Individual Feeding Therapy                      

 

Patricia Huntley, M.S., OTR/L

 

Individual feeding treatment, one child with one therapist, allows a child to learn and practice feeding skills.  Alternatively, treatment can be accomplished in a group, allowing a child to see and model the eating of and for peers.  Each modality has its own value. Individual treatment and group treatment can occur simultaneously, complimenting one another, or may follow one another. 

Before beginning…

Children develop the need for feeding therapy for one of two reasons:

  1. He or she was medically fragile and didn't learn (or forgot how) to eat.

  2. He or she failed to thrive because of poor sucking, poor eating or picky eating.

First, we’ll look at the medically fragile child.  Oral feeding may not be the highest priority for a child like this, nor should it be. A medically fragile baby will tend to have an immature nervous system, which may later show signs of sensory defensiveness or sensory integration dysfunction.   This, in turn, interferes with oral eating.  There are, however, some things that can be done to make oral feeding easier for the child when feeding does become appropriate:

Positive experiences around the face and mouth are extremely important. As the baby becomes stronger, non-nutritive and/or nutritive sucking should be encouraged.  This skill is important even if supplemental tube feedings become necessary. Too often, once the tube is placed or shortly thereafter, the child's intake by mouth decreases, sometimes to the point of totally stopping oral eating. It is extremely important to encourage oral feedings as long as they are safe. If it is deemed unsafe for the child to eat by mouth, it still is important to maintain sucking abilities and oral exploration.

Next is the child who has either always been or is becoming a picky eater. He or she has gradually eliminated foods, either by volume or variety, and has developed negative responses to eating, e.g. refuses to sit, spits out or gags on foods, cries when meals are presented. At first you may not think too much of it but gradually you become more frustrated. Your child may lose weight or may not gain as recommended.  Try to catch the problem before it gets to the point of refusing to eat entirely, as the most difficult condition to overcome is a child who has totally stopped eating.

Have a discussion with your pediatrician if this is a concern. Typically, such children are referred to a gastroenterologist to begin the diagnostic process.  The diagnostic process may include various gastro-intestinal (GI) tests to rule out medically based feeding disorders. Children may also be referred to a feeding team. Some feeding teams are diagnostic only and may not be able to provide ongoing treatment for your child. Be sure to communicate your desire for ongoing treatment and request a referral for an experienced feeding specialist.

Before beginning individual feeding therapy, it must be determined that:

·     It is safe for the child to feed orally.

This can be determined by a video swallow study. Children who are not safe to feed orally may still benefit from treatment (occupational, speech, and physical therapy services) to improve oral abilities. As he or she matures, it may become safe for the child to eat.  Even if it remains unsafe for the child to feed orally, oral exploration and oral abilities are essential to other developmental skills.

·     Parents must be ready to become involved in the treatment process.

Feeding is a team effort often involving the therapist, parent, physician, nutritionist and school system (if the child is school age). The most successful outcomes of feeding treatment are when the team works together toward the same goal, at the same speed. It is essential for the parent to be willing to fully participate in the process.  Be open and honest with your therapist. Every family has its own unique structure and moves at its own pace. Communicate with your therapist as to what is a comfortable pace for you. If you don't agree or wish not to pursue an area that has been recommended, you must discuss this in order to collaborate and make a plan for the course of treatment.  The family's expectations and the therapist's expectations must be similar or the outcome will be compromised. The parent must also be willing to develop a daily routine, spending, at least 10-15 minutes per day addressing feeding. If you are ready to commit to this then you are ready for an intense feeding program.

Ready to begin…

When you're ready to participate in an intense feeding program, seek out a qualified professional. The typical course of treatment will involve a parent interview and an assessment of the child's oral motor and eating abilities.  At this point a treatment plan will be established. This plan should include your goals as the parent, as well as the therapist’s goals based upon his/her knowledge of the feeding process. There also may be recommendations for ancillary services to address other issues, e.g. strength, stability, sensory defensiveness and/or oral motor treatment of underlying conditions related to the feeding disorder. The age of the child will have a lot to do with how the treatment is provided. For the younger child, 0-2 years, treatment may be facilitated by the therapist, yet provided by the parent. Often it will be recommended that these children receive developmental services to address other underlying conditions. The feeding therapist will make suggestions for routine placement of food in the mouth, healthy exploration of the mouth and mouth toys. This treatment may include manipulation of diet, recommendations for appropriate seating, and transitions to appropriate food. At this age the therapist’s main goal is to educate and train the parent.  The treatment session may focus on underlying conditions (e.g., proximal stability and sensory defensiveness).  The parent will be the direct caregiver, with the therapist observing, making recommendations and educating the parent.  Homework will also be given.

At the age of 3 years, the therapist will take a more active role interacting with the child and manipulating the environment to encourage positive experiences with food. Part of the session will address underlying conditions in a play like manner.  First, the environment will be set up with equipment and materials which will encourage the child to participate in challenging activities that address sensory and strength related conditions.  This will be followed by approximately 20-30 minutes of oral stimulation with food/non-food items.  Skills will be demonstrated and reinforced with positive feedback.  The therapist will gently establish a routine for this part of the session, and there will be expectations for the child's participation. Children tend to become willing participants when expectations are reasonably within the child's skill level.

Goals of feeding treatment include eliminating barriers to oral feeding. These may include strength/stability, sensory defensiveness, oral motor, as well as managing reflux and bowel related medical issues.

Therapeutic strategies to overcome common complaints…

The advantage of individual feeding therapy is that it can accommodate the specific needs of an individual child.  The following are some common feeding issues that parents have raised and my typical recommendations for feeding treatment.

My child will not take the time to eat. He won't sit. 

Set up a routine for feeding, even if your child is a non-eater.  Make this oral playtime. Children between l8 months and 3-4 years old may be too busy to sit for something that is not their favorite thing to do.  Make sure the child is comfortably positioned in an appropriate seat. Ideally, the child's knees, hips, and elbows should be flexed at a 90-degree angle, and the feet should be firmly placed on the floor or a footrest. (The chair may need to be modified or extra supports added.) A tray or child's size table is extremely helpful.  Have novel toys available, special toys, which are only used at this time. The mealtime should last approximately 15-20 minutes maximum as tolerated by the child.  Distraction may be helpful in lengthening the duration of the mealtime for the slow eater. Make this a pleasant experience.

My child eats or drinks small amounts over the course of the day but refuses to eat meals.

Children eat because they are hungry. If they eat or drink continually throughout the day, they may not be hungry enough to eat a meal, especially those with a poor appetite. Try to keep about 4 hours between each meal for the child 18 months and older.  This will develop a cycle of fullness and hunger, which is important for a child. Try to minimize the amount of juice a child consumes as this may decrease their appetite.

My child is tube-fed all night and he won't eat anything in the day.  He never seems hungry.

If a child is getting all his nutrition at night he won't be hungry. Talk to your nutritionist about moving towards a typical mealtime schedule e.g. breakfast, lunch, supper and snack. If you can spread the feeding over the day you will have more time to encourage a full-empty cycle which may encourage hunger.

My child gags at the sight of food.

Your child may benefit from desensitization treatment.  He may be experiencing sensory defensiveness which produces a visceral response.

My child gags when food is placed in his mouth.

Your child may benefit from an oral stimulation program to desensitize his mouth. This program will involve play with various textured toys in enjoyable mouth play.

My child will eat creamy puree foods but will not tolerate any other  textures. 

What I typically recommend is to gradually increase the consistency or thickness of the puree.  This can be done in many ways by using additives with the purees (e.g. cereal, "Thick It", cornstarch, or breadcrumbs).  This will make it necessary for the child to move the food around in the mouth, facilitating increased stimulation in the mouth. This needs to be done carefully under the guidance of your feeding specialist.

My child shows interest in solids but cannot chew.

Again try thickening the foods gradually. If the child manages this well then you can move to chewing. There are various devices that can be purchased in which solid foods can be placed in a mesh-like bag. This allows the child to practice chewing and tasting food without allowing the food to escape into the mouth. Children tend to like this as they can taste the food and crunch but have little risk of choking on the food.

My child appears to enjoy eating however only eats a small amount.

Volume is a very difficult issue to overcome. Some children may never be big eaters.  The important issue here is to make sure that the food your child is eating is calorie packed. Your nutritionist will be helpful with this.  Some strategies that may help are to combine liquid and solids at meals. Some children have an easier time drinking and could potentially drink an additional 4-6 ounces of milk or a high calorie drink.

My child pools the food in the front of her mouth  and has difficulty swallowing.

Placing the food toward the side of the mouth and developing the tongue's ability to move may help this. Also, if this causes difficulty swallowing then sometimes a drink may help clear the mouth.  Children who tend to do this do it to control the food.  They may have difficulty with bolus size and therefore pool it in front until small amounts can be sent back for a swallow.  These children need more experience with varied size boluses on their tongue. 

How do I find the right tube-feeding schedule for my child as  feeding therapy progresses?

It is indeed a challenge to create a  feeding schedule that allows a child to experience the normal hunger-satiety  (empty-full) cycle, while still receiving needed calories and fluid volume. The  most ideal feeding schedule is 3-4 daytime boluses (the bolus size depends on  the age and size of the child), typically breakfast, lunch, and supper.   Oral feeding can then be offered prior to tube feedings and calories eaten may,  under the care of a nutritionist, be subtracted from tube feeds.  Nighttime  feeds may continue to be necessary, however, when a child can only tolerate slow  titration over a longer period of time, or when the full amount of calories/volume are tolerated in the daytime schedule. Fine tuning this is challenging as  nighttime feeds often interfere with morning hunger. In many cases, it is a  gradual transition from slow titration feeds to bolus feeds. Finding the right  feeding schedule can be tricky and must be worth the disruption to the  child.  Special thought must be given to those children who become  sensitive to changing their schedules or who have a tendency to  vomit.

Any of these strategies should be used cautiously and only under the direction of a qualified professional. Each child's course of treatment and response to treatment is so individual and so are the strategies. The most important things are to hang in there, learn to read your child's body language (it often is extremely revealing) and develop achievable expectations and pleasant routines.   Seek out help early.