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"She Always Gags!" - Understanding a persistent gag reflex in Feeding

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  • Article summary:

    Food is no longer fun to eat when you put it in your mouth and all of a sudden, you’re gagging and you can’t swallow it

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"She Always Gags!" - Understanding a persistent gag reflex in Feeding

“Ugh, feeding Sally is such a challenge. Whenever I try to feed her certain textures or tastes she gags and sometimes vomits, why does this happen?”

Similarly to Sally’s mother, many parents of children with special needs frequently comment that their child appears to have a sensitive gag reflex affecting eating. 

The gag reflex is a normal spasm that occurs in the back of the throat caused by touching the back of the tongue, top of the palate or the back of the throat. This is a protective reflex that prevents choking while eating and protects the body from any noxious or unpleasant items from going down the throat. Additionally, a gag is often triggered when a child feels like they cannot cope with the amount or texture of food in the mouth in order to aid in expelling the food so that they feel safe to continue eating again.

When a baby is born the gag reflex is triggered in the front of her mouth. As a child grows, develops and begins eating new foods and mouthing toys and objects the gag reflex becomes desensitized and is triggered further towards the back of the mouth allowing for an easier transition to more solid foods. This usually occurs between six and seven months of age. If the child is unable or unwilling to mouth toys or transition to more solid foods this desensitization often does not occur. It is important however to note that gagging is a normal part of development especially when solids are first introduced. Gagging however becomes problematic when it persists, causes the child distress or if they begin refusing food groups or specific textures.

In some children, the gag reflex does not become desensitized and the reflex remains hyperactive leading to frequent gagging and vomiting on foods with increasing texture. Children with sensory processing challenges, autism spectrum disorder and motor challenges like cerebral palsy often present with a hypersensitive gag reflex as their bodies do not experience and develop their sensory and motor systems in a typical way.

Children who have sensory challenges often do not tolerate the sensation of solid food in their mouth and due to their sensitivities gag. Liquid and pureed textures do often not elicit a gag response, as those consistencies are one consistency, smooth and easy to swallow. However, sticky, wet or mixed food textures often lead to a gag response when the food touches the child’s palate or tongue. Additionally, children who have previously gagged or choked on sticky or solid foods are often resistant to try that consistency again due to the fear of choking and therefore will refuse those consistencies or gag at the sight the food or texture that they previously choked on.

Although gagging when eating is often attributed to sensory difficulties, children who have motor impairments also gag when eating. When a child transitions to solids their oral-motor pattern of eating has to adapt to the thicker consistency. Instead of sucking the food, as with milk, the child has to move the food around their mouth with their tongue to place it on to their gums/teeth for chewing. This shift in oral motor skills generally occurs between five to six months of age when the child’s tongue protrusion reflex integrates and the child is able to move his/her tongue laterally. If they have not developed this movement due to a motor difficulty or delay they will attempt to suck back the solids often resulting in a gag as a means of protecting the child from choking on the thicker texture. The child will therefore consistently gag on thicker foods or remain on pureed foods as these can safely be sucked back without being manipulated in the mouth.

For many children, the distinction as to whether the cause of the gagging is sensory, motor or a prior negative experience with eating is hard to delineate. If a child has sensory challenges, they do not process sensory information correctly and therefore often their motor skills are affected too. Additionally, if a child has a negative experience with a meal or specific food, they may refuse all similar foods entirely and therefore limit their food variety reducing their ability to practice their oral motor skills.

In order to address gagging in young children there are a few steps parents can follow:
• Have your child assessed by a speech or occupational therapist with a special interest in eating in order to evaluate the underlying reason as to why they gag.
• Don’t force your child to eat textures that cause him to gag as this will exacerbate the sensitivity and increase the frequency of gagging and food refusal.
• Encourage your child to play with food and non-food items to increase their tolerance of different textures on his/her hands and in his/her mouth.
• Continue to give your child his/her preferred textures while slowly increasing the texture of foods. Lumpy, sticky and mixed textured foods are often the most difficult to manipulate in the mouth as they are not one consistency and therefore easily elicit a gag due to the sensory and motor complexity required to manage these consistencies.
• Let your child feed himself as gagging is often lessened when a child is able to feed himself as he is in control and can manipulate the food in his mouth on his own terms.
• Encourage your child to mouth food and non-food items to desensitize their gag and aid them in tolerating more textures in their mouth. Additionally encourage your child to brush his teeth in order to desensitize his mouth and aid in his tolerance of new textures and sensory input in his mouth.

Andrea Fourie

Andrea Fourie is a speech therapist with a special interest in paediatric feeding. She runs a private practice and works in a number of neonatal and paediatric hospital units in Johannesburg.

Website: thrivetherapyservices.co.za

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