A gag is a normal reaction of the mouth and throat. In young babies, its purpose is to ensure that foods or foreign objects are not swallowed or breathed into the airway. Gagging pushes things forward off the back of the tongue and throat.
Newborns typically have a gag response when touched halfway back on their tongues. As babies spend time with nipples, fingers, toys, and spoons in their mouths, they usually become less sensitive, and the place on the tongue that sets off the gag moves farther back.
The gag response continues to change as children develop. As children move from eating only liquids to runny strained foods, to thick strained foods, to soft lumpy foods and cracker pieces, it usually takes more and more to make them gag.
However, some children continue to gag very easily long after they should, to the point where it may interfere with their eating and drinking. This article looks at some of the possible causes of excessive gagging, and what can be done to help your child.
A hypersensitive gag or overreactive gag is an exaggerated reaction compared to the response that would be expected. A child may gag when the spoon touches the tip of the tongue instead of the back of the tongue. Or a tiny lump may cause a gag well after the child’s tongue and throat should be able to handle it.
An aversive reaction goes one step beyond the hypersensitive reaction. It is a stronger, emotional reaction. The child will cry, fuss, pull away, push food away, or refuse even to let you near or in the mouth. Gagging may turn into vomiting in an aversive reaction.
Children can have hypersensitive and aversive gag reactions to a variety of factors, including food textures, smells, tastes, temperature, and even color. Once a cycle of these reaction is begun, all the senses can get involved.
It is important to understand the cause of your child’s hypersensitive gag, so that proper treatment can be determined.
For most children, hypersensitive gagging is due to a general or oral (mouth) oversensitivity to touch or changes in touch. Treatment is designed to relax or calmed down the overreaction.
For some children, however, the reaction is due to an abnormal structure of the throat or esophagus (the tube that leads from the throat to the stomach), which makes it hard to swallow most foods. In other children, the esophagus does not efficiently move food toward the stomach. This can lead to collection of foods in the tube and gagging as it becomes too full.
Some children gag when they’re stressed. Others gag when they have foods backwash up from the stomach with reflux. Still others gag as a response to unpleasant oral medical experiences. Still others use it to control the mealtime and the feeders.
Your child’s doctor can help pinpoint the exact cause of your child’s problem.
If medical testing shows any structural problem in the throat or esophagus, the doctor will help you understand the next steps in medical treatment or medications.
If nothing is wrong physically, your next move is to contact a feeding specialist, to work out a program for gradually normalizing your child’s gag reaction. A nutritionist also will be needed to help ensure that your child has a balanced diet during this time.
Below are some general suggestions for dealing with hypersensitive and aversive gags. Talk to your feeding therapist and doctor about what is appropriate for your child.
What to Do About Oral Sensitivities
Your child needs to learn that touch around the face and in the mouth can be fun. It does not have to be as emotional and scary as your child has learned to perceive it.
- Play face-touching games with stuffed toys and dolls.
- Kiss your child’s face with a stuffed toy, and then let the child kiss your face or the stuffed toy. Playfully taking turns in face touching can help your child learn to tolerate play around the mouth.
- Encourage your child to put toys in the mouth during play.
- Tooth brushing with regular or electric toothbrushes may help.
- Wipe the face regularly with warm cloths, using comfortably firm pressure.
Remember to start farther away from the mouth and gradually work toward it. The mouth is the most sensitive area of the face. If you start on or in the mouth, it can be too upsetting for the child.
Making the Move from Liquid to Strained Foods
Children who overreact by gagging as you offer strained foods probably need to have the transition made more slowly. Instead of using strained foods or thick strained cereals, try very gradually thickening the formula your child is taking. A gradual change in the texture of liquid being swallowed in the bottle or cup can be less noticeable to an oversensitive mouth.
Making the Transition from Strained Foods to Lumpy Foods
The same slow move is needed from strained foods to lumpy foods. Unfortunately, store-bought baby foods are not designed with the overly sensitive gagging child in mind. The textures often move from very runny strained foods to strained foods with carrot lumps or obvious pasta pieces. These children need to have the changes made very slowly.
They usually do better moving from strained foods to thickened strained foods, to blended foods, to thickened blended foods, to thickened blended foods with tiny, very soft lumps. Remember, it is easier to hide lumps in thickened foods. They are much too obvious when presented with strained foods.
Some good ingredients for thickening foods include cereal, dehydrated baby foods, instant potatoes, instant puddings, and ground cracker crumbs.
Think of gagging as the way your child communicates stress, discomfort, or fear of whatever food you’re offering. If you continue to offer the food and don’t “listen” to these efforts to “talk you out of it,” the child may become very emotional or even begin to vomit.
Sometimes, what starts out as an oversensitivity can develop into a way of controlling the mealtime. Gagging or vomiting seems to become easier with time. Pretty soon it can take less and less to cause the reaction. If a child becomes upset at a meal, gagging may be the way that has been learned to control the situation.
Gagging and vomiting can be emotional for parents too. Try not to react too much to the gagging or vomiting episode. Be calm, distract your child, or even change the subject. If vomiting did occur, clean it up without emotion. These children need to have very sensitive, individualized programs developed to help them and their families deal with this situation.
Why Do Problems Occur?
Some children can’t make these changes as smoothly. They may accept strained fruits but reject baby cereal. Or they may accept watery purees but reject the lumps in junior or ground foods. Lumps may always be spit out, or they may cause gagging and even vomiting. Sometimes even the sight of lumpy foods may cause these reactions.
Physical, medical, and touch-sensitivity problems can cause these difficulties. For some children, muscle tightness or weakness allows food to become too scattered in the mouth and the child has little control. Others may have immature tongue movements and may continue to push food out rather than keep it in their mouths. For still others, tongue movements are so limited that the mouthful is swallowed whole rather than chewed and organized for swallowing. And some may be so sensitive to touch that texture changes cause too much gagging or even vomiting.
If your child consistently becomes fussy and refuses, gags, coughs, chokes, or even vomits when fed lumpy foods, you may need to contact your child’s doctor and a feeding specialist. Together you can figure out why your child is having trouble, if any further medical tests are needed, and how to present lumpy foods in a more enjoyable way.
How to Help Your Child Make the Transition
Once your doctor has determined that nothing is wrong medically and give you the go-ahead to continue to try lumpy foods, you and your child’s feeding specialist may try some of these ideas.
- Be sure your child is sitting in a comfortably supported position. Usually a tucked chin is appropriate. Discuss your child’s posture with your child’s developmental team.
- Mealtime should be fun. Start with fun food experiences—with what your child will eat—and work from there.
- Move from one texture to the other slowly.
- Start with foods your child likes.
- Thickened strained foods. Helpful thickeners in dried baby cereal, instant potatoes, dried puddings, and dehydrated baby cereals. Thick-It® is a commercially available product that is designed to thicken foods. Although it thicken well, it doesn’t add texture. The preference here is thicker with texture, but when that is not tolerated, just thickening is a starting place.
- Serve food flavors your child likes, but in a homemade or blended form. These foods generally have more texture than commercially purchased baby foods. They can be watered down at first, and then gradually thickened.
- Introduce new textures with the old. Try putting some of the more easily accepted texture in the same bowl as the expanded new texture. Give taste of the familiar texture. Next give a spoon that has a little of the new texture added to the old. Follow with a spoonful of the old texture, then more of the new with the old. By alternating with familiar textures, you may keep your child’s interest longer.
- Try grinding foods your child likes. Baby food grinders are available quite inexpensively in department and children’s stores. The grinder provides a consistent texture size without noticeable lumps.
- When your child is handling thickened blended or ground foods, very tiny soft lumps can be hidden in the thickness. Mashed banana, puff rice, and cooked fork-mashed vegetables add nice, soft, but easy-to-swallow lumps.
- Gradually add more and more soft lumps, continuing to use foods that “stick together.” These “stick-together” foods are called binder food and prevent the food from becoming scattered in the child’s mouth as tolerance of texture improve.
- As your child handles a variety of lumps with binders (such as fork-smashed macaroni and cheese with thick sauce) the sauce can be thinned so that the binder doesn’t hold the food together as much. Gradually your child will be able to handle the food scatter and will be able to organize it for swallowing. You will be thinning the binder and fork smashing less, as your child shows you that these changes can be handled.
- Remember, throughout all these changes, you need to listen to your child’s reactions. Give your child choices: “Would you like the beans or scrambled egg first?” or “We are having macaroni. Would you like it on the red spoon or the silver spoon?” Let the child tell you when it’s time to move on by doing such things as leaning toward the spoon or opening the mouth. When children feel more in control, their fear level decreases, making feeding easier.
- Be patient. Go slowly. Ask for more help if you need it.
A commercially available thickener Thick-It® is available through Kent Precision Foods Group, Inc., 11457 Olde Cabin Road, Suite 100, St. Louis, MO 63141
Milani Foods, 2525 Armitage Ave, Melrose Park, IL 60160, (800) 333-0003
Another thickening agent is Thick & Easy, available through American Institutional Products, Inc., 2733 Lititz Pike, Lancaster, PA 17601.
Morris, S.E., and M.D. Klein. 1987. Pre-Feeding Skills. Tucson, AZ: Therapy Skill Builders.