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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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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!

Picky Eater vs. Problem Feeder

Eating. What’s not to love? Whether it’s a gooey, cheesy slice of pizza or a warm cookie fresh out of the oven (yum!), let’s face it -humans love to eat.  Little humans, ehh not so much. Little ones can be incredibly stubborn when it comes to eating, especially when they’re toddlers. What three year old didn’t go through a phase of just eating her go-to; whether it was mac-and-cheese, hot dogs, or PB&J. Many parents have said the words “picky eater” in reference to their child’s eating habits, but it’s important to know the differences between your run-of-the-mill picky eater versus your problem feeder.

Problem feeding is not a normal part of child development. Feeding problems are estimated to occur in up to 25% of normally developing children and in up to 35% of children with neurodevelopmental disabilities. A common definition for feeding problems is “the refusal or inability to eat certain foods.” Feeding problems can lead to serious medical issues such as malnutrition, dehydration, and impaired intellectual, emotional and academic development. Because of these potential impacts on the child’s development, early recognition and management are critical.

The table below can help you determine if your child’s eating skills are following a normal trajectory or further evaluation is needed:

Picky Eater

Problem Feeder

Eats a decreased variety of foods, usually around 30 foods Eats a restricted variety of food, usually 20 or fewer foods
Foods lost due to “burn out” (i.e. one too many hot dogs = refusal) are typically incorporated back into the child’s diet after about 2 weeks Will eat food over and over again like a picky eater but once they burn out, they will not incorporate that food back into their diet
Can tolerate new foods on their plate, will touch or taste a new food even if they aren’t really excited about it Crying/screaming/melt-down mode if a new food is on their plate and will not tolerate touching or tasting
Eats at least one food from most food group textures (e.g. crunchy, soft, puree, etc.) Refuses entire categories of food textures
Will eat a food after being exposed to it at least 10 times Will not try a new food after 10 or more exposures
Sometimes reported as a “picky eater” at pediatric wellness visits Persistently reported as a “picky eater” at pediatric wellness visits

What to do if you suspect your child is a picky eater:

  • Always eat with your child. Eating is a social experience! If your child is expected to eat alone he may feel left out or neglected. (“Why do I have to eat if no one else is?”)
  • Stick to a routine. Give your child three meals and two snacks at the same time each day (or about the same time each day, let’s be realistic here).  Offer juice or milk with his meals, not in between, to avoid filling up his tummy and decreasing his appetite. Offer water in between meals to quench his thirst.
  • At meal times, always offer him one to two preferred foods (i.e. hot dog, chicken nugget) and one new food. When he sees his preferred food, he will feel more comfortable with his plate. Try to make the new food something you’re eating as well.
  • Always talk positively about food! Even if you don’t like something, do your very best not to talk negatively about it. For example, “Mmm, these sweet potatoes are so yummy!” NOT “Ugh, these potatoes are mushy and gross!”
  • Make it fun! Get some different dips out for his chicken nuggets – ranch, BBQ sauce, ketchup, mustard! Cut sandwiches out with a cookie cutter. Use food coloring. Serve breakfast, for dinner!
  • Have your child help! Let him pick things out at the grocery store. Have him wash the vegetables or fruit. Let him mix up the batter.

What to do if you suspect your child is a problem feeder:

Works Cited:

  1. Sisson LA, Van Hasselt VB. Feeding disorders. In: Luiselli JK, editor. Behavioral Medicine and Developmental Disabilities. New York: Springer-Verlag; 1989. pp. 45–73.
  2. Palmer S, Horn S. Feeding problems in children. In: Palmer S, Ekvall S, editors. Pediatric Nutrition in Developmental Disorders. Vol. 13. Springfield: Charles C Thomas; 1978. p. 107–129.
  3. Feeding problems in infancy and early childhood: Identification and management
  4. Debby Arts-Rodas, Diane Benoit
  5. Paediatr Child Health. 1998 Jan-Feb; 3(1): 21–27.
  6. Toomey, Kay. Copyright 2000/2010. Picky Eaters versus Problem Feeders.

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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Help! My child is a picky eater!

The picky eater phenomenon is not uncommon, and can be quite challenging and stressful for parents.

Picky eaters have the following characteristics/behaviors

  • Eat a limited number of foods (20-30).
  • Avoid classes of foods such as red meat or green vegetables.
  • May reject foods they previously accepted, but will re-accept these foods after a two-week break.
  • Will try some new foods after being exposed to the food several different times.
  • Will touch and play with new foods, although they may not eat it at first.
  • Picky eaters usually eat enough to support growth within normal ranges.  (1, 2)

How To Encourage Your Picky Eater, To Eat More:

To alleviate some stress, first examine if your expectations for your child’s eating is realistic. Kids are naturally wary of new things (think “stranger danger”), including new foods. Picky EaterTheir first reaction to something they have never seen, smelled, touched or tasted before is to not trust it. Do not be discouraged if your child doesn’t love hummus, spinach, and salmon right away. It takes an average of 8-15 exposures to a new food before the child will actually eat it (2). Also, toddlers and teens particularly want to exert their sense of control and opinion, including what they will (and won’t) eat. In other words, sometimes a strong-willed child will refuse to eat what you want them to just because it gives them control over that aspect of their environment.

Typically developing young children will eat according to their innate hunger and satiety cues. That is, they will eat what they need when they are hungry and not when they are satisfied. Imagine how you might feel if you were full from dinner, and someone comes at you with a spoonful of food telling you to take another bite. Imagine you are really full, and the thought of taking another bite makes you sick. Now this person starts yelling at you and threatening to punish you. How would you feel? It can be difficult to let go and trust your child’s appetite. Your job as the parent is to provide healthy meal choices, regular mealtimes and snacks, and a positive eating environment without toys or TV.

Finally, using bribes like “one more bite and you can have dessert”, and punishments such as “you can’t play outside if you don’t finish your plate” are not effective in the long run. Doing these things negates children’s natural ability to eat what they need. It also creates a negative, untrustworthy dynamic between the child and the caregiver at the table. Picky eaters will continue to thrive and meet their nutrition needs when provided an optimal mealtime environment. A dietitian at North Shore Pediatric Therapy can counsel families to help picky eaters.

However, there is a difference between a picky eater and a problem feeder. Problem feeders have more rigid food preferences, a dwindling number of accepted foods, and will refuse food (and drinks) that are not part of their repertoire to the point of malnutrition. These children require more intensive evaluation and therapy, and benefit from multidisciplinary treatment available at North Shore Pediatric Therapy. I will further discuss problem feeders in my blog next week.




  • Carruth BR, Skinner J, Houck K, Moran III J, Coletta F, Ott D. The phenomenon of “picky eater”: a behavioral marker in eating patterns of toddlers. J Am Coll Nutr 17:180-186, 1998.
  • Carruth BR, Ziegler PJ, Gordon A, Barr SI. Prevalence of picky eaters among infants and toddlers and their caregivers’ decisions about offering a new food. J Am Diet Assoc. 2004 Jan;104(1Suppl1):s57-64.