Hypothetical anatomical model to describe the aberrant gag reflex observed in a clinical population of orally deprived children

In this 'clinical conundrum', we propose a hypothetical anatomical model to explain the abnormal gag reflex that is consistently observed in a clinical population of children experiencing feeding delays. This model is based on the presence of 'transient' connections formed during the normal development of autonomic brainstem circuitry involving the nucleus tractus solitarius (NTS). We propose that, as a result of normal feeding and swallowing, the activity of these transient fibers typically diminishes shortly after birth. In children who are orally deprived during infancy, these transient connections persist and the aberrant gag reflex is maintained into childhood. The most critical feature of the proposed model is the idea that swallowing during feeding initiates the retraction of the tactile 'transient' input to NTS. In the NICU feeding clinics, it has been suggested that triggering the gag reflex in neonates by tactile stimulation of non-oral body areas and anterior portions of the mouth directly or indirectly may contribute to oral feeding delays. To the contrary, we propose an anatomical model to suggest that oral feeding delays and lack of swallowing food, when experienced by neonates, actually contribute to the development of the aberrant gag reflex observed in later developmental stages.