely that overstuffing is linked to poor processing of oral-motor sensations which, ordinarily, would tell your child when their mouth is full and they need to start chewing. The lack of registration of these oral sensory sensations can result in your child not getting that full mouth sensation until their mouth is overstuffed to maximum capacity. Once this occurs (as for any child) there is the realization that they can’t handle the amount he/she has stuffed into their mouth, they become anxious and are afraid to swallow. As a result your child may choke or gag.

“Table manners” are important for social acceptance, but managing the potential dangers of choking is the greater priority. It will be helpful therefore to explore a range of strategies in the hopes of identifying particular interventions which can help.

To address poor registration of oral-motor sensation due to a high sensory threshold there is the need to help “wake up” the oral senses before a meal by providing deep pressure proprioceptive (resistive) input to the mouth, teeth and jaw.

‘Waking up’ the Senses Before Eating

Below are some suggestions to try before food is offered.

  • High Intensity Input

Provide a carbonated and/or iced drink or a small amount of intensely flavoursome or high-textured food. For example, a bite of something quite sour, spicy or crunchy, such as pretzels or crackers, or celery or carrot sticks (especially if chilled).

  • Chews and Toothbrushes

Try the use of a ‘chew’, which may be appropriate on occasions. To gain the most proprioceptive input a chew with an additional bumpy ‘texture’ is advised. There is an increasing range of chews available on the market and a few are suggested below.

Use of ‘Chewies’:
Make a chew available throughout the day for the child, so that he/she can choose when they wants to chew or bite on it. But 5 mins prior to a meal is the ideal time, so as to prepare and ‘alert’ the child’s mouth and sensory system ready for eating. With greater awareness of his/her mouth they may self-regulate their oral intake better.

Examples:

Chew Noodles
Chery Tube with a Knobby Texture
Chew Stixx with texture for more aggressive chewers and biters
Chew buddy for more agressive chewers and biters

Toothbrushes
As an alternative to a ‘chew’ try a medium/hard Toothbrush or something like a Bug Brush Toothbrush to chew on prior to a snack or meal. These can be simply chewed on or dipped in cold water for additional ‘impact’. The image on the right is of a Bug Brush Toothbrush

Bug brush toothbrush to use prior to a meal or snack
  • Battery-Powered or Electric Toothbrush, and Z-Vibe

The Z-Vibe is a therapeutic tool designed to develop oral-motor control to assist with speech production difficulties. But it can also form part of an oral de-sensitization programme as well as an ‘alerting’ programme when there is poor processing and registration of oral-motor sensations.

Vibration sensations can provide intense proprioceptive input to wake up the sensory system. Therefore the trial of a battery-powered toothbrush (with or without toothpaste) prior to a meal can be beneficial. A Z-vibe provides gentle vibration which can be

helpful for those with oral/tactile defensiveness. But to alert the mouth, teeth and jaw, when oral sensitivity is not an issue, the stronger vibrations of a simple battery-powered toothbrush may achieve a better result (before more expensive electric toothbrush options are considered).

(If you require more specific information about this please contact the Therapy Lead)

Z-Vibe used to develop oral-motor control

Other Sensory, Visual or Cognitive Behavioural Therapy-based (CBT) Strategies to Try at Mealtimes include:

  • Encourage Sips Between Bites

Keep a glass of water or another favourite drink at hand and encourage your child to take sips in between bites. The liquid will encourage swallowing before taking another bite. A cold or carbonated drink can also provide additional oral sensory input. The sensory experience can be increased with a straw. As a matter of safety, encourage your child to clear their mouth with a swallow before drinking to avoid choking

  • Make it Visual Support

Many children, particularly those with autism, do best with visual cues. So try using a visual schedule or picture story to help the child become aware of the number of pieces they puts in their mouth at one time. For example, take three pictures of a crisp and another of a glass of water. Attach them to a page or picture board in order and explain “You can eat up to three crisps. Then it’s important to take a sip of water before you have another cracker.” Put this visual aid on the table where your child can see it as a reminder at snack time.

  • Mirror Feedback

As another potentially effective cue, provide your child with a table-standing or handheld mirror and have them watch themself put food into their mouth and chew. The visual feedback of watching themself eat can help them gain self-awareness and self-control when verbal reminders fail. The use of a mirror will also allow them to see if they have a messy face and to self-monitor as to whether they need to clean their face.

  • Include “Alerting” Textures

Some foods are easier to sense in the mouth than others so try and include some sense-alerting textures in their meal or snack choices. For example, rather than a soft slice of bread, give your child a piece of warm and crunchy toast. Similarly, cheese can be paired with a hard cracker.

  • Increase Variety

Increase sensory input by offering a variety of textures in each of the child’s meals and snacks. Combinations might include chewy foods (e.g. dried fruit and Pepperami), crunchy foods (e.g. vegetable sticks, apple pieces, crackers) and soft foods (e.g. pasta, rice). By prompting your child’s mouth to “adapt” to different textures, this tactic may decrease their tendency to needlessly overstuff their mouth.

  • Dip It

Encourage “dipping” food into sauces to slow down the eating process. Chicken nuggets, carrots and bread sticks can be dipped in bowls of ketchup, barbeque sauce, etc. In addition to slowing things down dipping increases the variety of textures and flavours.

  • Use a Behavioural/Reward Chart

Try a reward system to reinforce learning and motivate your child to stop and swallow between bites. A reward system can involve earning points for each mealtime – or portion of mealtime – completed without overstuffing their mouth.

For each meal or snack completed without mouth stuffing, the child gets, for example, to place a stamp, sticker or check in the corresponding box for that day. When, for example, three reward

markers are gained, allow them to select a motivating reward such as a favourite food, small toy, a special activity with you, etc.

  • Coordinate with Other Caregivers

Be sure to enlist other caregivers such as school TAs. Explain the goals and the reward system so they can be integrated into your child’s day such as snack or lunchtimes. This will provide your child with consistency that reinforces their new skills and helps them carry these skills over into other environments.

For Further Information and Guidance please contact:-

Liz Skilton, Therapy Lead or Karen Al Khina, Milestone Occupational Therapist