The four levels of the chewing hierarchy in children with Down Syndrome

I do not think that I have ever posted all four of the chewing hierarchy levels together…pretty sure that I posted about them individually….so wanted to repost them, as seen below.  Please remember the importance in following the chewing hierarchy with your little one…every level has a different goal.  This is what your little one is working on during the chewing hierarchy:

Tongue retraction and the lateral chew, tongue tip pointing and tongue retraction, and tongue lateralization across midline





Once again my thanks goes out to the amazing Lori Overland and Sara Rosenfeld-Johnson for sharing their invaluable information. As I have posted before I’ve taken many of Sara and Lori’s classes offered through Not only am I thankful for the tremendous amount of information I have obtained…I am blessed to be able to work with the little ones I see for therapy…being able to implement what I have learned in order to help the children I see presenting with Down Syndrome…..and helping the mamas too of course! Below you will find information regarding Chewing Hierarchy Level 1.



“The goal of this hierarchy is to teach a graded, lateral chew with tongue-dissociation and movement across midline. Use a thin bolus such as a veggie stick, thin pretzel or crunchy Cheeto. Move to the next level in the hierarchy when the child can independently demonstrate the skill at the level you are working on with a stable jaw and dissociated tongue movement.”~Lori Overland, MS, CCC, SLP-Developing Oral-Motor and Feeding Skills in the Down Syndrome Population


Chewing Hierarchy Level 1 can only be addressed in feeding when the child has mastered this level in the pre-feeding exercises. So…if your little one does not have a munch-chew….and you are only seeing a suckle (many children with Down Syndrome do not move past the suckle)… need to go back to pre-feeding Chewing Hierarchy Level 1. This means instead of food you will be using various tools in order to facilitate the chew. You can use the chewy tubes…offered at The yellow ones are smaller and better for babies. So it is important to remember….do NOT practice Chewing Hierarchy Level 1 during feeding if you do not see a munch-chew. The goal of the chewing hierarchy is to teach all of the levels of chewing. However, with little ones…babies that are learning to chew…the hierarchy MUST be presented as a pre-feeding exercise at first…and then foods are introduced.

So….one last time…if your little one is still suckling and is not demonstrating the munch-chew….this is a pre-feeding Chewing Hierarchy level 1 exercise.

Okay…so once you are seeing the munch-chew….present a stick shaped bolus…. like a pretzel stick or a veggie stick perpendicular to the lateral molar ridge…have the child take three bites…be sure to do this on both sides of the mouth. That is the excersie…three bites on both sides of the mouth. So: bite, bite, bite on the left….and bite, bite, bite on the right. Question: How much food should go in the child’s mouth?- As much as they can handle…small bites for the little ones of course.

Why is this so important….because hierarchy level 1 is not only teaching chewing…it is motor planning for the following: tongue retraction and the lateral chew. It is important to note right here…during your pre-feeding Chewing Hierarchy level 1…with the chewing tube…..once you see lingual retraction and the lateral chew on the chewy tube…and you see the munch-chew…NOT the suckle…you are ready to do Chewing Hierarchy level 1 with food.

Since you will be doing Chewing Hierarchy level 1 during feeding….what will you be doing during the pre-feeding exercises with your little one…YES!….Chewing Hierarchy level 2. My next post will be about chewing Hierarchy level 2…but wanted to end this post with the goals of level 2: teaches the motor planning for tongue tip pointing and tongue retraction.

A few extra tips….when you are doing the pre-feeding Chewing Hierarchy Level 1……you can also use the Z-vibe with the green head (found on and the Ark Probe also at talk tools.



Chewing Hierarchy Level 2 in children with Down Syndrome:



Chewing Hierarchy Level # 2 as a pre-feeding exercise:

If you are working on Chewing Hierarchy Level #2 as a pre-feeding exercise…this means during regular feeding your little one is chewing food at Chewing hierarchy level #1…while she is eating at level #1…during pre-feeding you work on level #2…with toothettes presented to the lateral incisor and then to the back molar… or you can use chewy tubes….go to for tools and supplies for this level.  When using the toothettes…be sure to cut the wings off to make it easier to put inside your little one’s mouth.

So you want your little one to take two bites:


One bite at the lateral incisor



One  bite at the back molar


What are we motor planning for?  Tongue tip pointing and tongue retraction.

Be sure to alternate sides…whatever you do on one side you do on the other side…unless you see asymmetry.

Once you see that your little one is capable of biting at the lateral incisor and then at the back molar ridge….you are ready to present this level during feeding.

And when you are working on chewing hierarchy level #2 during feeding…you are working on chewing hierarchy level #3 during pre-feeding.

Not only are you teaching your little one these chewing skills…you are also motor planning for the skills indicated above.



Chewing Hierarchy Level Number 3 for children with Down Syndrome



Below you will find information regarding chewing hierarchy level three….remember you will do level #3 as a pre-feeding exercise while you are working on level #2 as a feeding exercise.  This means if you are working on level #3 as a pre-feeding exercise you are using chewy tubes not food…..because you are developing the muscle memory for chewing…and when your little one is ready….you will do this level during feeding…and addressing chewing hierarchy level #4 in your pre-feeding.




Present a stick shape bolus-like a veggie stick or a pretzel…I also like the Snikkidy Cheese Fries…they are the same shape as a veggie stick..and the same consistency…but are very cheesy…and give lots of good sensory information…they are in the chip aisle….I love them too! 

What to do:

Present the food on the lateral incisor.  Be sure to provide support to your little one’s jaw to prevent jutting or sliding…if needed.  Encourage your little one to bite.  Quickly present the bolus to the opposite lateral incisor.  Alternate the side you start on as well. 

What does this level work on?

~Tongue tip pointing

~Tongue lateralization across midline

I plan to post about level number four tomorrow…the five point bite…which addresses the rotary chew…tongue lateralization across midline.





How to teach chewing hierarchy level number four in children with Down Syndrome: 


Chewing Hierarchy Level Number 4

This is the five point bite.  So you will be presenting the stick shaped bolus (veggie stick or Snikiddy Cheese Fries) perpendicular to the lateral molar ridge.  Be sure to support your little one’s jaw if needed.  This is to prevent jutting or  sliding.  Now you will move the bolus around to the opposite molar ridge: there will be five bites in total: lateral molar ridge, lateral incisor, front central incisor, lateral incisor and finally the lateral molar ridge on the other side.  Be sure your little one takes small graded bites. 

What are we addressing:  Encourages tongue lateralization across midline








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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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