Promoting Good Head Positioning for Safer Eating

There are approximately 40,000 deaths in the U.S. each year due to aspiration pneumonia and people who require feeding are more vulnerable to aspiration (which can lead to aspiration pneumonia) than people who self-feed. Ensuring good body and head positioning, with the chin lowered in a “chin tuck” while eating or drinking can reduce the risk of aspiration and is high on the list of good practices, whether being fed by another person or being aided by an assistive device.

Even though there is no precise anatomical definition of “chin-tuck”, in general, a chin tuck is a head position that places the chin slightly downward towards the individual’s chest. Regardless of the exact execution of the chin tuck, it is a position that can improve the probability of taking a bite of food, chewing it, and swallowing it safely. When the head is slightly forward and down, the windpipe is in a protective position; food or liquid is less likely to enter the airway than if the head is upright or the chin is raised. When food enters the airway, the result is choking, or, if the individual does not have an adequate gag reflex or cough, aspiration. (Aspiration occurs when food or liquid is drawn into the lungs instead of going down the esophagus into the stomach. Aspiration frequently results in an infection in the lungs known as aspiration pneumonia.)

The greatest difference in interpretation of how to implement a chin tuck appears to lie in the alignment of the head over the spine and the level of the chin relative to the chest. In a practical sense, having the head aligned over the spine with the chin tilted downward allows the muscles to work at their best to chew and swallow. A simple experiment to understand this phenomenon can be conducted by taking a drink with your head in a chin tuck, and repeating the process with your head fully extended upward. Note how the muscles of the mouth and throat feel in the different positions. Also, note how the muscles are elongated and feel tighter when the head is raised. Basically, more demand is placed on the muscles when the head is raised and controlling swallowing is more difficult. This is particularly significant if the person already has swallowing difficulties.

Some people lack sensation on one side of their throat. This lack of sensation is caused by a variety of reasons ranging from diseases and illness, to scarring due to a previous intubation. For people with numbness in the throat, not only is a chin tuck important, but turning their head to the side that lacks sensation in the throat, will help produce a safer swallow. With the head in this position, the side of the throat that is insensitive is narrowed so food and liquids are directed to the side of the throat that has greater sensation.

For people who sit in a chair that has a chest strap or chest harness, it is important that the straps are not so tight that they prevent a good chin tuck. If the person is normally in a reclining position, the chair should be put in an upright position and the straps checked to verify that they do not restrict the individual from adequately lowering their head for safe eating and drinking.

Most wheelchair seating positions can be adjusted, but the standard wheelchair seating position is designed for transporting someone safely because that is a requirement of the Food and Drug Administration (FDA) who provides the guidelines for all medical device safety. For the same reason, the second most important position for seating is for the user to be able to drive (i.e., control) the wheelchair. Acquiring the appropriate wheelchair position for eating or accomplishing other tasks (like eating) will probably require further seating position adjustment as the safe transport and driving positions are usually inappropriate for performing other tasks.

The normal feeding position for an infant is reclining. However, as the infant grows, and their diet expands from milk to mixed foods, their position should become upright. It is easy to continue feeding children in a reclined position if they have oral motor difficulties and are eating a soft textured diet. However, it is advisable to transition from this position as rapidly as possible as it does not allow the child to experience eating and drinking in an upright position and prohibits the appropriate muscles from developing.

Some people are easier to feed in a reclined position because of their poor oral motor control. When reclined, the food stays in their mouth and, therefore, it is easier and cleaner for the person providing the food, to feed them. But, just because it is easier, doesn’t make it appropriate, or safe.

Fifty years ago it was common to find people in institutions being fed lying in bed. However, with the availability of technology that allows visualization of a swallow, we are now able to see the negative impact of eating in a reclined position. Safe feeding practices have evolved significantly in the past half-century. We have moved from “bird feeding” (feeding someone with their head tilted back) to understanding that good positioning for eating significantly reduces the risks associated with eating and drinking. Through the use of videofloroscopy1, safe eating practices can now be defined.

Regardless of whether someone has difficulty eating or not, if they are fed by another person, good positioning is not only wise but can make the meal more enjoyable. Remember, whether being fed by another person or using assistive technology – a chin tuck is a wonderful thing.

  1. A videofluoroscopic swallow study (VFSS) is a procedure performed using medical imaging technology. During the test, the patient sits next to x-ray equipment and is fed a variety of foods and liquid mixed with barium. The barium makes the food or drink visible during x-ray. The x-ray equipment records a video of the movement of the barium.