Thursday, October 4, 2012

Therapy Thursday: To Sip or Not to Sip (3 for 21, Day 4)

There has been a lot of controversy and discussion around self-feeding, especially when it comes to bottles and "sippy cups".  I myself am smack dab in the middle of this with my twins at the moment.  On one hand, we have to do what is right for them and their individual development.  On the other, we have the needs of the family.  What's right?  What's wrong?  More importantly in terms of my kids, what am I going to do?

First, consult the experts.  According to several (including our own OT and pediatrician), the following is recommended:

  • Introduce a cup a month or so after introducing spoon feeds (6+ months)
  • Use thickened liquids at first to help with swallowing

How to teach your baby to use a cup:

  • Ensure the baby is sitting up and well supported.
  • Using a small cup, place the rim on the child's lower lip
  • Let a small amount of the liquid flow slowly into the front of the mouth.  (Do not pour it in!)
  • Ensure the tongue is above the rim of the cup
  • If your child has difficulty closing their mouth when swallowing, provide some jaw stability with your thumb and forefinger by placing them around the chin
  • As time goes on and the baby gets better at it, leave the cup on the bottom lip and allow the child to take small sips on their own

Regular spout sippy cups are not advised as:

  • they encourage a poor latch-style mouth shape, 
  • they encourage jaw protrusion
  • they encourage chewing on the stem
  • there is a high incidence of dental cavities among children who use or have used sippy cups.
  • they encourage an "open bite" (misaligned teeth)

Several sources recommend:

  • a "coffee style" or recessed hole opening cup (as it helps keep good posture and a good mouth shape).  This is favoured by our OT.
  • the "Doidy" cup (a slanted handled cup available in the UK),
  • a cup with a nose cut out (??),
  • Mr. Juice Bear
  • juice boxes as you can squeeze juice into the straw to aid with sucking

That, in a nutshell, is it.

However, what I am about to say may shock a few people:  this is not exactly what I am doing.

Before the pitchforks and torches arrive however, I would like to preface my personal choice for Wyatt with a little refresher on his back story. My twins are preemies, delivered by emergency C-Section at 34 weeks, 4 days.  They were six weeks early and every single development has had to be adjusted accordingly.  Every age given to a physician or specialist since they have been born has had six weeks subtracted from their age and the suffix "6 weeks corrected" added to the answer.  It doesn't sound like much until you consider that they are almost 2 months behind full term babies born on the same day.  When you look at Wyatt, you add a little more time as he is a boy (who, statistically take longer to develop than girls).  You can also add a little more time for his extra 21st chromosome and even more time as he was born with a hole in his heart.  I can't really guess at his developmental age (and I shouldn't be either);  what I can say is that he is right on with some things and a little behind in others.  In terms of motor skills he's about where his neurotypical older brother and younger sister were at about 10 or 11 months or so.  The twins will be two in February.   There is a developmental gap in this house, that is true.  Most of the time, it really isn't an issue except when it comes to feeding.

Feeding them is an especially tender topic as I had to teach them to eat when they were born.  Most babies come out with rooting and sucking instincts, my little people did not.  Also, being so tiny and early (Zoe was 4 lbs, 1oz and Wyatt was 4 lbs, 13oz), if they attempted to eat, it would have exhausted them.  Zoe was tube fed for most of the first two weeks of her life and Wyatt for the first month of his.  I had to patiently teach them both to suck.  You can read more of that here.  Once they were able to latch properly and breast feed, they did, with top-up bottles afterwards to help them gain weight.  Zoe, with her strong latch, preferred Avent, while Wyatt, with his unusual latch, did better with the Medela bottles.  Feeding time around here is a huge issue; if you think keeping track of what one baby is eating and doing, try doing it with two babies.  And a six year old.  Also, you will probably be alone as I will be at work.  Things get interesting for my husband and I.

Right now, they are eating pretty much the same things.  He has smaller chunks than her, takes longer and we have to make sure he isn't over stuffing his mouth.  He "chews" with his back gums and moves food around in his mouth like a pro.  They've been off puree for a very long time now;  they've been self feeding the same amount of time.  Unless we sneak in an applesauce or pureed fruit dessert, we rarely use the spoons any more.  Most of the time, we let them play with them, to get used to handling them. 

We have tried various shapes and sizes of covered drinking cups with Wyatt as we have a stack of them left over from our first son, Quinn.  We loaded up many different designs over a couple of days to see what kind of reaction they would get.  Zoe had little or no problem with anything except one of the new straw models as the straw was too small in diameter.  Our Wy guy, however, was totally overwhelmed and would cry and cry when he saw the sippy cup or straw or what-have-you.  The straw would poke him in his palate, the others would pour down the front or he would choke.  His oral muscles are not as big of a problem as you may think as he and his sister were breastfed for 17 and a half months.  Trust me, dude can eat. I'm also not totally anti-sippy cup for two other reasons:  one, we do not let our kids run around with anything other than water.  They have milk or juice at meals and milk only before bed.  Which, is still in a big bottle and fed to them individually before putting them down as bedtime is also a big production (no, we don't put them down with bottles in their beds...).  Sippy cups aren't to blame for the increase in pediatric cavities:  parents and constant access to sugary drinks are (the sippy cup is just the mode of delivery... like they say, don't shoot the messenger).  I've got a mouth full of "why you don't walk around drinking acidic things off and on all day long at your leisure when you are already dental compromised".  Even when my kids do get juice, it's 1/3 strength (so, juice boxes are on the no bueno list for the wee ones as well).  Two:  I'm sorry, but no matter how cute and useful Mr. Juice Bear is, I will never be able to look at my darling child using it without thinking that he is drinking out of a bong.  I was also having difficulty rationalizing spending almost ten dollars on one cup with one straw that looks like it is just a re-vamped honey bottle.  I am assured that it isn't.  In fact, one of my dearest friends recommends it highly as it helped her daughter transition to drinking after the NG.  Her testimonial is enough for me;  Mr. Bear gets the official seal of "Awesome".  However, she's in agreement with me:  it still looks like a bong.

There were two versions of drinking cups that Wyatt did manage to use with some success.  We found an Avent sippy cup with a soft Nuby like protrusion on the top that wasn't exactly nipple like and not exactly a spout.  The other, my first choice, was a Nuby cup with a soft straw like top.  Sadly, I was afraid he was going to chew it off and the cup itself was so large he had to tip it back to drink out of it.  We went with the Avent with the soft spout and I had a chat with my OT and pediatrician.  Our pediatrician is a hard core old fashioned cup advocate, however we can't practice with cups safely (and sanely) with both of them unless both of us are here.  What I decided to do, for the best of everyone was to slowly wean him to an open cup and my secret weapon. The soft nipple went away after a few weeks and was replaced by the medium one.  It is soon to be replaced with a hard, smaller one, once he gets used to the valve not being there (as I have removed it to simulate more of a cup)  He will then go to some kind of straw.  In the meantime, when I am home, we will do proper cups.  Once we get the hang of that, we break out the secret no spill weapon which, in the absence of the "coffee cup" type covered cup, has gotten the thumbs up from Wyatt's team.  It's this:

Say hello to my little friend...

This is the Advent "Natural feeding cup" which has a valve only to stop the liquid from pouring out once either one of them throws them on the floor (as, if you read yesterday's post, they do multiple times a day each).  The top is indented to allow for the nose and by indenting the middle circle on one side (as the top lip naturally would, with the jaw in alignment and not thrust forward and the tongue where it should be), the liquid easily flows out.  Stop pressing, liquid stops.  It's elegant in it's design.  You drink out of it like you would a proper cup.  If you don't, it doesn't work. It also has handles. 

So far he hates it.

However, two wait patiently in the kitchen, one for each of them. 

I wouldn't recommend doing what I am.  However, I would recommend doing what is right for you, your child and your family.  Not everyone has my circumstances, that is true.  However, for those that do, you may want to rethink a few things.  But, and I can't stress this enough, run it past your team first.  Perhaps there is a way to incorporate good practice for your family that fits into your life.  You won't know until you ask.

No matter which method you choose, raise your cups high.  Salut!

Perez, Jennifer, and Gwenyth Gorlin. "Feeding & Swallowing in Children with Down Syndrome." Lecture. Allen C. Crocker Family Lecture Series on Down Syndrome. Children’s Hospital Boston Feeding & Swallowing Program. 24 May 2010. Boston Children's Hospital. Web. <>.

VanVuren, Marinet. "Developing Good Drinking Skills in Children with Down Syndrome." DownSyndromeCentre: Information and Services for Parents of Children with Down Syndrome. DownsyndromeCentre, 27 Feb. 2009. Web. <>.

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  1. Thanks for this post, very useful! I have tried different cups with our 16 month old daughter with Ds, but so far no success. I might try the cup that seemed to work for Wyatt, actually it sounds very similar to one we used to use for her older sisters...

    1. See what happens. Just make sure you run it past your team at some point. :)

  2. My kid is 3 and still drinks from a bottle. He knows how to drink from a regular cup, and hates it. The dentist says it's what they drink, not what they use to drink that's important. No juice, no sugar.

    1. Agreed. However, with kids with poor oral tone, getting the right shape is important for speech development down the road.

  3. Great post,I saw this cup and was wondering if it would be good to try.

    1. As of today (10/19/12) it still is in the cupboard. It's day will come.

  4. Good on you for giving it a second thought. This whole feeding thing is so important when it comes to speech later on and, like I've said before, if the speech isn't easily understood, there aren't that many people out there who will not immediately connect 'poor' output with 'poor' understanding and diminished abilities (schmucks!), even when the issue is simply the physical producing of the sounds.
    That being said, we've gone from the bottle to the honey bear which we love and which works perfectly for us and i think I'm going to stick with a straw until the Babe begins to get the whole 'if I don't hold onto this here cup the contents will pour all over my hairless head and up my teeny nose and into places that will require a bath and/or possibly a doctor to get a look at before attempting liquid extraction.' So, you know, just avoiding that ER with the straw, totes.

    1. For sure. Aspiration pneumonia is a big deal too. Good luck with the honey bong... er, bear. :)


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