Question:  I have a 2 and a half year old boy. He stopped eating and drinking just before he turned 2. He has an NG tube through his nose for 6 months so far. He started eating solid foods with great appetite three months ago. Now we use the NG tube for drinking only. Since they put the NG tube, I was able to give him water in a spoon from a glass jar while he was in the high chair. Now he sits at the table with us in a small chair where he can walk and sit down on his own. I had no success with sippy cups, open cups or cups with straws. He is afraid to put his lips on the cup. Now he started chewing on a straw last week, but does not want to put the straw in the cup with the water. Could you please let me know if you have any methods / techniques for just making him put his lips on the cup or straw to drink?

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1. RULE OUT ANY UNDERLYING MEDICAL ISSUES

First, I'd recommend consulting with his doctors and therapists to rule out any underlying medical issues (doing a swallow study, esophageal study, etc.).  They'll be able to evaluate things in person, make sure there aren't any medical reasons behind this, and provide guidance specific to his needs.  For example, it may be that he isn't able to manage thin liquids well, or perhaps there's an issue with the NG tube. Or, he might be okay taking a small, manageable sip of water off of a spoon, but cannot orally manage bigger sips/gulps from a cup or straw. I have found that some kids very adeptly refuse food that they know they can't orally manage to prevent themselves from choking.  So it may be that he knows he can't manage a large sip of water - that he will choke or aspirate on a large sip - and is avoiding it as a self-defense mechanism.  Consulting with his doctors and feeding therapist, the swallow study (aka MBSS - "modified barium swallow study"), etc. will give you more information.  

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2.  INTRODUCING CUPS THROUGH PLAY

Once all potential medical reasons have been ruled out, then play may be a good approach.  Play with cups first.  Do NOT request that he drink from them.  Use the "get permission first" approach with him.  So play, play, and play some more with cups.  Cut them into different sizes and make pictures or designs out of them.  Make cups out of paper.  Use cups to cut out shapes of play dough or make castles.  Roll the cups and make a race out of it.  Cut or tear the bottom out of a large cup.  Put your hand through it and pretend it's a bracelet.  Put objects in the cup with a lid and make a noise maker.  Pour water using the cups in a sink full of soapy water.  Get ready to just have lots of messy fun!  The goal here is to desensitize him to cups by introducing them through play.  Your OT can offer guidance here with more sensory play activities.

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3.  GETTING CLOSER TO THE MOUTH

After he's comfortable using cups during these activities, you can start bringing them to the face - but still through play.  Cut the bottom out of the cup use it as binoculars - "Look, I can see you now!"  Play Peek-a-Boo, I see you!  Using the "binoculars," spot the bird outside, the door, the floor, etc.  Pretend it's a shell and see if you can hear the ocean.  Work on a few more activities involving the face, but not the mouth yet.  Then, just happen to hold the cup in your mouth while you are busy doing something with both hands.  He may imitate you doing that (don't ask him to, just see if it happens naturally).  You can even use the bottom-less cup so that he knows that no liquid will be in it.

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4.  INTRODUCING FOOD

Next, put just a little bit of applesauce or another puréed food in the cup.  Have him scoop the food himself and put it in the cup.  This is still play, slowly working towards the goal of getting the cup to his lips.  Maybe he will drink the food!  Have him feed you from the cup.  Then scoop water from a bowl into the cup and play at the high chair.  You can take a sip here to set an example.  He just might put it to his lips eventually copying you doing it.  He has been through sooooo much and may just need some time.

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5.  MOVING ON TO STRAWS

Once he accepts cup drinking, I think straw drinking will naturally follow, especially since he has chewed on a straw before, and especially if it's from something cute like the Bear Bottle (which also comes with a Lip Blok, which discourages biting/chewing on the straw and prevents kids from putting the straw too far back in their mouth).  If using straws doesn't come naturally next, go through the same procedure with straws.  Cut them up and make patterns/designs or string them onto a necklace.  Make a crown.  Paint them and make eyebrows, mustaches, etc. (you are getting closer to the mouth here).  Use them to blow cotton balls across the table.  Put a dab of thin paint on a piece of paper and have him blow the paint around to make cool designs.  Then let him use straws to play with food - put thin, puréed carrot baby food on the plate and let him blow or move it around.  If necessary, add a little water to make it easier to blow.  He just might suck up some of the food.  Then he's on his way to using a straw for liquids.  Be inventive and playful, and always follow his lead.

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Debbie

Debra C. Lowsky, MS, CCC-SLP

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