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What Parents Need to Know About Feeding Therapy

Should I Have my Child Evaluated for a Feeding Disorder?

Does your child…

  • Experience extreme anxiety or exhibit behaviors during mealtime?
  • Find mealtime to be an exhausting process that requires too much time and energy to complete?
  • Have difficulty tolerating a variety of food groups?
  • Require you to prepare a separate meal from the family dinner or snack time at school?

If so, a feeding evaluation by a qualified speech-language pathologist or occupational therapist may be warranted.

What Does an Evaluation Look Like?

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The parent interview often provides the most valuable information and it is important to fill out all case-history information completely. The therapist may inquire specifically about your child’s medical history of any respiratory, gastrointestinal, renal, and craniofacial issues. Report any food allergies or restrictions (soy, gluten, dairy, egg, nuts) to ensure your child’s safety. If time allows, a 3-4 day feeding diary that includes a detailed report of all the food/drink ingested would allow the clinician to analyze any patterns of behavior and preferences related to feeding. The therapist should know the child’s regular feeding times, a list of all foods and drinks preferred/tolerated, any foods the child used to enjoy but no longer accepts, the length of a typical mealtime, and any positive or negative behavioral or physiological reactions to foods.

The clinician will examine the oral cavity (jaw, tongue, hard/soft palate, dentition, etc.) for appropriate symmetry, strength, and range of motion for feeding. Based on your child’s level of comfort, food and/or drink brought by the parent may be presented. The clinician will observe the child’s postural stability, acceptance of food/drink, munching or rotary chewing patterns, chewing side preferences, and the timeliness/success of the swallow response, and overall rate of feeding. The clinician will take note of signs/symptoms of airway penetration such as coughing, wet vocal quality, watery eyes, or excessive throat clearing. All of this information will assist the therapist in making appropriate referrals and/or developing a feeding treatment plan tailored to fit your child’s needs.

What’s the Difference Between a Picky Eater and a Problem Eater?

A picky eater is a child who accepts 30 or more foods, requires repeated exposures prior to eating the food consistently throughout varying food environments, and has specific routines with food presentation (e.g., needs crust cut off, no foods can be touching, will only eat one specific brand of chicken nuggets). Children who are picky eaters are still able to maintain adequate nutrition and hydration without nutrient-based supplements. Parents complain that new food experiences such as going to restaurants and birthday parties are often difficult due to their child’s feeding preferences.

A problem eater is a child who accepts roughly 5-10 foods and has no more than 20 foods in their food repertoire. The child presents with extreme phobic reactions to new foods such as crying, screaming, throwing foods, and most often times, absolute refusal if their foods are not preferred. Physiological symptoms become evident with facial grimacing, gagging, or vomiting when presented with or during mastication of foods. Parents often feel obligated to allow their child any food so they will eat something. A problem eater likely has underlying medical or functional impairment such as autism spectrum disorder, gastroesophageal reflux disease (GERD), reduced strength and coordination of the oral musculature, and/or sensory processing disorder. Extreme self-restriction can occur if problem eating is left untreated and most often leads to pediatric undernutrition (PUN). Most parents express that the “wait it out” approach does not work with a problem eater and they will continue to self-restrict for days until preferred foods are presented. Children who are problem eaters often require nutrient-based supplements to maintain their health.

A speech-language pathologist can treat both a picky and problem eater to expand the food repertoire and increase tolerance of various tastes, foods, and textures.

What Does Feeding Therapy Look Like?

There are many different approaches to feeding therapy. Your speech or occupational therapist will choose a technique and plan of care that suits your child’s needs most appropriately. Since feeding is a daily activity that requires parent assistance and preparation, you will likely be included in the sessions for education and training purposes.

A feeding therapy session will focus on creating a positive mealtime experience for the child. Intervention targets will likely include increasing awareness, stability, or strengthening the oral cavity, improving the motor plan sequence for feeding, and/or imposing behavioral modifications during feeding, and educating the parent. Behavioral modifications may include a daily mealtime schedule, with no “grazing” in the kitchen allowed, restricting the amount of preferred foods presented to the child, or implementing positive reinforcement for when a child is trialing a new food (access to a favorite toy for 1 minute.) Parents also benefit from behavioral modifications, such as allowing the child to choose foods from two choices, reestablishing trust after hiding something nutritious in the food, and maintaining the promise of “just 5 more bites.”

A technique called “food chaining” uses the child’s core diet (what they will reliably eat across all settings) to “chain” or transition to another similar flavor and texture of foods.

Here is an example of the steps taken while food chaining:

  1. Core diet – what the child will eat reliably across all settings.
  2. Flavor mapping – analysis of your child’s flavor preferences
  3. Flavor masking – use of a condiment or sauce to mask a new taste
  4. Transitional foods – favorites used to transition a child to a new food.  These foods cleanse the palate in-between bites of new foods
  5. Surprise foods – new foods that are significantly different – something you make together, for example: chocolate to peanut butter, apples to pears, and chips to veggie sticks.

Food chaining often incorporates all senses to transition to a new food using a feeding hierarchy. A feeding hierarchy is a tool to teach the child how to taste/trial food in slow increments in attempt to reduce the amount of anxiety associated with trialing new foods. The feeding hierarchy may include providing the child with a goal to interact with the food, or an item of similar consistency a number of times.

Some examples of what may be included in a feeding hierarchy are:

  • Tolerating the food and its scent in the room
  • Allowing the food on the table or on the child’s plate
  • Touching the food with a utensil or hands
  • Touching the food to the lips (kissing) teeth, and tongue
  • Licking or sucking the food
  • Sinking the teeth into the food
  • Taking a small “nibble”
  • Taking an average bite of food

If your child is experiencing these symptoms consult with your physician regarding your concerns. Should you have any questions regarding a feeding evaluation/therapy, consult with a qualified speech-language pathologist or occupational therapist as soon as possible.

References:

  • Fraker, C., Fishbein, M., Cox, S., Walbert, L. (June 2004). Food Chaining: A systematic approach for the treatment of children with eating aversion. Retrieved from Journal of Pediatric Gastroenterology and Nutrition: Volume 39, pg. 51.
  • Fraker C., Fishbein M., Walbert L., Cox S. Food Chaining: The proven 6-step plan to stop picky eating, solve feeding problems and expand your child’s diet. Cambridge, MA: Da Capo Press; 2007.
  • Roth, M., Williams, K., Paul, C. (August 2010) “Empirically Supported Treatments in Pediatric Psychology: Severe Feeding Problems”. Journal of Pediatric Psychology, vol. 24, no. 3, 193-214.
  • Toomey, K. Ross, E. “SOS Approach to Feeding”. Perspectives on Swallowing and Swallowing Disorders (Dysphagia). 2011. 20: 82-87. Retrieved from http://spdfoundation.net/library.html#effectiveness.

NSPT offers services in Bucktown, Evanston, Deerfield, Lincolnwood, Glenview, Lake Bluff, Des Plaines, Hinsdale and Mequon! If you have any questions or concerns about your child, we would love to help! Give us a call at (877) 486-4140!

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What Parents Need to Know About Feeding Therapy

There are a variety of reasons why a child may need feeding therapy. To many of us, it would seem like Feeding Therapyeating should be a basic instinct. However, eating is one of the most complex activities we do, especially for the developing, young child. Eating involves several processes in the body, including sensory, oral-motor, muscular, neurological, digestive, and behavioral systems. Feeding problems can arise involving any one of these systems, and often more than one of these is implicated.

The following are reasons why a child may have feeding difficulties:

  • Sensory processing issues
  • Picky eating
  • Food allergies or severe reflux
  • Autism
  • Developmental delays
  • Complex post-op recovery course
  • Transition from feeding tube to oral nutrition

Feeding therapy is usually done with one or more clinicians. Depending on the type of feeding problem, therapy may involve a speech-language pathologist, an occupational therapist, a registered dietitian, a social worker or behavior therapist, and/or a physician.

A speech-language pathologist will approach feeding in a comprehensive manner, looking at the actual physical swallow mechanism as well as the sensory aspect of feeding. Before beginning a more structured feeding treatment approach, it is key to rule out any medical reasons that a child is not safe to be taking food or drink orally. If there are concerns regarding vomiting, choking, gagging, etc. then the family should seek further guidance from their pediatrician who may recommend a modified barium swallow study. This test looks at the actual swallow mechanism in real time using x-ray to determine whether or not food or liquids are being aspirated (i.e., food items may slip into the lungs rather than where it is supposed to go). If a child is aspirating, physical symptoms may or may not include choking, wet/gurgly voice, and refusal to eat. Feeding therapy can move forward once it has been determined that a child is safe to take food by the mouth.

In addition to safety concerns, therapists will also look at the various chewing and swallowing stages to see if there is a breakdown in this complex process, once food is in the mouth. There is a developmental sequence of chewing for a child as well as development of independent feeding, first using hands and then moving to use of utensils. Each child will have different needs and a feeding therapy plan should be developed that is unique to your child. One approach to feeding therapy that has high success and is evidenced based is the Sequential Oral Sensory Approach to Feeding.

The Sequential Oral Sensory Approach to Feeding is a therapeutic intervention developed by Dr. Kay Toomey. Certification by Dr. Toomey and her associates through a training course is required for therapists to utilize this technique. Once certified, occupational therapists, speech language pathologists, dieticians, social workers and other health care professionals can intervene using the SOS approach. Under this approach, children are exposed to a variety of foods to increase their comfortability with a range of foods, focusing on exploration of the foods using all the senses: sight, sound, touch, smell, and taste.

Each week, the therapist will send the family a list of 8-14 foods based on sensory characteristics that will help the child experience foods that he/she might never have tried before. The family then brings these foods to the therapy session that week. During the session, the child and therapist (and often the caregiver) engage with the food in a playful manner to move up the “Steps to Eating” with each food, a 32-step process involved in eating developed by Dr. Toomey.  The ultimate goal is for the child to explore a variety of foods and expand the range of foods that he/she tolerates. The goal initially is not for the child to eat the food, rather discover and interact with a variety of foods and develop the skills needed to do so. Parents receive feedback after each session and are given recommendations to continue practicing these techniques at home during the week for ultimate success and generalization across environments. Using this approach, children become more comfortable with and generalize the skills needed to eat a wide variety of foods.

NSPT offers services in Bucktown, Evanston, Highland Park, Lincolnwood, Glenview, Lake Bluff, Des Plaines, Hinsdale and Milwaukee. If you have questions or concerns about your child, we would love to help! Give us a call at (877) 486-4140 and speak to one of our Family Child Advocates!

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This blog was co-written with Julie Paskar.

J-PaskarJulie Paskar is a speech-language pathologist, and the Branch Director at the Lincolnwood clinic. She joined North Shore Pediatric Therapy in August of 2012. Julie obtained both her Bachelor of Arts in speech and hearing sciences and her Master of Arts in speech-language pathology at Indiana University in Bloomington, Indiana. She has lived and worked in the Chicago area for the past eleven years. During that time, Julie worked for a pediatric clinic providing Early Intervention services as well as speech-language therapy services to children ages 3-12. She has her Early Intervention credential in speech pathology as both a provider and an evaluator. Julie’s areas of interest include: phonological disorders, motor speech disorders: specifically childhood apraxia of speech, feeding disorders, and expressive language disorders/delays. Julie is a Hanen certified therapist, has also attended both the Introduction to PROMPT and Bridging PROMPT trainings, has attended Picture Exchange Communication System (PECS) Level 1 and Level 2 trainings as well as the Kaufman Speech to Language training. She has been trained in the Orton-Gillingham program which is a treatment program for dyslexia. Julie is a member of the American Speech-Language Hearing Association and is licensed to practice in the state of Illinois. Julie is dedicated to working with children and their families to make communication both fun and functional.

Does Your Child Need Feeding Therapy?

There are a variety of reasons why a child may need feeding therapy. To many of us, it would seem like eating should be a basic instinct. However, eating is one of the most complex activities we do, especially for the developing, young child. Eating involves several processes in the body, including sensory, oral-motor, muscular, neurological, digestive, and behavioral systems. Feeding problems can arise involving any one of these systems, and often more than one of these is implicated.

The following are reasons why a child may have a feeding problem:

  • Sensory processing issuesFeeding Therapy
  • Food allergies or severe reflux
  • Autism
  • Developmental delays
  • Complex post-op recovery course
  • Transition from feeding tube to oral nutrition

Feeding therapy is usually done with one or more clinicians. Depending on the type of feeding problem, therapy may involve a speech language pathologist, an occupational therapist, a registered dietitian, a social worker or behavior therapist, and/or a physician. Read more