Straw Drinking Hierarchy in children with Down Syndrome..and a special thank you


The straw that you see above is the first one in the straw hierarchy….it is Hello Kitty…the one below is also the first straw (both bunny and Hello Kitty are the first straw to be used in the hierarchy). 

 I’m re-posting this post with a very special thank you to Kim Nobre….while I was working with her little one today..she wondered if the  Hello Kitty straw would fit in the lid of the Take and Toss cups….and it does!!! I was thrilled because I did not like the fact….when working with Bella…when we put the straw in an open cup…she of course just wanted to pull it out…this keeps the straw in place. 

So thank you to Kim…and to my good friend Patricia (Posha-I love working with you!!)…to Patricia for helping me to take this picture today.



I just finished taking Sara Rosenfeld-Johnson’s Straw Kit class.  Through I was able to take the Straws as Therapy DVD class this weekend…..I love that I can take the talk tools classes at my leisure.
This post is specifically in reference to the first straw in the straw kit….as seen above…..there are eight straws in total.
Therapeutic straw drinking addresses the following skills in children that present with Down Syndrome: tongue retraction and lip rounding.  You are teaching the child dissociative movements of the tongue, jaw and lips…this means that the lips, jaw and tongue move independently in order to draw the liquid from the straw. 
The bunny on the top of the straw acts as a lip block.  This means that the lips can not move past the bunny.  Allow the child to place the straw inside of her mouth and draw the liquid up through the straw. Observe how much of the straw is inside of her mouth….you will then have to place your fingers where the straw enters the child’s mouth….this way you can determine how much of the straw is inside of her mouth.  For now…the top part of the straw is long….so at this point the longer straw creates more of a suckle pattern with the straw.  Let  her feel comfortable with the straw….this should be the straw that she drinks from whenever she drink liquids.  You want her to feel comfortable with the straw and learn to use it with ease.  After observing her drinking from the straw… the top of the straw in hot water..and use scissors to cut off 1/4 of the top….throw that piece away…and with a nail file…smooth away any rough edges.
Now present the straw to your little one…you have made the straw more challenging because now she has to use more of the front of her tongue to draw the liquid from the straw… the back of the tongue needs to retract.  This is working on retraction skills.  Over the next week your little one should practice using the straw when drinking all liquids.
One week later…..put the straw in hot water and cut another quarter of an inch……it is about a five-week process…so there are about five levels with this first straw.  So each time you cut a quarter-inch off….your little one should use the straw for one week.  By the time your little one has gotten to the last level….she should have primary tongue retraction.  This means that the lips are protruded and the tongue is retracted.  You have taught her tongue retraction…and have taught her jaw, lip, tongue, dissociation.  If working on articulation skills….she is not yet ready to practice the S sound…you still have to work through the other straws.   She does not yet have 75% tongue retraction. 
When straw drinking….if more than 1/4 to 1/2 is inside of your little one’s mouth…she may be biting on the straw for jaw stability and suckling on the straw to draw the liquid.    Her tongue also may be under the straw…all of these are not good. 
Following the straw hierarchy is good for children with low muscle tone, children with Down Syndrome, children with articulation issues.  The straw hierarchy is good for certain sounds such as: /t, d, l, n, k, g, s, z, ch, sh, j & r/ and the straw hierarchy is good for children that need to improve velar pharyngeal insufficiency.
How do you know when to move to the next straw?
Thank you again to Sara Rosenfeld-Johnson…the information below was taking from her Straws as Therapy DVD class and literature:
When drinking through the existing straw on the hierarchy becomes easy, the criteria for introducing the next straw has been met.  Criteria for Success involves:
*No liquid leakage or air leakage between the lips.
*The jaw should be relatively still/stable, indicating jaw-tongue dissociation (a pronounce up/down or forward/backward movement of the jaw ill be noted if the client continues to use the suckle pattern).
*The lips should be slightly protruded. (lip retraction is noted when the muscle fatigues or secondary to lack of lip-jaw dissociation.)
*The client should not be pushing into the lip block for support on Straw #4 (I have not discussed this yet).  The client should be able to drink four ounces of liquid in two minutes or less.
I will continue to post about the other 7 straws.
Thank you to Sara Rosenfeld-Johnson….and  
If you go to talk tools website….search for straw kit……and you will see the eight straws.

About Kim

My name is Kim Marino and I have been practicing as a licensed speech and language pathologist since 1993. I work on Long Island providing diagnostic evaluations and services to children from birth to age 21. My experience is vast and am proud to say that I work with children that may present with articulation and phonological concerns, oral motor feeding concerns, Down Syndrome feeding, cognitive rehabilitation, auditory processing delays, receptive language delays, cleft palate feeding and sound development and expressive language delays. Most importantly, I am the mother of four amazing children and am happily married to my childhood sweetheart. I feel blessed to have my four children and so lucky to share this journey in life with my husband. I always had it somewhere in my head that I wanted to develop a blog or a website of some sort so that I could provide families with an additional that parents could help their little ones become a better communicator. And as I was developing this blog....I realized that I also needed to share the stories about my life and my children....and the funny things along the way that help to keep me smiling. Whether you are a working mother or not...finding balance between home, children and life can be a challenge....I hope that my blog helps to bring a smile to your face..and also some tools to help you help your little or big one. I hope you enjoy! Kim
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8 Responses to Straw Drinking Hierarchy in children with Down Syndrome..and a special thank you

  1. Kim says:

    Promise! This week I will do. Xo

  2. Betty says:

    Hi, At what point should we begin working with my 7 week old granddaughter with DS on keeping her tongue in her mouth and how should we begin? (I am not sure of the proper terminology for this). The nurse at the hospital said we should rub her lips when we see her tongue sticking out, but this just seems to make her do it more. When do you suggest beginning with the talk tools? Any suggestions?

    • Kim says:

      Hi Betty. Start right now with the prefeeding exercises listed under the Down Syndrome page… can find at the top of my home page. Post with any questions and send video for me to assess if you can. Best, Kim.

  3. Allison S. says:

    Hello! I was wondering where you found those straws! Thanks!

    • Allison S. says:

      I see that you posted to find them on, however, it’s hard to tell if that straw in the kit on is similar to the ones discussed in this post. I’m assuming they are, but for $28 I’d like to be sure! : )

    • Kim says:

      Hi Allison…yes the straws on tallk tools site are the ones I use during therapy..I have inlcuded the quick link for you: straw kit Please post with any questions. Best, Kim

  4. Karyn says:

    Hi Kim

    I love this post, thanks for sharing. We have been practicing a lot of strategies from your feeding hierarchy and now I am VERY interested in transitioning Salvatore off the bottle and onto a cup with straw. I know he can do it, but he is inconsistent. Every time I try a new cup he loves it for that one sitting and then he is no longer interested. Any suggestions? Any suggestions you can offer in terms of strategy would be helpful. Could it be that he is just not ready?

    Thank you,
    (sal’s mom)

    • Kim says:

      Hi Karyn….Sorry for the late reply…I have been so busy….he is off the bottle??? Can he drink from a straw…it sounds like not yet…you need to use the honey bear to teach him effective straw drinking…I did post strategies on how to teach the Honey Bear. Now until he is successful drinking out of the Honey Bear…we have to be sure that he has a means to get the nutrition he needs. Is he willing to drink out of the open nosey-cut out cups…they are the best ones to teach open cup drinking. How old is he again…and how many onuces of liquid does need to have a day. Send me that information…and I will see what other suggestions I have. If he is still on the bottle…he will need to stay on that for nutrition…until he is able to drink from the straw. Nutrition is most important while teaching straw drinking…and open cup drinking. I did post on how to teach that as well. I hope this all makes sense.

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