Prevention and Management of Feeding Problems in Infants and Very Young Children

1
12th Annual Institute on Infant Toddler Mental
Health September 26 28, 2007

• Prevention and Management of Feeding Problems in
  Infants and Very Young Children

Arizona Child Study CenterChildrens Health
Center ofSt. Josephs Hospital Medical
CenterPhoenix, Arizona
Daniel B. Kessler MD, FAAP Director, Arizona
Child Study Center Clinical Professor of
Pediatrics University of Arizona College of
Medicine
2
Learning Objectives

• Upon the completion of this seminar, participant
  will
• Recognize common concerns of parents
• Describe normal feeding skills
• Make recommendations for families to support the
  development of appropriate feeding skills

3
Why talk about feeding?

• Crucial to survival of the species
• Imbued with emotional resonance
• Optimal Growth signifies the health vitality of
  the child
• For the child feeding is sustained by the
  pleasures taste and texture, satiety, and parent
  contact
• For the parent successful feeding is emotionally
  satisfying and a powerful affirmation of
  competence
• Feeding is critical for growth, development,
  culture.
• And feeding is

4
Prevention and Management of Feeding Problems

• What is a feeding problem?
• Is that different from a feeding disorder?
• How common are they?
• How to prevent them?
• How to manage them?
• We will not discuss
• Pica
• Rumination disorder
• Anorexia Nervosa
• Bulimia
• CNS dysfunction

5
Prevention and Management of Feeding Problems

• Whats what?
• Terminology
• Disorder v Problem?
• Feeding v Eating?
• Classification systems
• What are we really talking about?
• Whats to know?
• How to help?

6
TerminologyNo two terms alike

• The term feeding problem is used to refer to
  variations in ingestive behavior that are
  sufficiently divergent from the norm to result in
  personal or familial distress, social or
  developmental risk, or negative health
  consequences. Feeding problem is used
  interchangeably with disorder, granting that
  the latter term often suggests a problem that is
  symptomatic of a mental or emotional disturbance,
  whereas in other contexts feeding disorder has
  been used to refer to an exclusively organic
  problem.
• Kedesdy JH, Budd KS. Childhood Feeding
  Disorders. Biobehavioral Assessment and
  Intervention. 1998. Paul H Brookes Publishing.
  Baltimore MD

7
Terminology

• The term feeding is chosen in preference to
  eating because, in infancy and early childhood,
  eating is more often a dyadic process.
• Kedesdy JH, Budd KS. Childhood Feeding
  Disorders. Biobehavioral Assessment and
  Intervention. 1998. Paul H Brookes Publishing.
  Baltimore MD
• The term feeding is generally used to emphasize
  the dyadic nature of eating in infants and young
  children.
• Chatoor I. Feeding disorders in infants and
  toddlers diagnosis and treatment. In Robb AS.
  Eating Disorders. Child and Adolescent
  Psychiatric Clinics of North America. April 2002.
  WB Saunders Company. Philadelphia, PA

8
Disorders vs. Problems

• Disorder
• A disease as in medicine
• A disease is an abnormal condition of the body or
  mind that causes discomfort, dysfunction, or
  distress to the person afflicted or those in
  contact with the person
• Medically defined

• Problem
• Refers to a situation, condition, or issue that
  is unresolved or undesired
• Parent or child defined

9
Classification Systems

• An integrated multidimensional classification of
  childhood feeding disorders
• Descriptive Categories
• Children who eat too little
• Children who eat too much
• Children who eat the wrong things
• Children with feeding skill deficits
• Etiological Constructs
• Diet (decreased calories, inappropriate diet)
• Physical competence (cleft palate, hypotonia)
• Appetite (grazing, aversive conditioning)
• Illness (acute or chronic) (AOM, celiac disease,
  cystic fibrosis)
• Interaction/management (misplaced social
  contingencies)
• Child constitution (sensory deficit, difficult
  temperament)
• Caregiver competence (parental mental illness)
• Systemic (poverty, family stressors, multiple
  feeders)

Kedesdy JH, Budd KS. Childhood Feeding Disorders.
Biobehavioral Assessment and Intervention. 1998
Paul H Brookes Publishing. Baltimore MD
10
Classification Systems

• Feeding Disorder of State Regulation (newborn)
• Feeding Disorder of Reciprocity (2 to 6 months)
• Infantile Anorexia (transition to spoon and self
  feeding)
• Sensory Food Aversions (introduction of baby or
  table food)
• Feeding Disorder associated with concurrent
  medical condition
• Post-traumatic Feeding Disorder
• Feeding Disorder secondary to anatomic deficits
• Feeding Disorder secondary to neurologic
  impairment

Chatoor I. Feeding disorders in infants and
toddlers diagnosis and treatment. In Robb AS.
Eating Disorders. Child and Adolescent
Psychiatric Clinics of North America. April 2002.
WB Saunders Company. Philadelphia, PA
11
Feeding Disorders

• Have a medical and behavioral component
• GERD
• Most common
• Aversive Feeding Behaviors
• Sensory
• Oral hypersensitivity with distinct patterns of
  food textural preferences and refusals
• Learned behavior from painful or distressful
  experiences (GER, forced feeding, gagging)
• Oropharyngeal Dysphagia
• Oral motor
• Often associated with neurological and or other
  chronic handicapping conditions (e.g., as
  chromosomal abnormality, congenital infection)
• Prematurity/Maturational delay/Other

Schwarz et al. Diagnosis and treatment of
feeding disorders in children with developmental
disabilities. Pediatrics 2001108671-676
12
Feeding Problems

• Problems are in the eyes of the beholder
• Mealtime tantrums
• Delays in self feeding skills
• Difficulty in accepting new foods and new food
  textures
• Multiple food dislikes
• Rumination, FTT/PUN, obesity
• Bizarre food habits

Satter E. The feeding relationship problems and
interventions. J Pediatrics. 199012115-20.
13
Feeding Problems are Common

• 25 of parents complain of feeding problems and
  concerns
• 33 for children with special health care needs
• 50 of mothers of toddlers and preschoolers
  complain about
• poor food acceptance
• preference for junk food
• poor behavior at the family table
• 10 of mothers report the need to bribe or
  force their children to eat

Satter E. Child of Mine Feeding With Love and
Good Sense. Palo Alto, CA Bull Publishing, 2000
14
Feeding Infants and Toddlers Study FITS (2004)

• Random national sample of 3,022 infants and
  toddlers
• Ages 4 months to 24 months
• Typically developing
• Above 5th percentiles height and weight
• Born at term
• Parents reported if child was very picky,
  somewhat picky or not picky

Carruth, B. , Ziegler, P., Gordon, A. Barr, S.
(2004) Prevalence of Picky Eaters among Infants
and Toddlers and Their Caregivers Decisions
about Offering a New Food. Journal of the
American Dietetic Association, Supp. 1, Vol. 104
(1), S57-S64.
15
PICKY EATERS

• Report of children being a very picky eater
• 4-6 months 19
• 7-8 months 25
• 9-11 months 29
• 12-14 months 35
• 15-18 months 46
• 19-24 months 50
• It is important to note that no child, picky or
  otherwise, was taking inadequate calories. There
  were significant differences in picky eaters
  nutrient intake however.

Carruth, B. , Ziegler, P., Gordon, A. Barr, S.
(2004) Prevalence of Picky Eaters among Infants
and Toddlers and Their Caregivers Decisions
about Offering a New Food. Journal of the
American Dietetic Association, Supp. 1, Vol. 104
(1), S57-S64.
16
What to do?

• Primum non nocere
• Hippocrates
• Do no harm

17
How to Prevent Feeding Disorders?

• Listen to parents
• Dispel the Myths (dont maintain them)
• Identify and treat underlying medical factors
• Learn about normal feeding development and
  problem feeding behaviors
• Always look for feeding skill deficits and
  behavioral problems
• Intervene early

18
Top 10 Myths of Mealtime in America

• Eating is the Bodys number 1 priority
• Breathing is number 1 and Postural Stability is
  number 2. Eating is 3.
• Eating is instinctive
• Eating is instinctive for the first month. After
  the first month a set of primitive reflexes take
  over (rooting, sucking, swallowing) up to the 5th
  to 6th month. After this eating is a learned
  behavior
• Eating is easy
• Eating is the bodys most complex physical task
• Eating is a two step process (you sit, you eat)
• There are actually 32 steps (give or take a few)
  in learning to eat
• It is not appropriate to touch or play with your
  food

Toomey KA. Top Ten Myths of Mealtime in America.
Colorado Pediatric Therapy and Feeding
Specialists. 2002
19
Top 10 Myths of Mealtime in America

• If a child is hungry he or she will eat
• True for about 95 of the population. For those
  who have feeding problems they will starve
  themselves by refusing to eat.
• Children only need to eat 3 times a day
• If a child wont eat, there is EITHER a
  behavioral OR an organic problem
• Certain foods are only to be eaten at certain
  times of the day and only certain foods are
  healthy foods
• Food is just food
• Mealtimes are solemn occasions. Children are to
  be seen and not heard
• Feeding should be a social experience. Meals
  should be about talking about and experiencing
  one of lifes great pleasures--eating

Toomey KA. Top Ten Myths of Mealtime in America.
Colorado Pediatric Therapy and Feeding
Specialists. 2002
20
Myth Eating is Easy and Instinctive
21
Learning to Eat

• Making the transition from a complete liquid diet
  to a modified adult diet in the first two years
  of life
• Not always easy or automatic
• Some of the difficulties are compounded by
  popular myths about eating
• Stress is reduced by having a pediatric
  practitioner who can learn about and help educate
  parents about the process

• What is it?
• How hard can it be?
• What makes it harder?
• How can we help?

22
Helping ParentsUnderstanding Normal

• Kids will develop self feeding skills when they
  are capable of doing so
• Kids are fed solid foods when they can
  participate in the feeding
• Not before 6 months
• Kids are encouraged to develop skills and are
  provided opportunities to do so
• Responsibilities follow abilities
• What can kids do when?

23
Transition to Solid FoodsAAP Recommendations

• Exclusive breast feeding is ideal nutrition and
  sufficient to support optimal growth and
  development for approximately the first 6 months
  after birth (Pediatrics, 1997, 100(6), 1037)
• In the first 6 months, water, juice and other
  foods are generally unnecessary for breast fed
  infants (Pediatrics, 1997, 100(6), 1037)
• Position re-affirmed (Pediatrics, 2001, 108(5),
  1216-1217)

Not before 6 months! (corrected for developmental
age)
24
Feeding Strategies for Older Infants and Toddlers

• Goal Smooth transition from liquid diet to
  modified adult diet
• Kids need to develop
• Postural stability (OT)
• Oral-motor skills and Jaw skills (OT/Sp)
• Sensory skills (OT)
• Hand to mouth skills (OT/PT)
• Parents (providers) need to know
• Parents role vs. Childs role

Toomey KA. Feeding strategies for older infants
and toddlers. Pediatric Basics. 20021002-11
25
Motor Milestones and Feeding Skills

• Allow Exploration
• Provide Mastery Expectations
• Responsibilities Follow Abilities
• Know what your child is ready for

26
Normal Feeding SkillsMotor Milestones for
Feeding and Postural Stability

• 2 - 3 months of age
• 4 - 6 months of age
• 6 - 7 months of age
• 8-10 months of age
• 10-12 months of age
• 14-16 months of age
• 18-24 months of age

• Steady head control
• Hand-to-mouth play
• Reaching skills
• Trunk/head control
• Independent sitting
• Transfers hand to hand
• Uses fingers to rake food
• Puts finger in mouth to move food and keep it in
• Pincer grasp/pokes food with index finger
• Uses fingers to self-feed soft, chopped foods
• Efficient finger feeding
• Practicing utensil use
• Pick up, dip, and bring foods to mouth

Toomey 2002.
27
Sitting for Postural Stability90-90-90

• Correct
• 90 degrees hips
• 90 degrees knees
• 90 degrees ankles

Kay Toomey, 2004
28
Developmental Sequence for Feeding

• 0 to 3 months
• 4 to 6 months
• 7 to 9 months

• Suck/swallow reflex gag reflex in/out tongue
  movement
• tongue and jaw move as one unit suckle in
  anticipation of spoon poor coordination of suck,
  swallow and breathing
• cup drinking some vertical chewing lip closure
  following semi solids transfer of food (center
  to side and side to center)

Ayoob KT, Barresi I. Feeding disorders in
children Taking an interdisciplinary approach.
Pediatric Annals. 200738(8)478-483
29
Developmental Sequence for Feeding

• 10 to 12 months
• 13 to 15 months
• 16 to 18 months
• 19 to 24 months

• Cleans lower lip with teeth tongue
  lateralization, beginning of rotary chewing
  controlled bite on soft cookie
• Lip closure during chewing independent tongue
  and lip movements may bite on cup to stabilize
  jaw
• Controlled bite without associated head movement
  good control of liquid
• Uses tongue to clean lips chews meats with
  rotary chewing can drink in long sequences

Ayoob KT, Barresi I. Feeding disorders in
children Taking an interdisciplinary approach.
Pediatric Annals. 200738(8)478-483
30
Sequence of Introduction of Foods/Textures

• Birth to 12 months
• 4 to 6 months
• 6 to 8 months
• 9 to 10 months
• 10 to 12 months

• Human milk or iron fortified formula water not
  routinely recommended before 6 months
• Introduction of solids now is common but not
  recommended by AAP iron fortified cereal (rice
  cereal because of its low allergenicity)
• Strained vegetables and fruits (no fruit
  deserts) dry unsweetened cereals and zwieback
  plain strained meats
• Soft bite-sized fruits finger foods soft
  breads cooked fork mashed vegetables
• Soft table foods ground meats, strips of tender,
  soft meats, noodles soft canned, bite sized
  fruits and ripe banana soft cooked, bite sized
  vegetables

Ayoob KT, Barresi I. Feeding disorders in
children Taking an interdisciplinary approach.
Pediatric Annals. 200738(8)478-483
31
Dispelling Another Myth

• The myth of parental control
• Parents are responsible for what and how
  much
• their children eat

32
The Work Of Ellyn Satter

• Division of responsibility
• For the infant
• The parent is responsible for what
• The child is responsible for how much (and
  everything else)
• For the toddler
• The parent is responsible for what, when, and
  where.
• The child is responsible for how much and even
  whether
• Parents
• Choose and prepare food
• Provide regular meals and snacks
• Make eating times pleasant
• Provide mastery expectations

Satter E. The Feeding Relationship Problems and
Interventions. The Journal of Pediatrics. 1990.
117S181-9.
33
How Parents Can Help

• Choose appropriate foods
• Show and tell your baby how to eat and enjoy new
  foods
• Dress up the flavor of foods for
  interestcheese sauce on peas, lemon sprinkled on
  cooked carrots

• Toddlers are neophobic. Repeated exposure is
  the key to learning to like a good variety of
  foods
• Can take 10 to 20 exposures or opportunities to
  try a new food, paired with positive
  reinforcement, before a child will consistently
  accept it (Satter the rule of 15s)

Birch L. Development of food acceptance patterns.
Developmental Psychology 199026515-19
34
Helping children develop healthy eating patterns

• Structure
• Have a routine to mealtimes, eating in the same
  room, at the same table, with the same utensils,
  which capitalizes on the need for repetition
• Social modeling
• Allow children to learn through the observation
  of good mealtime role models
• Positive Reinforcement
• Meals need to be pleasant and enjoyable, and any
  interaction with food should be rewarded
• Manageable foods
• Foods need to be prepared in small, easily
  chewable bites, or in long, thin strips that a
  child can easily hold
• Learning about the physics of food
• The mouth and teeth will need to use hard
  pressure to break apart a carrot stick. Wiggly,
  squishy string cheese is chewy in the mouth.
  Yogurt which is cold, wet and smooth, can just be
  sucked down

Toomey KA. Feeding strategies for older infants
and toddlers. Pediatric Basics. 20021002-11
35
Normal Feeding Progression(Videotape segment)
Peter Dawson, MD Denver, CO
36
Lessons from the past...
Volume 28, Number 5, May 1946 pp. 595-596
37
The Runabout Child

• Summary Physiologic Anorexia
• Among 360 children, from 1 to 3 years,
  encountered in a well-baby clinic, eighty two
  (23) were reported by their mothers to be
  troubled by anorexia.
• Simple directions were given to the mothers of
  these children, usually in one visit only.
• Several months later, sixty-five of the
  eighty-two children were re-examined. It was
  then found that the anorexia of 91 per cent of
  the sixty-five children had been cured.
• The remaining 9 percent (1.7 per cent of the
  entire group of 360) presented multiple behavior
  problems.

38
Simple Directions?

• To stop forcing food, allowing the child to eat
  what he wanted in a reasonable, but limited time
• To offer mostly the foods the child liked without
  undue coaxing or threats
• To remove any food left, without comment, and to
  offer no more until the next meal and
• To give no more than approximately 1 pint (500
  cc) of milk in twenty-four hours.

39
Food Rules

• Scheduling
• Regular mealtimes, only planned snacks
• Mealtimes no longer than 30 minutes
• Nothing offered between meals, except water
• Environment
• Neutral atmosphere
• Sheet under chair
• No game playing
• Food is never given as a reward

• Procedures
• Small portions
• Solids first, fluids last
• Self feedings encouraged as much as possible
  (finger feeding, holding spoon)
• Food is removed after 10-15 minutes if child is
  only playing without eating
• Meal is terminated immediately if child throws
  food in anger
• Wiping the childs mouth and cleaning up occurs
  only once at end of meal

Adapted fromArvedson JA. (1997). Behavioral
Issues and Implications with Pediatric Feeding
Disorders. Seminars in Speech and Language,
18(1) 31-69
40
C. Anderson Aldrich MD

• 1888-1949
• Founder AAP
• President, American Pediatric Society
• President, ABP
• Journal of Pediatrics, Pediatrics
• Chief of Staff, Childrens Memorial Hospital
• Director, Rochester Child Health Institute (Mayo)

41
Cultivating the Childs Appetite
First Edition 1927 Second Edition 1932
42
Feeding Our Old Fashioned Children
1942
43
Babies are Human Beings
1942
44
no sweets
45
Dispelling Another Myth

• A childs intake should be regular and
  predictable
• If you child doesnt eat ____
• she will surely starve...
• you must make your child finish
  everything that is on their plate
• everything is fair
• Force feeding

46
Self-regulation of infants

• Children demonstrate tremendous variability in
  calorie requirements for growth
• The National Research Council publishes the
  Recommended Daily Allowances (RDA) every 5 years
• average calorie requirements are stated as a
  range with a coefficient of variability of plus
  or minus 20.

47
Lessons from the pastSelf-regulation of infants

• Not only do children vary child-to-child,
  children vary day-to-day as well
• A series of bottle-feeding
  experiments performed at the
  Gesell Institute in 1937

48
Self-regulation of infants

• Babies were bottle fed
• Babies were fed when they were hungry and allowed
  to feed as much as they wanted
• Babies were allowed to sleep when they wanted and
  were allowed to sleep as long as they wanted
• When they woke up they were fed whenever they
  asked for it

49
Self-regulation of Baby J

• Intake varied from day to day by as much as 30
• At 8-weeks he had a cold and his intake varied
  even more
• 20 to 32 ounces
• His growth was consistent throughout

50
Summary

• Children will eat
• They are capable of regulating their food intake
• They generally react negatively to new foods but
  will usually accept them with time and experience
• the rule of 15
• Parents and physicians can either support or
  disrupt childrens food acceptance and food
  regulation

51
How to help?Advice for families

• Provide regularly scheduled foods and snacks
• 3 meals and 3 healthy snacks
• Allowing children to eat when they are hungry
• No grazing, juice bottles, coaxing between meals
• When children do not eat the food is put away
  without comment until the next regularly
  scheduled meal or snack
• Never force feed children
• one more bite
• healthy food before desert
• Children may eat less before they eat more
• Need to take a longer term perspective while
  monitoring growth and development
• Follow-up is important

52
Preventing Feeding Problems in Tube Fed Children

• Thinking before doing
• Tubefeeding should not be the initial
  intervention tried for lack of sufficient oral
  caloric intake
• Tubefeeding is associated with a significant
  increase in morbidity and mortality especially
  for children with less severe disabilities
• Anticipate and prepare for the resumption of oral
  feeding
• Tubefeeding should go hand in hand with plan for
  resumption of oral feeding and preparation for
  same

53
The Pros and Cons of Tubefeeding

• Cons
• except for severely disabled tubefeeding is not a
  primary solution, but a delay in the resumption
  of oral feeding
• tubefeeding eliminates early exposure to a
  variety of textures necessary to the development
  of normal oral motor skills

• Pros
• may assure nutritional adequacy
• allows for a decrease in emotionally charged
  interactions over feeding (i.e., forced feeding)
• permits desensitization and provision of
  interactive therapies

54
The Pros and Cons of Tubefeeding

• Pros

• Cons
• decreased oral stimulation during feeding leads
  to hypersensitivity and irritability of the oral
  cavity
• may be an associated loss of sucking and
  swallowing skills
• tube in the nasopharynx can cause low level
  inflammatory response with excessive secretions

55
The Pros and Cons of Tubefeeding

• Pros

• Cons
• nasal congestion may reduce sense of taste
  (smell) and eliminates gustatory reinforcement of
  oral feeding causing child to resist oral feeding
• placement of NG tube may be seen as aversive to
  child leading to oral defensiveness and food
  refusal
• continuous NG feeding leads to the suppression of
  appetite
• mechanical problems with placement, dislodgment
  or pump function

56
Use of tubefeedings in pediatric feeding
disorders

• Tubefeedings as a last resort, after
• an assessment of the feeding interaction
• a trial of increasing oral intake
• use of calorically dense diet
• use of enteral supplements in place of all oral
  liquids
• Tubefeeding must be accompanied by an oral motor
  treatment program and preparation for oral feeding

57
How to intervene when there is a feeding problem

• Try to understand the problem
• History, history, history
• Birth and social history
• Accurate plot of growth parameters
• Dietary history (adequacy of calories offered)
• 72-hour record
• 3 x 24 hour intervals over 1 week
• 1 weekend day and 2 weekdays
• Past and current medical history
• Feeding history/ indication of feeding battles

58
What to look forHistory and observation

• Breast fed infants
• Length and frequency
• Strong or weak suck
• Mother stressed or fatigued
• Strong let down reflex
• Observation of a feeding (video)
• When child is hungry
• Nature of parent/child interaction

• Bottle fed infants
• Formula preparation
• Who feeds the infant
• Bottle propping
• Ounces taken per day
• Spitting or vomiting
• Toddlers
• How many meals/day
• Who feeds the child and where
• How long do meals last

59
When parents complain about difficult mealtimes

• Observe a feeding interaction
• Schedule for a time the child is hungry
• Have parents bring in foods child will and will
  not eat
• Videotaping is invaluable
• Non-judgmental observation and reflection
• What did you see, what do you think?

60
Behavioral Problems in Feeding(Videotape segment)
Brief Observation and Intervention is Possible
Peter Dawson, MD Denver, CO
61
PICKY EATERS VS PROBLEM FEEDERS

• Decreased range/variety of foods that will eat gt
  30 foods
• Foods lost due to burn out usually re-gained
  after 2 weeks
• Tolerates new foods on plate and usually can
  touch or taste
• Eats gt 1 food from most all food texture groups
• Adds new foods to repertoire in 15-25 steps

• Restricted range or variety of foods, usually lt
  20
• Foods lost are NOT re-acquired
• Cries/falls apart with new foods
• Refuses entire categories of food textures
• Adds new foods in gt 25 steps

Kay Toomey, 2002
62
When to refer?

• Refer sooner than later to a feeding specialist
  with Occupational Therapy or Speech Therapy
  support
• Determine if there is a multidisciplinary team in
  your community
• Dont overlook the need for additional help
  including parent support groups
• azfeedingsupport group at Yahoo! Groups
• http//groups.yahoo.com/group/azfeedingsupport

63
RED FLAGSIs child a candidate for referral?

• Ongoing poor weight gain or weight loss
• Ongoing choking, gagging or coughing during meals
• Ongoing problems with vomiting
• More than one incident of nasal reflux
• History of traumatic choking incident
• History of eating and breathing coordination
  problems with ongoing respiratory issues
• Inability to transition to baby food purees by 10
  months of age
• Inability to transition from breast/bottle to cup
  by 12 months
• Has not weaned off baby foods by 16 months of age

64
RED FLAGSIs child a candidate for referral?

• Child cannot manage majority of all table foods
  by 22 months of age
• Aversion or avoidance of all foods in specific
  texture or food group
• Food range of less than 20 foods, especially if
  foods are being dropped over time with no new
  foods replacing those lost
• An infant who cries and/or arches at most meals
• Family is fighting about food and feeding (meals
  are battles)
• Parent repeatedly reports that the child is
  difficult for everyone to feed
• Parental history of a eating disorder, with child
  not meeting weight goals

65
The Feeding (Speech or Occupational) Therapists
Role

• Assist in the Evaluation
• Based on careful history
• Dietary history
• Feeding history
• Medical history
• Family history
• Social history
• Diagnostic evaluation might include
• Anthropometric assessment
• Videofluoroscopic swallowing study
• 24-hour intraesophageal pH monitoring (GERD)
• Esophagogastroduodenoscopies and biopsy
  (esophagitis)
• Technetium-sulphur colloid milk scintigraphy
  (aspiration)
• Feeding Therapy

66
Assisting the Development of Oral Skills

• Babies need to learn to
• First, move food around in their mouths without
  gagging
• Then, move their tongues from side to side
• Finally, place food on the molar area of the gums
  for chewing

• Parents can help by
• Rather than spooning food into the mouth, touch
  the spoon to the infants lips allow them to
  explore and taste the food, then taking the spoon
  into the mouth by their own initiative

Toomey KA. Feeding strategies for older infants
and toddlers. Pediatric Basics. 20021002-11
67
Assisting the Development of Oral Skills

• To transition from pureed foods to table foods
  the older infant/toddler must develop a
  controlled lateral tongue movement
• Tolerate the feel of a hard object in the mouth
• The mouthing of teething toys helps
• Before going from Stage 2 to Stage 3 foods an
  intermediate step to hard munchables, meltable
  hard solids, soft cubes, and then soft mechanical
  foods (Stage 3) is recommended
• When older infants are given pureed baby foods
  that have chunks of other foods in them (Stage 3)
  before they learn to lateralize their tongue the
  chunk of food may become stuck on the top of the
  tongue and cause the child to gag
• Gagging may cause the child to avoid textured
  foods altogether

Toomey, KA. Developmental Food Continuum. 2002
68
Development of Sensory Skills

• Coordination of the 8 senses
• Seeing
• Hearing
• Tasting
• Touching
• Smelling
• Balance
• Body awareness
• Joint information

• Parents should allow kids to experience all the
  qualities of the food and allow them to get messy
• Difficulties with the sensory system is the most
  common clinical reason for children not being
  able to transition from baby food purees to
  textured table foods
• Look for signs of sensory overload
• Aversion to loud noises or certain textures may
  be signs of sensory problems

Toomey KA. Feeding strategies for older infants
and toddlers. Pediatric Basics. 20021002-11
69
Eating is not a 2-step processHelping children
tolerate the eating hierarchy

• Visually tolerating the food
• Interacting with the food without actually
  touching it
• Smelling
• Touching
• Tasting and then, finally
• Eating

Toomey KA. Feeding strategies for older infants
and toddlers. Pediatric Basics. 20021002-11
70
Additional Resources
71
Thank you!
Sam Age 23 years
Hannah Age 19 years