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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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Picky Eater’s Guide to Thanksgiving

Ahhh, Thanksgiving. For some kids, it’s their favorite meal that comes just once a year! For others, they may dread the sticky mashed potatoes that get plopped on their plate or the smell of Aunt blog-picky-eater-main-landscapeCathy’s green bean casserole. Preparing your picky eater for this time of year might help you avoid the epic battle you fear is coming!

Here are 5 tips to help this time of year be fun and festive, not frustrating and frightful for a picky eater:

  1. Exposure!- Don’t let the Thanksgiving meal be the first time your picky eater sees all the new foods. Thanksgiving foods are not commonly seen throughout the year and can be overwhelming (in an already overwhelming situation!). In the weeks leading up to the big meal, try incorporate one or two Thanksgiving-type foods a week into your family meals or a snack time. Even if they don’t want to eat it, they can touch it, smell it, play with it and talk about it!
  2. Encourage your child to be your sous chef Incorporating your picky eater into cooking and creating the meals gives them a varied sensory experience. Even if it’s a food they’ve never had (or have tried and disliked), they get to see and feel the ingredients, use spoons and mixers to combine it all, and smell the final product, and feel accomplished for helping!
  3. Let your child choose something to make- Allowing your child to choose a menu item guarantees they will have something they like! Macaroni and cheese, or mozzarella stick appetizers, chocolate chip cookies, or homemade rolls may be some favorites.
  4. Bring sauce!- Sauces and dressings can be the key to kids eating new or less-preferred foods. Even if you’re not hosting, bring it with you. If they love barbecue sauce, put a small bowl next to their plate and let them add it to whatever they want!
  5. When in doubt…bring foods they like– If you’re going to someone’s house where you have little to no control as to what is served, you can always bring a few healthy foods you know your child likes. You can re-heat it when the other food is served, and explain to the host that they don’t even eat your cooking (so the host isn’t offended!). Just prepare for all of the kids at the kids table to be jealous!

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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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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.

My Child Vomits When I Encourage New Foods

If this describes your child, then it’s important to contact your pediatricianBlogNewFoods-Main-Landscape to rule out any food allergies, swallowing dysfunction, or other medical conditions, as these can lead to gagging or vomiting and need to be addressed. If you know that your child is not experiencing any of these challenges, then it’s likely your child struggles with oral hypersensitivity affecting his ability to tolerate different textures and temperatures of foods. Oral sensory aversion can negatively impact a child’s diet. There are many signs of oral hypersensitivity, but one sign that is concerning for many parents is vomiting or gagging with new foods. This often occurs when a child’s sensory system is overloaded, and as a result, his body perceives the new food as noxious.

When your child is a problem feeder due to hypersensitivity, mealtime often causes stress and discomfort for both the parent and child.

Here are 5 tips to reduce stress and help your problem feeder to conquer sensory aversion with new foods.

  1. Set aside a specific time each day to work on introducing new foods.

Mealtime is stressful as it is, adding new foods in the mix when you have a problem feeder on your hands can not only escalate your frustration, but can overwhelm your child’s sensory system. Setting aside a separate time to work on feeding with your child will help to reduce the demand, establish a calm and safe environment, and provide the structure of a daily routine that will help support your child in being successful.

  1. Warm-up, provide regulating oral and tactile input prior to beginning.

Your child’s sensory system needs to be in an optimal state of functioning for him to be able to accept novel foods. Providing regulating input prior to beginning feeding time can help to reduce sensitivity and also warm his system up to prepare him. Some regulating oral activities include blowing through a straw or biting on a washcloth. Consider tactile activities as well, such as finger painting, playing with dry rice or beans, or playing with putty or clay.

  1. Set the stage—Reduce additional sensory stimuli to avoid over-stimulation.

Prepare your child’s environment in order to support his success. This includes turning off the television and the tablet and reducing other visual and auditory distractions. Introducing new foods provides a lot of sensory input. By reducing additional stimuli in the room, a parent can prevent over-stimulation and help a child to more successfully interact with the foods presented.

  1. It’s ok to play with your food!

When working with a problem feeder with oral hypersensitivity, it’s very important to allow a child to feel safe playing with his food. This means that he will need to learn to interact with new foods, whether this includes eating the food or not. Start slow, with tolerating the food on the plate, working up to touching the food, and eventually bringing the food to his mouth. Children often require several exposures to a new food before they will feel comfortable trying it.

  1. Praise and encouragement for all improvements, no matter how small.

Remember that the new food that is causing your child discomfort or distress is noxious to his sensory system. Trying and interacting with new foods is hard work, and any progress made deserves praise. Remain positive and provide positive reinforcement for each new interaction your child has with a food.

NSPT offers services in BucktownEvanstonHighland ParkLincolnwoodGlenview, Lake Bluff and Des Plaines. 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 today!

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picky eater or problem feeder

What’s the Difference Between Picky Eaters and Problem Feeders?

Having a child that is a picky eater can mean different things. Sure, your child doesn’t like vegetables and it seemspicky eater or problem feeder
nearly impossible to get anything into their mouth besides chicken fingers and french fries. But, when should you begin to worry that this is a problem that you can’t handle all on your own? For the answer, we need to examine picky eaters vs problem feeders.

A picky eater is very selective about the foods that they will eat. This may be in regards to taste, texture, or appearance. Don’t worry, you’re not alone! Picky eating is not uncommon in childhood and may occur when a child begins to assert independence or when they begin to feed themselves.

A problem feeder may present like a picky eater, with some key differences. Read below for signs and characteristics of picky eaters vs. problem feeders. If your child shows signs of being a problem feeder, call in the professionals!

The Difference Between Picky Eaters and Problem Feeders:

Picky Eaters Problem Feeders
Accept more than 30 foods Accept fewer than 20 foods
Will regain foods lost due to frequent consumption Do not regain foods lost due to frequent consumption
Are able to tolerate new foods on plate and perhaps even taste them Become upset when new foods are presented (throwing, crying, pushing food away)
Eat at least one food from each food group Refuse entire groups of food textures
May be picky about varieties and brands Often demonstrate red flags for feeding disorders (excessive drooling, sensory processing difficulties, immature swallowing and/or oral motor skills, etc.)

 

If your child shows signs of being a problem feeder, seek the help of an occupational therapist or speech and language pathologist.


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NSPT offers services in BucktownEvanstonHighland ParkLincolnwoodGlenview and Des Plaines. 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 today!

North Shore Pediatric Therapy (2011). Picky eating: when to be concerned and how you can help. [PowerPoint slides].

 

Picky Eater

Picking Apart the Picky Eater: 5 Tips to Address Your Child’s Problem Feeding

In an era with Whole Foods, Paleo diets, and organic produce at our fingertips, how do we improve a child that is a picky eater? Modern day life can be hectic and as the result feeding may reflect fast, convenient options that taste good but are not always the most nutrient-dense. So, how does one correct picky eating to support a more balanced diet?

5 Tips to Address a Picky Eater

  1. Re-create expectations around feeding. Eating does not just have to be about pleasure, it can be about sustenance, nutrition, and a time for social interaction/community. To frame feeding in terms of just for pleasure, we overemphasize the role of taste in our feeding practices; if it doesn’t taste goodPicky Eater or initiate our pleasure receptors, we shouldn’t eat it. Really, we eat for a variety of reasons and taste can be one of them. If we re-create our expectations to encompass eating for nutrition, sustenance, as well as taste it can become easier for your child to engage with non-preferred, more healthful foods.
  2. Motivate compliant behaviors through incentives. Feeding is a behavior just like any other so if you want to target increased compliance with eating certain foods, provide incentives to encourage the desired behavior. For example, if your child refuses to eat vegetables with dinner, create a log that tracks compliance with trying at least 3 bites of the non-preferred food. Upon completion of the bites, the child can get a sticker, equating with a long-term prize at the end of the week for compliant behaviors or result in shorter-term gratification which can look like being served dessert. Identify what may motivate your child the most to get through challenging tasks and work with this to create investment towards a new mode of eating. The 3-bite rule can help the child also determine if this is truly a food they like or not as they engage with it more.
  3. Debunk negative thinking. Chances are your child’s refusal of food is due to negative thoughts around how they perceive the food to taste or impact them. For example, if a child fears that a food will make them gag, taste disgusting, or make them sick, it would make sense that they would want nothing to do with these foods. The fact of the matter is, there may be limited to no evidence supporting these interpretations so it is important to challenge or debunk this negative thinking. If the child asserts that they don’t like broccoli, inquire about what they believe will happen to them if they eat it. Will they gag? Will they dislike the taste? Will it make them sick? Likely, they will report they just won’t like the taste. If that is the reality, this is a small problem that they can overcome with practice, perseverance, and supplemental positive thinking. Thinking that broccoli is just “ok” but nothing bad will come as the result can facilitate easier engagement and consumption with the non-preferred food item.
  4. Pair foods together. No one says that a meal will only consist of just preferred or just non-preferred foods so it is important to teach balance This can look like pairing favored foods with non-favored foods to emphasize this point; incorporating chicken nuggets with vegetables or fruit instead of French fries or dipping peanut butter and apples together can make unpleasant foods more pleasurable.
  5. Model. Model. If you want your children to get healthy foods and interact with a balanced plate so do you! Align with your child and demonstrate for them that these foods are good and good for you.




NSPT offers Sensory Processing Disorder (SPD)  and Nutrition services in BucktownEvanstonHighland ParkLincolnwoodGlenview and Des Plaines. 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 today!

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

Problem Feeders: When Picky Eating is a More Serious Problem

Following my last post about picky eaters, parents should know that there is a more severe level of picky eating, which has been termed problem feeding. In the medical community, it is often diagnosed as “feeding difficulties”.

Problem feeders have the following behaviors:

  • Young infants who refuse bottle or breast, or drink a small Mother feeds a babyamount then refuse. This results in a decreased overall volume consumed, and eventually weight loss and dehydration.
  • Toddlers and children who eat less than 20 foods.
  • Kids who “lose” foods that they once ate, and do not resume eating them even after a few weeks break. Eventually they may be down to 5-10 foods.
  • Kids who refuse certain textures altogether.
  • Kids who scream, cry, and panic over touching, smelling, or tasting a new food.
  • Kids who are unwilling to try almost any new food even after 10+ exposures.

Why do some kids become problem feeders?

There is an underlying reason why they have a strong negative association with eating, to the point where they will starve themselves before consuming foods outside of their repertoire. There is often a medical diagnosis that contributes to the development of a problem feeder, such as:

In these cases, the child forms “oral aversion” associated with the pain and discomfort they feel/felt as a result of eating or swallowing. This association is made very strongly in the young developing brain, and in the case of problem feeders, overrides hunger. Oral aversion becomes a protective mechanism, which is why they panic over eating new foods. Problem feeders can be underweight or overweight as a result of their rigid food choices, depending on what type and how much food they eat.

The big difference between picky eaters and problem feeders:

Eventually, a picky eater will come around to eat some type of food they are presented with outside of their usual repertoire, if they are hungry enough. A problem feeder will not respond to hunger cues to meet their needs with the food options presented to them if it is outside of their “accepted” foods. Problem feeders will go on a food “strike”, even if it results in dehydration and malnutrition.

Problem feeders need assessment and feeding therapy, which can be effectively achieved with a multidisciplinary team, such as at North Shore Pediatric Therapy. NSPT has occupational therapists, speech therapists, and dietitians to work through sensory, oral-motor, and nutritional deficits as well as mealtime behaviors. We also have social workers for additional support and behavior guidance.  If you are concerned that your child is a problem feeder or a picky eater, contact our facility for an evaluation.

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