PFD Treatment Considerations and Transitional Feeders Flashcards
ICFQ 6 Question Screener
early identification/early intervention integrate into all case history for preschool and younger (6-question subset):
1. does your baby/child let you know when he is hungry? yes/no
2. do you think your baby/child eats enough? yes/no
3. how many minutes does it usually take to feed your baby/child? yes/no
4. do you have to do anything special to help your baby/child? yes/no
5. does your baby/child let you know when he is full?
6. based on the questions above, do you have concerns about your baby/child’s feeding?
assessments: general overview
- your assessment is a window into the child and family’s story
- this can be a stressful time for many families; give them grace and be respectful of cultural norms, the medical journey, etc.
- family’s understanding about your skill set and how you will be able to help the family, or where you can refer them for appropriate services
- you may not gather everything you need in the first session
- what you see is most likely the tip of the iceberg
- chart review, preparing for the assessment, evaluation of skill, parental goals, and synthesizing information
- stressing the importance of humility in one’s knowledge and skill
assessment: you may not gather everything you need in the first session
every session following this will be treatment and ongoing assessment
assessment: what you see is most likely the tip of the iceberg
go deeper and understand what underpinnings exist
assessment: stressing the importance of humility in one’s knowledge and skill
- you may not be ready for this particular child
- be honest and let the parents know that you are learning or will need mentorship but are willing to work together
evaluations: using the PFD domains
- address each area of the PFD framework
- we “live in” the oral skill/sensory domain but still need to see the “big picture”
- list the referrals already undergone and results and also make appropriate referrals
- have the most naturalistic observations
- caregiver input is paramount
- if the child is coming from a community providers, you may be the first stop!
- advocate advocate advocate
clinical assessment session structure
- chart review
- case history and interview
- oral mech
- observation of typical feeding/what is successful
- challenge foods/what the concerns are
- sensory and skill assessment with foods
clinical assessment session structure: sensory and skill assessment with foods
- want to see a variety, levels of interaction, etc.
- use norms to guide what you present and look for
parent interview across the age spectrum: key questions to ask all parents (regardless of the age)
- feeding time: how long does it take to feed your child?
- mealtime stress: are mealtimes stressful to child and/or parent?
- growth: is your child gaining weight ok?
- respiratory system: are there signs of respiratory problems?
- GI system: are there things like reflux, GI retching, irritability with feeds?
- consider a food dairy
parent interview across the age spectrum: you obviously need to gather information about skill, utensils, etc., however, these are some key areas that you should target first
- you can always gather skill data and utensils etc. in subsequent appts as well
- take mental notes of the care
- family and child interaction
parent interview across the age spectrum: take mental notes of care
- family and child interactions
- immature vs. disordered/abnormal patterns
- food refusal may occur for many reasons (in-depth treatment of the topic would be an entirely separate session)
parent interview across the age spectrum: family and child interaction
gather the following information (by direct observation and caregiver reports):
- what is the child’s appetite, hunger, interest in eating?
- does the child have regular mealtimes or snacks/grazing?
- what is the duration of mealtimes?
- are distractions present?
- are rewards give for eating?
developmental feeding continuum: approximate developmental age and type of food
- 0-13 months: breast milk/bottle (formula)
- 5-6 months: thin baby food cereals
- 6-7 months: thin baby food purees (Gerber Stage 1)
- 7-8 months: thicker baby food cereals
- 8-9 months: soft mashed table foods and table food smooth purees
- 9 months: meltable solids (Towne House crackers, Gerber biter biscuits, graham crackers)
- 10 months: soft solids (bananas, Gerber Graduate fruits, avocado)
- 11 months: soft single texture solids (Gerber Stage 3, macaroni and cheese, french fries, lasgna)
- 12-14 months: soft table foods
assessment considerations for children over 6 months: sensory regulation
food and non-food related experiences and input
assessment considerations for children over 6 months: oral mechanism exam
adapting it with considerations for behavior, dentition, previous oral experiences
nutritive feeding assessment
- observation across textures (accepted and challenging/new foods)
- is the utensil choice contributing to the deficits
- be prepared to step back and build rapport during this session or not even get into the mouth
thoughts on formal assessments
- multiple from feeding flock group (now infant feedingcare.com)
- PediEat is a good resource for a wide range 6 months +
- no one standardized assessment: still researching broad range of “typical”
- one you’ve identified that “feeding skills” is the top domain for intervention (oral sensory, oral motor, or pharyngeal function), you must determine what therapeutic activities to utilize…treatment next
intervention considerations: oral sensory function
using intake log and assessment of various texture to determine
intervention considerations: oral motor function
- postural stability correlated to oral motor skills
- use identified areas of growth from oral motor assessment to identify areas of needed intervention
intervention considerations: pharyngeal function
- silent aspiration not uncommon in infants
- can target exercises from physiological deficits identified in MBS in preschoolers + (same activities as adults but with a peds twist!)
feeding skill domain: intervention considerations
note that sensory function and motor skill can be closely tied/not easy to tease out
establishing treatment priorities and goal writing
- finding balance between caregiver goals child’s ability/stage
- are there treatment targets we can address, while waiting for information regarding other areas?
- communication on what we plan to target and how to measure progress
- clinician expertise and comfort level
establishing treatment priorities and goal writing: are there treatment targets we can address, while waiting for information regarding other areas?
while we wait for results from a swallow study (medical/skill domain), can we work on educating the parents on stop cues, not forcing a child (psychosocial)
establishing treatment priorities and goal writing: clinician expertise and comfort level
- know your scope and expertise
- “do no harm”, “just wing it”, “trial and error”, is it appropriate?
- establish common ground and jargon so clinicians and caregivers are on the same page
- carryover goals into the home in a realistic manner
general feeding therapy considerations
- part of a larger picture so you are one part of the team managing the child’s feeding
- ongoing reassessment of interventions, effectiveness, and need to revise plan
- carryover to home
- learned avoidance
general feeding therapy considerations: learned avoidance
- result of aversive experiences (medical, sensory, skills)
- can be historical
feeding should be fun and feel good!
- parents are responsive
- parents know what to do when therapist isn’t there
- behaviorist approach to feeding
parents are responsive
- child has success at every level
- children and parents feel celebrated
behaviorist approach to feeding
- view feeding as a behavior that you can modify through positive reinforcement
- however, this is proven evidence-based to work short-term
- some data looking at long-term effects that demonstrate the short-term effect do not last
behaviorist approach to feeding: thoughts why?
- external motivator loses the luster
- exhausting without the internal motivation
- preschools, daycares, and schools cannot physically do physical-based behavioral therapy
basic tenants of therapy
- PFD interventions should be positive and/or neutral
- we want them to enjoy eating
- stop the negative cycle
- take the anxiety and fear away
- consider fight or flight
sessions should resemble a meal as much as possible
- food isn’t plastic –> use food to teach eating
- it doesn’t vibrate either…
- use tools with caution (what is the why? what is the evidence?)
treatment considerations: seating and positioning
- postural stability
- collaboration with PT to target this area
treatment considerations with seating and positioning: postural stability
- 90/90/90 (seated upright, head/neck neutral, feet on floor)
- need adequate postural stability and trunk support to facilitate child’s ability to focus on oral motor skills
treatment considerations with seating and positioning: can use
- towel rolls
- seat/chair inserts
- adaptive seating
- tumbleform chair
- rifton chairs/rifton activity chairs
- boppy pillow, standard pillows
other treatment considerations: social modeling
- you model what you want them to do
- family mealtime
- visual feedback
- exaggerate oral motor movements
- use of mirrors
- language
- use descriptive language can help build bridges between food
- slow and steady wins the race
- can take 15-20 + presentations of a new food before accepted
roles and responsibilities in therapy
following child’s lead can be longer but increased carryover
parent or therapist’s responsibilities
- what is offered
- when it is offered
- importance of schedule/not grazing/establish hunger/satiation
- how it is offered
child’s responsibilities
- which items to eat
- how much to eat
red flags in sensory function
- decreased tolerance for smells (food or environment)
- inability to tolerate the sound of chewing and crunching
- decreased/heightened sensation of food in or around the mouth
- overstimulated by sounds and visual stimulation in the environment or during mealtimes
- walking around the house while eating/unable to sit in the chair for sustained periods of time
- limited to poor hunger sensation
- collaboration with an OT to design a systematic sensory diet, while targeting oral sensory programs is crucial
- just a glimpse to revisit and reground before targeting treatment options
red flags in sensory function: just a glimpse to revisit and reground before targeting treatment options
- may not be all related to oral function, but play a part in the feeding experience
- collaborating with OT to figure out what other sensory systems are involved and impacted
- sensory seeking, sensory avoiding
treatment of oral sensory function
- outside in approach
- sensory preparation (guided by OT not always required)
- access cognitive ability of child/play (turn food into items to explore)
- involve in food prep/cooking
- can even consider stepwise exposures/interventions once get into mouth
- packaging consideration
- access language skills to make bridges between foods
- consider all sensory stimuli
- consider environments and how responses may vary
treatment of oral sensory function: outside in approach
- stop at the outermost space and move systematically toward the mouth/consumption
- process is slow, systematic, small, repeated steps
- can the child move through varying degrees of complex interaction with food? sight, smell, direct/indirect interaction, touch, taste (lick, bite, swallow, etc.)
outside in approach: sight
can they tolerate seeing it? (peak a boo on the plate)
outside in approach: direct/indirect interaction
- passing it around the table in a bowl/on a plate? (family mealtime serving/tea time with dolls/animals)
- can they serve it with a utensil to another’s plate? their plate?
outside in approach: touch (extremities, face, mouth)
- can they touch it with their hands? (poke it with a fingertip, grasp it in their palm, even to pick up to put in the trash or feed another?)
- can it move up their arm towards their face (like driving a car, walking animal)
- can they put it to their lips?
treatment of oral sensory function: can even consider stepwise exposures/interventions once get into mouth
- mouse bite
- small taste
treatment of oral sensory function: consider all sensory stimuli
- vestibular
- proprioception
- tactile
- taste
- smell (how fragrant is it?)
- visual input
- auditory stimuli
treatment of oral sensory function: consider environments and how responses may vary
- change one property at a time
- similar colors, shapes, textures, temperature
treatment of spoon feeding
- consider spoon type: depth of bowl, textured surface, metal/silicone/plastic
- volume on spoon: can impact jaw grading needed and create additional challenges
- present within visual field and at the level of lower lip to avoid neck extension
- J presentation in/down –> out/up
- sideways presentation of the spoon
- tactile cues to upper lips
treatment of spoon feeding: J presentation in/down –> up/out
- downward pressure with the spoon on the midblade of tongue
- provide mandibular stability with your other hand if needed
- once lips close, draw the spoon out without scraping
treatment of spoon feeding: sideways presentation of the spoon
- contacts the corners of the lips and works on eliminating tongue protrusion
- provides additional stability
- pause and wait for closure, prompt with tactile cue if needed
treatment of spoon feeding: tactile cues to upper lips
- adding texture or sticky foods on the spoon to re-alert sensory system
- vibrating spoon like Zvibe (use only with strong individual data that this is effective)
using the spoon to bridge from purees to more complex solids
- tongue lateralization
- needed to transition to solids
- crucial for oral motor control/bolus control, cohesion
using the spoon to bridge from purees to more complex solids: tongue lateralization
- lateral placement of spoon: activate transverse tongue reflex with purees if still present
- use alerting tastes for increased input when placed laterally
- sticky purees on molars/sides
chewing
- move through the IDDSI or developmental food continuation
- consider tulle/cheesecloth or other chewing supports
- consider lateral placement of small meltables on molar surfaces
- ensure you also work on tongue lateralization
- ensure they are chewing not tongue mashing
treatment of cup drinking
- cup type
- flow rate of the liquid
- present cup to lower lip
- provide jaw support
- sensory properties of the liquid
- reflo cup, infa trainer for bolus grading
- cold or tart flavors can assist with muscle contraction, provide more intra-oral awareness
treatment of cup drinking: cup type
- ability to tip the cup and get bolus without neck extension
- should give feeder a view of the mouth
- consideration for lip/rim depending on oral motor skills (is the child using their teeth to stabilize the cup?)
- easy to hold and regulate flow by feeder and eventually child
treatment of cup drinking: flow rate of the liquid
- thin puree, milkshake, smoothie, nectar juices: easier to control, increased sensory input
- shorter cups like a medicine cup shorten the flow time from cup to mouth
treatment of cup drinking: present cup to lower lip
avoid stimulation of teeth to promote lip use vs. jaw/teeth stabilization
treatment of cup drinking: provide jaw support
- ensure bottom lip stays in contact with the cup
- use hand under the jaw
treatment of cup drinking: sensory properties of the liquid
consider drinkable yogurts until the child gets used to the flow
treatment of cup drinking: cold or tart flavors can assist with muscle contraction
- provide more intra-oral awareness
- carbonated drinks for increased sensory feedback
treatment of straw drinking
- straw type should match skill and goals
- flow rate of the liquid
- method of presentation
- sensory properties of the liquid
treatment of straw drinking: straw type should match skill and goals
- consider length, diameter
- can be cut to match skill
- shorter = easier
- skinnier = requires harder sucking but smaller volume
treatment of straw drinking: flow rate of the liquid
- thin puree, milkshake, smoothie, nectar juices
- easier to control, increased sensory input
- thinner straws or shorter straws
- bending the straw to decrease flow, pinching to stop flow
treatment of straw drinking: method of presentation
- present tip of straw to bottom lip to promote lip rounding vs. biting
- present straw to buccal cavity to work on eliminating tongue protrusion
- provide jaw support as needed
- pipette technique
- feeder assisted delivery: Honey Bear straw cup, squeeze bottles
- use of lip block to promote lip rounding
Honey Bear straw cup
cut straw length, use the one with central hole vs. wannabe bears with hole on the side (lid serves as lip block)
treatment of straw drinking: sensory properties of the liquid
thicker is harder to get up through the straw
responsive feeding strategies and interventions: hallmarks
- modeling positive eating behavior at mealtimes
- encourage shared mealtimes
- no pressure
- offering enjoyable foods to encourage internal motivation
- avoid using food as rewards for eating other foods
- respond promptly to child’s cues of hunger and satiety
responsive feeding strategies and interventions: what they aren’t
- adult controlling presentations of food
- verbally directing child to eat one food before another or larger quantity of a food
- overly focusing on quantity of intake and neglecting skill development
- tangible reinforcers for tastes/bites taken
- using food as rewards for eating other
- foods (“if…then”), separating child from family mealtimes or from parents in sessions
responsive feeding interventions
- BLW on the child’s diet strictly depends on whether the family eats healthy and suitable foods for the child’s development
- no evidence that children who follow BLW don’t get enough food or have impacted growth, nutrients, etc., however, Boswell (2021) did find that reported growth measures in BLW all came from parent report, so further controlled study of the nutritional impact is needed
- no solid data on whether it really results in less picky eating all done via questionnaire, a few studies found less pickiness in comparison to spoon fed infants, but another did not echo the findings
- reduction in obesity (jury is still out)
- in summary, there are still major unresolved issues in BLW that require answers from research, which should be considered when advises are requested from health professionals by parents willing to follow the BLW approach
responsive feeding strategies: autonomy
baby is boss
responsive feeding strategies: competence
- sit upright without support
- grasp food independently
- airway protection
responsive feeding strategies: relatedness
- baby sits at table with family
- active family engagement
responsive feeding strategies: baby lead weaning (BLW)
- this feeding intervention does not follow the typical American/Eastern European traditional pattern of first foods (ex: smooth purees)
- baby-led weaning is the process of allowing a baby to self-fed rather than spoon-fed
- foods are usually given in their whole form rather than being pureed
- it emphasizes skipping first foods and starting with solid foods that is salient to the family (will vary and be very child specific)
- “The BLW differs from the traditional approach because infants are encouraged to feed themselves from the complementary feeding period. During the BLW, parents select a range of foods to offer to their babies, who decide what to eat, quantity, and feeding pace.”
the acquisition of 4 abilities has been suggested to indicate the readiness of a child for the BLW
- the child can adequately sit upright without the need for support
- the child can coordinate their eyes and hands to observe, grasp, and bring food to their mouth
- the child can swallow solid foods
- once sitting at the table with the rest of the family, the child shows interest in what other people are eating and actively ask to eat the same foods
Brown (2018) completed a qualitative study the surveyed parents to determine if infants were at higher risk for choking when a parent was utilizing BLW
- they found that infants who used BLW had lower incidence of choking
- they hypothesized that infants who are being traditionally weaned at a greater risk of number of choking episodes?
- considering finger foods, it could be a lower exposure increases choking risk
- infants who predominantly receive finger foods do not need to switch being solid and pureed foods meaning they know what to expect from a meal and how to manipulate it in their mouths
- if a finger food is a rarer event amongst smoother foods, perhaps this increases risk of choking
who is not a candidate for BLW? (from the Brown study)
- infants who have an early choking experience (or even gagging frequently on milk) may be generally more prone to choking and more likely to be spoon-fed out of concern that they will choke (even if they start the weaning process following BLW)
- infants with significant health problems should be excluded
- reflux should be a precaution
responsive feeding strategies: candidates
- infants who are seen as “good eaters” may be far easier to baby-led wean, whereas their fussier or more difficult peers may be spoon-fed in an attempt to encourage them to eat
- understanding the role of infant temperament is an important step in understanding who the method may be appropriate for
- improves maternal anxiety that could be driven by food transitioning
responsive feeding strategies: choking/risk
- actually choke and gag less
- why? still not sure
- theory is earlier introduction results in more advanced oral motor skills but no solid evidence (nor the claim it results in improved speech production skills)
responsive feeding strategies: what theory drive practice and evidence tells us
- monitor meals
- stick shapes
- harder foods to mouth/chew
- limit the amount presented at once
- variety, variety, variety
- postural support is key!
responsive feeding strategies: one of the critical aspects of the BLW approach is that no formal definition exists
- in its purest form, BLW should not include any spoon-feeding and the child himself should put foods into their mouth
- as a limitation, most existing studies on the baby-led approach include participant families who self-identify as following a BLW
- in some studies, participants were asked to estimate the use of spoon-feeding opposed to self-feeding and the amount of pureed foods given during the weaning period in percent
- in others, they were just asked to identify themselves as followers of BLW approach
- it is unclear whether BLW can include limited use (less than 10%) of purees and spoon-feeding, or if it is ruled by a more strict definition, where exclusively finger foods are provided
- actually, both views exist among parents who believe in a baby-led style infant feeding
responsive feeding strategies: currently, there is still insufficient evidence to draw conclusions about the BLW approach, in terms of adequacy of energy and nutrient intakes, due to the low quality of the evidence
- in fact, concerns persist since some previous observational studies indicated that mothers using the BLW approach estimated that their babies ate more milk feeds and less solid foods compared to those following weaning, focusing attention on inadequate nutrient intakes for infants from 6 months of age onwards
- nevertheless, other evidence from more recent randomized studies suggest that a modified BLW approach, including recommendations about the introduction of selected iron-rich foods, as well as avoiding foods at risk of choking, might have positive preventing effects on the risk of choking and nutrients deficiency
- thus, these issues require further investigation in larger randomized studies
sensorimotor feeding interventions > 6 months
- gradual exposure to feat/anxiety stimulus
- play-based
- relaxing environment to reduce fight/flight
- fight/flight suppresses appetite, work against goals
- bottom-up approach
- scaffolding steps that build upon each other
- sensory and motor
- play-based
sensorimotor feeding interventions > 6 months: focus is on internal motivation vs. external
goal: internal motivation hopefully result in longer carryover
sensorimotor feeding interventions > 6 months: commercially best known as SOS approach, but SOS is an approach you must be trained in and follow to the T
many therapists use the theoretical underpinning of SOS, which is Systematic D, without following the SOS protocol to a T, recently reviewed in comparison to operant conditioning
sensorimotor feeding interventions > 6 months: intervention based on systematic desensitization (SysD)
- emerging in the literature as a newer treatment style for feeding difficulties and involves gradual exposure to a feared stimulus within a relaxing environment
- SysD is typically play-based, and internally driven (the child is not instructed to take a bite, and only does so out of their own volition)
- contrast with behavioral or operant conditioning (take a bite, get a reward)
- SysD is generally bottom-up therapy (look, smell, touch, then taste and eat), as in moving up a ladder
sensorimotor feeding interventions > 6 months: OC is generally
top-down therapy, starting at the level of taking a bite
sensorimotor feeding interventions > 6 months: SysD vs. OP
study where food was explored in a play-based environment and the therapist modeled desirable behaviors along an increasing continuum exposure (look, touch, feel, etc.) with social reinforcement
sensorimotor feeding interventions > 6 months: SysD demonstrated efficacy comparable to that of behavioral
- authors highlight the importance of matching intervention to client
- SysD showed efficacy in both pts with PFD only and those with medically complex dx
sensorimotor feeding interventions > 6 months: systematic desensitization ladder
- visually tolerate –> tactile interaction –> olfactory stimulation –> oral exploration –> tastes –> consumption
- in clinical practice, it is likely that each intervention style has features that may suit some children and families better than the other
- it is suggested that a “recipe approach” does not necessarily suit all families, and that some flexibility and individuality should be applied where required
- it also stresses the importance that health facilities should have a variety of intervention options available for families
sensorimotor feeding interventions > 6 months: research on general systematic desensitization
- largest study Marshall et al. (2018)
- improvement in feeding outcomes were noted in SysD interventions
- medically complex and non medically complex patients
sequential oral sensory (SOS) approach
- transdisciplinary program
- IPP team, OT, SLP, RD, psychologist
- requires formal training in the approach
- uses the principles of SysD
- assessment and treatment of children with feeding difficulties
- age considerations
- therapy routine
sequential oral sensory (SOS) approach: age considerations
- under 18 months of age, session is individual
- 18 months-7 years preference is group
- modified for children over age 7, food scientist adaptation
sequential oral sensory (SOS) approach: therapy routine
- formal set routine of SOS sessions
- using real food as a tool
- wash hands
- description and teaching re: food
- leveraging play skills to decrease anxiety and increase interactions across steps to eating
- also develop improved oral phase skills by offering foods (and increasing acceptance of more) to target improved feeding skills
evidence to support SOS
- 9 studies total that look at ‘by the book’ SOS (2006-2016)
- Redle-Sizemore (formerly Creach) 2006 (unpublished doctoral study)
- Boyd (2007) Dissertation “The Effectiveness of the Sequential Oral Sensory Approach to Group Feeding Program”
- Grey et al. (2020)
evidence to support SOS: Redle-Sizemore (formerly Creach) 2006 (unpublished doctoral study)
- significant differences found in the following pre/post test measures
- significant increase in positive mealtime interactions
- significant increase in food interaction
- significant decrease in negative mealtime interactions
- significant decrease in negative sensory responses
- significant decrease in food rejection for targeted foods
evidence to support SOS: Boyd (2007) Dissertation “The Effectiveness of the Sequential Oral Sensory Approach to Group Feeding Program”
significant increase in the range of food children learn to eat using SOS
evidence to support SOS: Grey et al. (2020)
- decrease of negative responses during mealtime
- improved parental stress during mealtimes when they utilize
SOS basic tenants
- myths about eating interfere with understanding and treating feeding problems
- systematic desensitization is the best first approach to feeding treatment
- “normal development” of feeding gives us the best blueprint for creating a feeding treatment plan
- food hierarchies/choices play an important role in feeding treatment
SOS specifics, session step up
- each session begins with a set routine
- therapists work on the children’s oral-motor feeding and perceptual deficits through the choices of the foods made, and the way in which they are presented (tastes, sizes, textures, shapes, colors, consistency, temperature)
- the children are advanced up hierarchy of steps to eating with each new food presented
- positive social reinforcement is use to support mastery of each step on the hierarchy
- range of foods at each step on the hierarchy is worked on first, because our works has demonstrated that range drives volume
*if a child with PFD eats a food repeatedly, there is a phenomenon called “food jagging”
SOS specifics, session step up: (3) the children are advanced up hierarchy of steps to eating with each new food presented
therapists interact with the food and children in a way to help the children achieve each of steps from a skill standpoint
SOS specifics, session step up: (4) positive social reinforcement is use to support mastery of each step on the hierarchy
social reinforcement is used to support mastery of each step on the hierarchy
SOS specifics, session step up: (5) range of foods at each step on the hierarchy is worked on first, because our work has demonstrated that range drives volume
- if needed, volume of food ingested is also directly worked on
- however, internal research indicates that the children in our Feeding Group program gain 1 pound and 1 inch, on average, across the 12 weeks of Group sessions
- this is in a group of children who typically have not gained any weight or height for the 3 months prior to enrolling in the treatment program
- in addition, these children consume an additional 200 calories per day, on average, after 12 weeks of Feeding Group sessions
food jagging
love that food, but then have burnout and never pick up that food again
SOS discharge criteria
- child will readily initiate tasting a new food when presented, 80%-90% of the time
- the child will have 30 different foods in his/her food repertoire
- child will achieve a weight/height growth curve appropriate for their age and medical condition
- the child will be able to eat age appropriate foods without gagging, vomiting, or battling with their parents
- child will be able to take in adequate amounts of fluid via an age appropriate container, in order to sustain hydration and to support growth
SOS discharge criteria: (2) the child will have 30 different foods in his/her food repertoire
- 10 of these will be proteins, 10 starches, and 10 fruits/vegetables
- this number of foods is needed in order for a child to go through 2 full days without repeating a food; 5 meals each day with a protein, starch, fruit/vegetable being presented at each meal
- this feeding schedule is necessary to provide for adequate nutrition for young children, and to prevent food jagging
- our internal research has demonstrated that children with significant food jagging problems also typically have significant problems with weight gain, growth, and nutrition
SOS discharge criteria: (3) child will achieve a weight/height growth curve appropriate for their age and medical condition
they will also demonstrate that they can stay on this curve for 3 consecutive measurements, taken every 2 weeks
other tips and trips in the SysD realm
- slowly grading bite size once a new food is accepted in a lick or taste and child may not want to take a larger bite
- try a nibble…
- from Marsha Dunn Klein and Get Permission Approach
sensory exploration
- tactile play/exploration
- rooted in the theory and educational evidence that children learn through play
- sensory play activities using fruits and vegetables may encourage tasting more than non-food play or visual exposure
- evidence for repeated and frequent tasting improving variety
sensory exploration: sensory play activities using fruits and vegetables may encourage tasting more than non-food play or visual exposure
- sensory play consumed more fruit and veggies than non-food sensory play
- effect generalized to targeted food and novel fruit and veggies
sensory exploration: evidence for repeated and frequent tasting improving variety
extend this principle from population of children without PFD children to PFD itnerventions
tactile exploration/food play
- for those who will not put food in their mouth to consume it and need to work to “getting there” (or only consume a very limited diet)
- research has found that both pre-school and home environments can improve young children’s fruits and vegetable consumption through repeated and frequent tasting known as taste exposure
- we extend this principle to feeding therapy with kids with PFDs
tactile exploration/food play: evidence, Coulthard and Annemarie Sealy, 2017
- children who engaged in the sensory fruit and vegetable play condition tried more F&V than both children in the non-food sensory play task (p < 0.001) and children in the visual FV exposure task (p < 0.001)
- finding was true for the 5 foods used in the activity (p < 0.001), but also 3 foods that were not used in the activity (p < 0.05)
- sensory play activities using fruits and vegetables may encourage FV tasting more than non-food play or visual exposure alone
tactile exploration/food play: research has found that both pre-school and home environments can improve young children’s fruits and vegetable consumption through repeated and frequent tasting known as taste exposure
- average 8-10 exposures to infant (typically developing) increase acceptance
- S.A. Sullivan and L.L. Birch Pediatrics, 93 (2) (1994), pp. 271-277
sensorimotor feeding interventions > 6 months
- crumbling/blending
- special considerations may nonetheless justify the use of blending in treatment
- each fo these factors may result in food “fear” and ultimately, food refusal
- sensory overstimulation triggers a fight or flight response within the sympathetic nervous system, which triggers extreme over-reactions to sensation from one or more of the 7 sensory systems (tactile, vestibular, auditory, proprioceptive, gustatory, olfactory, and visual)
- food chaining
- systematic texture manipulation
crumbling/blending
rooted established theory including systematic desensitization, stimulus fading, small systematic change
blending
- combining 2 or more items in a way that prevents separation, blending is recommended when the child avoids novel textures of flavors, the blending procedure typically involves presenting a child with a mixture predominantly consisting of a preferred item or texture
- interventionists subsequently increase the ratio of a nonpreferred texture (i.e., fade-in) until the child eventually consumes an unblinded substance
blending involves…
- incremental differentiation of an antecedent stimulus in order to change behavior (e.g., stimulus fading)
- gradually exposing individuals to nonpreferred objects in order to reduce their aversive properties (i.e., systematic desensitization)
- pairing of a preferred stimulus with a neutral or nonpreferred stimulus to expand a client’s range of preferences (i.e., respondent conditioning)
sensorimotor feeding interventions > 6 months: each of these factors may result in food “fear” and ultimately, food refusal
- given the complexity of feeding development, often the etiology of feeding challenges is multifactorial
- physiological etiologies are more frequently recognized and interventions are readily available
- in contrast, sensory and behavioral etiologies are often unclear as are intervention strategies
food chaining (limited empirical research, studies state)
- all children were able to increase their food repertoire over 3 months
- median number of accepted foods at onset was 5 and at 3 months was 20.55
- involves changing a small aspect of the food each time it is presented (e.g., the color, texture, taste, and/or shape) in order to help the child increase the variety of foods consumed
- for example, if the child exhibits a food jag by only eating McDonald’s chicken nuggets, the clinician might work toward helping the child accept similar foods, such as fried chicken tenders, followed by baked and breaded chicken tenders, and eventually moving to grilled chicken tenders
- food chaining allows children to expand on their food repertoire by using preferred foods as a starting point
systematic texture manipulation
theory for both discussed is that smaller incremental changes from a preferred starting point vs. larger changes allow child who may have fear/anxiety to acclimate over time which has support in psychology literature
food chaining
- consumer name of the therapeutic approach of fading, in which liked foods are gradually replaced by disliked foods with similar characteristics, or shaping, in which the volume or texture of food offered is progressively increased
- goal: expand food repertoire
- identifying similarities within the foods that your child is eating (remember the conversations you’re having with them about food)
food chaining: identifying similarities within the foods that your child is eating (remember the conversations you’re having with them about food)
- think about finding foods of the same color, food group, texture, shape, flavor, or smell
- presenting apples whole or cut –> green, red, and yellow apples –> smash it up to make applesauce –> juicer to make apple juice
- apple –> apple slices (sticks) –> apple straws –> dip in PB –> PB and cracker stick –> toast in strips with PB –> + apple butter + apple butter sandwich (could also do a PB sandwich)
chaining examples
- McDonald’s nugget –> dinosaur nugget –> homemade chicken nuggets with a soft breading outside –> reduce breading slowly –> get to grilled chicken breast
- McDonald’s fries –> store bough fries –> sweet potato fries –> homemade baked sweet potato fries –> baked sweet potato
- leverage cognition and language ability, same/different, + sensory exploration
visual considerations
- not visually overwhelming
- may need to visually divide plate
- visual considerations for CVI limited data
- have to rely on data from systematic desensitization literature which this is a component of that treatment modality
- how much, too much, 1 pieces vs. a few? napkin cover up
environmental considerations
- setting up routines
- schedules and expectations
family mealtimes
- can they pass the plate, getting exposed to various foods, sights, smells, positive peer models (texture desensitization, routines, predictability)
- no thank bowl: can taste, do various levels of interaction from other foods, have a way to get rid of food, reduce throwing, leaving table, etc.)
- cafeteria, seating, sights, sounds, smells
- fruit and vegetable intake and creating a positive mealtime atmosphere were the strong predictors for children’s higher nutritional quality (i.e., higher vegetable and fruit intake; p < 0.001)
family mealtimes: fruit and vegetable intake and creating a positive mealtime atmosphere were the strong predictors for children’s higher nutritional quality (i.e., higher vegetable and fruit intake; p < 0.001)
- findings indicate that mealtime routines obtained from independent meta-analyses represent distinct routines
- families practiced these independent and distinct routines to different degrees
- parental modeling and a positive mealtime atmosphere were most predictive of healthier child nutrition in daily family meal settings
interventions, compensatory active
- children: positioning, cup type, pacing (single sips, metered straw), can utilize dysphagia exercises with preschool age + depending on cognitive status and based on results of imaging
- conversation about risk/benefits of thickening, infants and kids, motor learning, overall healthy, why are we looking?
thickening in pediatrics
- supporting oral feeding skills in the pediatric population maybe includes use of naturally thickened liquids
- thickening agents span the gamut and include everything from infant rice or oatmeal cereal, xanthan gum based thickeners like Simply Thick, carob bean powder based thickener like Gelmix, etc.
- concerns that persist in the neonatal and pediatric population
- alternative strategies that can be trialed
thickening in pediatrics: thickening agents span the gamut
- include everything from infant rice or oatmeal cereal, xanthan gum based thickeners like Simply Thick, carob bean powder based thickener like Gelmix, etc.
- can vary based on geography or teams philosophy given limited evidence
- no “agreed upon” recipes/thickeners
- significant variability
- IDDSI is helping there to be some standardization in flow test
thickening in pediatrics: concerns that persist in the neonatal and pediatric population
- early introduction of allergens to the premature gut
- hydration and displacement of free water
- constipation, poor motility
- altering caloric density and nutrients
- long term impacts being studied include obesity and celiac disease
- commercial thickeners come with te risk of NEC
- motor learning (are we irreversibly changing their oral motor patterns?)
thickening in pediatrics: alternative strategies that can be trialed
- change in nipple flow rate to optimize bolus size and enhance timing of the suck-swallow-breathe sequence in infants
- change cups in older children (straw vs. open)
- feeding strategies like pacing, positioning, limited volumes for practice
thickening in pediatrics: in the neonatal/infant population thickeners typically include…
- infant cereal
- Gelmix (carob bean provider, FDA approved for breastmilk)
- Stage 1 baby foods (around 6 months)
- some medical teams will choose to use starch or gel based thickeners “off label” given child’s individual medical diagnosis
thickening in pediatrics: infant cereal
- oat vs. rice vs. mix grain
- arsenic levels, allergens, empty calories, hydration
- inconsistent thickening based on brand, flakes, base liquid
thickening in pediatrics: Gelmix
- only mildly thick/IDDSI level 2/nectar
- tedious mixing process
thickening in pediatrics: Stage 1 baby foods
- around 6 months
- use of IDDSI to measure viscosity
thickening in pediatrics: 1 year up
- even more variability
- can consider some commercial thickeners but need to consult with med team
- practice varies depending on region, medical team, diagnosis
- note: thickening can affect efficacy of absorption of medication so need to discuss with med team
thick-it
- modified food starch production
- many stores and online
- minimal additional calories
- use in breastmilk? no
- digestive changes? tendency toward loose and more frequent stools
- cost $$
- ease of use: must wait after mixing, gets thicker over time, relatively smooth
Simply Thick Easy Mix
- xanthan gum and other gum based thickeners
- online
- minimal additional calories
- use in breastmilk? yes
- digestive changes? varied
- cost $$$
- ease of use: no waiting after mixing, thickness does not change, very smooth
Gel mix
- carob bean gum
- online
- minimal additional calories
- use in breastmilk? yes
- digestive changes? varied
- cost $$$
- ease of use: must use warm liquid, must wait after mixing, gets thicker over time, smooth, cannot achieve a “honey” thick consistency
infant cereal
- rice or oat
- grocery stores
- considerable additional calories, can lead to excessive weight gain
- use in breastmilk? no
- digestive changes? can cause constipation (less with oat cereal)
- cost $
- ease of use: may be lumpy or clog nipple, gets thicker over time, different brands need different recipes, brown rice thickens poorly, rice has potential for arsonic exposure in some brands
systematic weaning
- a method for transitioning from thickened liquids to thin
- 10% reduction in fluid thickness every 2 weeks if no s/s of aspiration occur
- requires caregiver education on overt s/s of aspiration
- 80% of children with aspiration who underwent the SWP were successfully weaned from thickened fluids to a normal, thin-fluid diet
- during the SWP, 95% of successful patients were weaned without a significant respiratory event, while the remaining 5% (n = 2) developed pneumonia
- if SWP failed and kids had to resume their original fluid thickness this happened approximately 4 months after starting the SWP process
systematic weaning: 10% reduction in fluid thickness every 2 weeks if no s/s of aspiration occur
keeping the amount of thickening agent constant while increasing the amount of fluid or keeping the amount of fluid constant and decreasing the amount of thickening agent
systematic weaning: what premise is this based on?
- children may have difficulty adapting to the large, conventional changes in thickness during the step-down approach (e.g. honey-thick to nectar-thick)
- in dysphagia management, a child may demonstrate signs of aspiration when ingesting nectar-thick but not honey-thick fluids
- a child might manage a consistency well during instrumental assessment but have increased difficulty with larger volumes at home over longer periods of time
systematic weaning: children may have difficulty adapting to the large, conventional changes in thickness during the step-down approach (e.g. honey-thick to nectar-thick)
especially limited experience with thins or reduced thickness liquids
systematic weaning: in dysphagia management, a child may demonstrate signs of aspiration when ingesting nectar-thick but not honey-thick fluids
as a result, he or she would continue to receive honey-thick consistencies longer than necessary with limited opportunities to learn more mature motor plans
systematic weaning: if SWP failed and kids had to resume their original fluid thickness this happened approximately 4 months after starting the SWP process
most of these patients who “failed” syndromic or neuromuscular etiologies
best practice selection, principles of motor learning
principles of experience-dependent neural plasticity provide a basis for learning as a primary means for remodeling the damaged brain, regardless of when the brain damage occurs in rehab or rehabilitative therapy
1. use it or lose it
2. ASAP
3. maximize practice
4. specificity
5. fade compensatory support
6. attention and motivation
7. blocked and random practice
8. distributed practice
9. feedback
principles of motor learning: (1) use it or lose it
- feeding skills may plateau or diminish if infant no or limited opportunity to utilize oropharyngeal skills for feeding and/or oral exploration, important consideration for how and why we make recommendations including NPO, frequency of PO intake, opportunities to practice these skills
- if we practice opportunities significantly, are we strengthening neural pathways? are we giving enough practice to the child to ensure we solidify motor learning? we need to weigh safety and practice in light of the total clinical picture of the child
principles of motor learning: (2) ASAP
- begin intervention as early as possible
- for NICU this can mean we don’t wait until the problem arise
- not problem based consults but preventative
- setting up for success in EI
- home/daycare school/outpatient this means we do not take a wait and see approach
- we do not discredit familial concerns we ID sooner (feeding matters questionnaire-6 items) valid screening tool
- moving towards integration of screening into well visit
- earlier referral
- earlier service
- same as in EI language development
- earlier lessens the gap
- less likely to lose critical window
- ASAP working towards positive oral experiences for those with complicated medical hx
- make sure we’re not missing windows were skill development is prime and more likely to happen
principles of motor learning: (3) maximize practice
- repetition is essential for skill acquisition
- intense practice and support during early the learning phase and tapered off as the skill is mastered, but we need to practice the right things, the right patterns and repetitions of successful skill demonstrating, we need to establish motor patterns that are correct and into compensatory, what does prolonged thickened liquid usage teach?
- what if a child has been on thickening since birth? where is their opportunity to practice coordination SSB or oral and pharyngeal phase with thins via cups? we need to consider opportunities for practicing, and more repetitions of that practice to see progress while still respecting the communication of the child/infant and rapport
- should the child only practice with therapy? can the family offer opportunities? need to consider this in our interventions, what is the risk of less practice vs. the risk of allowing it?
principles of motor learning: (4) specificity
- practice task as close to meal as possible
- interventions involving food/fluid and swallowing (while closely monitoring safety), this is where the debate for NFOME comes into play, what is our goal (chewing food, sucking up liquids through a straw) should practice that task specifically
- we need to practice the skill we are working on, if a child cannot we need to find ways to bridge there…what is the role of a warm-up? the tool? can we practice that motor planning the specific task? passive vs. active practice, we need tasks that allow meaningful specific skill practice so they can transfer it…
- the concept of specificity refers to the similarity of the practice task to the target skill
- practice experiences that result in the fastest learning and best retention of skill are those that most closely approximate the movement coordination and the environment of the target task as well as typical conditions in which it will be performed
- importance of parent coaching too, so they can perform the skill in the environment they will most often do the task
principles of motor learning: (5)
- compensatory strategies can assist in motor learning if they are used to simplify the task in early stages and are regularly titrated down to work towards performing the task unaided
- strategies include modifying texture or sensory features of food or fluid, using different utensils, or slowing the rate of the feed
- all needed but should not be our end game
- we need to work on fading supports, improving task complexity, and reduction in prompts, cues and accommodations
- ensure we are picking skills that are in the ZPD, but fading the support needed or reducing compensatory supports to mature and develop skills and make progress (not just here and now focus once comp ID, but how do we facilitate development)
principles of motor learning: (6) attention and motivation
- ensuring attention, enjoyment, and motivation during snacks and at meals, this is where we consider things like food chaining, SOS, internal motivation, sensory processing/regulation
- are they regulated (infant or child) are they ready to participate in a challenging feeding tasks, are they hungry? do we need to adjust the feeding schedule to encourage hunger? are they motivated to participate, do they trust you as a clinician? do they have rapport with you to help them move through this challenging task, can we motivate participation through things like small systematic changes in the food temperature, texture, flavor, etc.
- internal motivation to establish to address carryover and be able to fade external motivators if they are being used at all, need to attend to the task, why we get concerned with distractions like TV mindless eating, we need them to know what they are doing, attend to it be engaged and motivated, again leads to rapport and intrinsic motivation
- the child will be more likely to engage if he or she feels comfortable with (tolerates) and is attentive to the sensory array that will be associated with the tracks
- in advancing swallowing and feeding, the child tolerates sitting in a chair, the smells and tastes of soft-solid and table food, the textures of table foods in the mouth, the sensations associated with utensils (spoon, fork, cup, straw) required for eating, the social closeness of the guiding/supervising adult, and the complexities of the environment in which the activity is taking place
- for self-feeding, the child tolerates a utensil in his or her hand at the same time that the food is being processed in his or her mouth
principles of motor learning: (7) blocked and random practice
- practice skill with one food/drink for blocked then generalize to others, alternate between food items and textures including food, drink, different textures to do random practice, so instead of continual blocked en mass practice we would alternate between food items/textures
- an example of blocked practice in eating is biting and chewing a cracker until finished, followed by taking repeated drinks from a cup until finished
- the same lesson structured for random practice would facilitate drinking alternately with bites of a cracker
- although blocked practice may be useful during initial practice of a task in the early learning stage, and fewer errors may occur
- random practice has been found to result in better learning as measured by retention, that is, the ability to recall what has been learned and perform it again
principles of motor learning: (8) distributed practice
- many short practices sessions, ties into maximizing practice, many short session so its multiple opportunities distributed t/o the day, i.e. we may need to start low 1x a week day but we need to make gains and movement towards distributed frequent practice
- results of this research demonstrate consistently that practice performance and retention of skill (learning) are better distributed practice
- an important advantage for advancing eating skills in the school setting is the multiple, daily practice opportunities that are available
- the typically developing child takes 2 to 3 years to fully develop mature eating skills–an indication of the large number of practice opportunities that are required during the period when brain plasticity is optimal
principles of motor learning: (9) feedback
- how are they doing, why are they doing it (if CA appropriate) need to give feedback that is meaningful so they can understand what we are asking them to do
- feedback used as positive reinforcement immediately following an action tends to increase the likelihood the action is repeated
principles of motor learning: (9) intrinsic feedback
- sensations associated with the bolus characteristics, the movements and emotions occurring during ingestion, and the child’s reaction following the experience
- why its important to read their NV, know they sensory needs, ensure positive experience
principles of motor learning: (9) extrinsic feedback
- adult provided supports learning in motor tasks through motivation, reinforcement, and correction of error
- specifically, extrinsic feedback consists of information about the adequacy of the child’s performance, expectations, etc.
- useful to beginners as they often are not able to interpret the adequacy of their own movements
the art and science of clinical approach
- no one cookie cutter approach
- we must look at the patient’s needs, the available evidence, sound theory and match interventions to child’s needs
adult control of feeding for kids with PFD
- controlling feeding may arise when children experience problems in feeding or growth, such as recovery feeding after illness
- under these circumstances, recommendations tend to be guided by a children’s nutritional needs, focusing on the quantity and quality of food and the frequency of feeding
- as a result, health and nutrition counselors may not focus on parent responsivity and parents may interpret the recommendations as a mandate to use controlling strategies to “get their child to eat”
- this strategy has the potential to undermine the child’s trust in an otherwise responsive parent
meet child and family where they are now
- what is comfortable now?
- what is working?
- how do we take what’s working and adapt it to promote change?
PTSD and PFD
- post-traumatic stress disorder is a mental health problem that some people develop after experiencing or witnessing a life-threatening event
- 10%-20% of parents with medically fragile children may have PTSD
your language matters
- no bad food
- food is food
- fed is fed is fed
EBP is best
- use food to teach feeding skills
- make sure to not ignore other domains
- consider family needs and dynamics
- have to have family buy in and support
- watch the science, it is evolving and not all products have the evidence to support their use
take home considerations
- know the domain of breakdown and what you are targeting
- consider the caregiver-child dyad when creating plan of care (carryover to home)
- spend time building trust and rapport
- feeding therapy cannot be just task based
- create a safe space
- ensure that you do not activate fight/flight
- encourage and challenge, but don’t force (slow steady, facilitate progress)
- by ready to pivot and adapt
- modeling
