Feeding Evaluation and Intervention

Question 1

What are the classifications of feeding interventions?

Answer 1

1) Oral motor
2) Behavioral
3) Sensory

Question 2

What is feeding?

Answer 2

The process of “setting up, arranging, and bringing food or fluid from plate or cup to mouth, sometimes referred to as ‘self-feeding’” (AOTA, 2007

Question 3

What is eating?

Answer 3

Eating is the “ability to keep and manipulate food/fluid in the mouth and swallow it; eating and swallowing are often used interchangeably” (AOTA, 2007)

Question 4

What is swallowing?

Answer 4

“A complicated process in which food, liquid, medication, and saliva pass through the mouth, pharynx and esophagus into the stomach” (AOTA, 2007)

Question 5

What are the stages of swallowing?

Answer 5

Pre-oral > oral/oral transit > pharyngeal > esophageal

Question 6

What is a feeding disorder?

Answer 6

• A medical diagnosis in which an infant or child is not able to achieve adequate nutrition
• Can result from varied etiologies including poor oral motor skills, oral sensorimotor impairments, and maladaptive behaviors during eating
• Failure to thrive is a medical diagnosis in which the infant is not meeting his or her nutritional needs

Question 7

What are symptoms of a feeding disorder?

Answer 7

• Poor weight gain
• Irritability
• Constipation
• Refusal to eat food offered
• Restricted acceptance of food and liquid variety
• Excessive crying
• Apathy
• Prolonged or stressful mealtimes
• Restricted acceptance of food and liquid variety
• Need for special strategies and distractions at mealtime
• Pocketing of food in the mouth - oral motor because unable to lateralize
• Gagging, retching, and vomiting associated with eating and drinking - GERD

Question 8

What should you ask parents about the food the child is eating?

Answer 8

Ask about food textures, colors, and temperatures that the child consumes

Question 9

What are the criteria for having a feeding disorder?

Answer 9

• Lack of adequate eating with significant weight loss or failure to gain weight, lasting one month or longer
• Behavior is not attributable to gastrointestinal or other medical condition
• Behavior is not better explained by lack of available food or another disorder
• Onset is before age 6

Question 10

How does an eating disorder impact a child?

Answer 10

• Medical: if caloric needs are not met, the child is at risk for stunts in physical and mental development
• Child may require a gastronomy tube or nasogastrostomy tube to increase caloric intake
• Child may not be able to actively participate in childhood occupations (i.e. socialization)

Question 11

What are advantages and disadvantages of a nasogastrostomy tube?

Answer 11

• Temporary and can be inserted without having surgery
• Therapists can work on feeding
• It is easy to pull out
• The child can feel the tube when swallowing and it can be irritating
• Risk of infection

Question 12

What are the advantages and disadvantages of a gastronomy tube?

Answer 12

• It is less visible
• The child’s throat is not irritated
• Can be a site of infection

Question 13

How does a feeding disorder impact a family?

Answer 13

• Increased stress of looming medical intervention if conservative measures do not succeed
• Family dynamic changes - particularly regarding family mealtime
• Possible decrease in time spend with other children
• Feelings of guilt/pressure from others for not being able to meet their child’s basic needs
• Medical expenses

Question 14

What questions might be asked during the sensory processing component of the feeding evaluation?

Answer 14

• Ask about child’s auditory abilities. If the environment is too noisy it may make it hard to focus on eating
• Ask if the child is a seeker, if so they may need to be given more colorful foods
• Ask about aversions to olfactory stimuli
• Ask questions about food preferences and food refusals. Tastes, texture, temperature, color
• Ask about the child’s general response to being touched and having food or other objects touch face, lips, mouth, and tongue

Question 15

What are things to consider during a tactile sensory evaluation?

Answer 15

• Observe general response to touch from therapist or environment
• Check allergies before introducing new foods
• Observe reactions to smooth foamy non-food texture (shaving cream), gooey/sticky non-food texture, smooth food texture, pureed food texture, mixed food texture
• Observe reaction to deep pressure and vibrational activities - usually these sensations are calming

Question 16

What behaviors should be assessed during a feeding evaluation?

Answer 16

• General temperament
• Ability to self-sooth or calm
• Attachment
• Coping skills
• Interaction with caregiver
• Interaction with therapist
• Eye contact
• Ability to follow commands
• Avoidant behaviors (“no moments”)
• Caregiver reaction to avoidant behaviors

Question 17

What should be assessed during an oral motor skill evaluation?

Answer 17

• Depending on scope of services at facility, OT or SLP may be responsible for this evaluation
• Lips
• • ROM and strength
• • Symmetry
• Cheeks
• • ROM and strength
• Symmetry
• Jaw
• • Strength
• • Chewing pattern with food and non-food items
• • Resting posture
• Tongue
• • Lateralization to molars
• • Protrusion and retraction
• • Elevation
• Palate
• • Shape/vault
• • Abnormalities (clefts, sub-mucus clefts, bony notches)

Question 18

What are some oral motor treatment strategies?

Answer 18

• Utilize concepts from biomechanical and NDT (i.e. providing stabilization to jaw, facilitating/inhibiting tone, building strength) FOR
• Lips
• • Treat ROM and strength using the Beckman stretches/Rona Alexander facial wrapping and clearing spoon with lips
• Cheeks
• • Treat ROM and strength using Beckman stretches/Rona Alexander facial wrapping (also used for oral awareness and can be preparatory)
• Tongue
• • Lateralization/elevation can be treated with Beckman stretches (tactile stimulation with pressure points) and Overland (tongue bowling exercise)
• Jaw
• • Strength can be treated with the Beckman chewing protocol, the Overland chewing hierarchy, and jaw support

Question 19

What should an OT remember when creating a sensory-based feeding intervention?

Answer 19

• Create individualized treatment plan based on child’s/family’s areas of need
• Collaborate with caregiver, teacher, and school staff to form a sensory diet, or daily schedule of sensory activities to incorporate at home and at school
• Educate family, teachers, and school staff on calming sensory techniques: possibly brushing or joint compression or application of weighted vest if appropriate

Question 20

What are some strategies for creating a sensory-based intervention?

Answer 20

1) Create sensory experiences for child
- Expose child to new sensory experiences in non-threatening, play-based manner
- Allow child to have some choice in activity selection, and then therapist adds a sensory component
- Grade the activity based on skill level/level of adverse behavioral reactions exhibited
- Introduce tactile textures in a play-based manner first before presenting them during feeding sessions
- Use vestibular and proprioceptive activities as reinforcements when appropriate
2) Pretend play for self-feeding
- Have child feed a doll or stuffed animal
- Then have the child feed him or herself
- Also practice scooping food or non-food objects (marbles, pegs) from one container to the next using a spoon
3) Whenever possible play with different textures (i.e. play-doh, cookie dough, finger paints, dried beans, wet noodles, sidewalk chalk, mashed potatoes, sand, and art projects that incorporate glitter and glue)

Question 21

What are some sensory treatment strategies for a hypo-sensitive/under responsive child?

Answer 21

• Target activities that will increase oral awareness (i.e. Nuk brush, vibration, chewy tubes)
• Use foods that will give child input (i.e. hot/cold, salty/bold, spicy, crunchy)

Question 22

What are some sensory treatment strategies for a hyper-sensitive/over responsive child?

Answer 22

• Target activities that will decrease the child’s sensitivity (i.e. Nuk brush, vibrations, chewy tubes)

Question 23

What is the Alert System: How Does Your Engine Run program?

Answer 23

• Adapted for preschool through high school
• Helps child identify and change how alert they feel by using an analogy of an engine
• Ideal for children with attention problems, autism, developmental delays and other learning challenges

Question 24

What is the feeding progression for a non-oral eater?

Answer 24

• Dry spoon
• Wet spoon
• Spoon with water
• Spoon with flavored water
• Spoon with thickened water
• Puree

Question 25

What are feeding treatment strategies for pureed and solid foods?

Answer 25

• Increase variety
• Use an “around the bowl”
• Food chaining
• Increase textures: crumbs, dippers, “around the bowl”

Question 26

What are feeding treatment strategies for liquids?

Answer 26

• Use cups with lids/straws

- Slowly add new flavor to liquids that the child will accept via ice cubes

Question 27

What is the “Steps to Eating” chart?

Answer 27

• Used by Feeding Sequential Oral Sensory method
• Child begins by tolerating being in the same room as food, then to interacting with food, then to smelling and touching food, then to tasting food, and then to eating food

Question 28

When is a behavioral modification approach appropriate?

Answer 28

• When the child has decreased intrinsic motivation to eat orally

Question 29

What the behavioral modification approach?

Answer 29

• Behavioral modification is a psychological approach that attempts to change or alter an individual’s reactions to stimuli through reinforcement of adaptive behavior or extinction of a maladaptive behavior through punishment

Question 30

What is positive reinforcement?

Answer 30

• Addition of something positive to increase the likelihood that a behavior will occur in the future

Question 31

What is negative reinforcement?

Answer 31

• Taking away something to increase the likelihood that a behavior will occur in the future

Question 32

What is punishment?

Answer 32

• Addition or removal of something to decrease the likelihood that a behavior will occur in the future

Question 33

What is compliance training?

Answer 33

• A system of reinforcement where verbal, gestural, and physical cues are given and positive reinforcement is given when the child complies

Question 34

What is planned or active ignoral reinforcement?

Answer 34

• Positive reinforcement is consistently withheld for non-dangerous, non-destructive problem behaviors

Question 35

What are the behavioral modification principles?

Answer 35

1) Goals
- Increase positive responses
- Prevent negative responses from impeding on participation and progress
- Generalize feeding techniques in therapy to home and school
2) Functional analysis of feeding
- Evaluate antecedents and consequences
3) Consistency is crucial

Question 36

What is the behavioral modification approach protocol?

Answer 36

• Let child play with toy for 1-2 minutes initially
• Remove toy and present a bite of food. In a neutral voice and facial expression say, “take your bite. When you take your bite, you may play with your toy”
• If the child takes a bite then you give the child the toy immediately and in a happy, intonated voice praising the child for specific behavior (knowledge of results). Ex: “good taking your bite or good cleaning the spoon”
• Continue letting the child play with the toy until the child refuses to take a bite
• If a child does not take a bite then leave the spoon only a few inches away from the mouth and continue to say “when you take your bite you may play with your toy”
• If the child continues to refuse you may change the toy you present, but keep the spoon in front of the child and do not offer the child the toy unless the child takes the bite
• If a stand-off develops, the therapist may turn around and utilize planned ignoring tactics for 2-3 minutes and then turn around and attempt to offer bite again
• Set a time limit for the meal (20-30 minutes)
• If the child continues to refuse taking the bite for the duration of the session, then end the session saying “the meal is over. Because you didn’t take your bites you do not get to play with your toys. Maybe next meal when you take your bites, you’ll get to play with your toy”

Question 37

What are general strategies to remember when using the behavioral modification approach?

Answer 37

• Keep a neutral voice and facial expression when offering bites
• Actively ignore negative behavioral reactions
• Begin with a 1:1 ratio of bites to opportunities to play
• Increase the ratio reinforcement system when child is consistently taking bites
• Begin building volume, then increase variety

Question 38

What is the definition of a feeding disorder?

Answer 38

• A medical diagnosis that affects the physical, social, and occupational aspects of the child and family

Question 39

What should a feeding evaluation entail?

Answer 39

• Holistic assessment of a child’s medical and feeding history, language, hearing, vision, motor, sensory processing, play, and behavior and self-help skills

Question 40

What sensory treatment strategies exist for feeding disorders?

Answer 40

• Establishment of sensory diet
• Creation of sensory experiences in a play-based manner
• Parent education
• Gradual exposure to purees and solid foods in a non-threatening, play-based manner