Category Archives: Feeding Therapy

Saturday Seminar: Interventions for Toddlers and School-Age Children with Feeding Difficulties

Events, Feeding Therapy

Kerry Pearl, MS, CCC-SLP, Therapro’s Saturday Seminar speaker on February 11th   drew attendees representing a variety of backgrounds who work with children having feeding problems. She spoke about Interventions for Toddlers and School-Age Children with Feeding Difficulties to a rapt audience.

Kerry, of Boston Children’s Hospital, specializes in evaluation and treatment of pediatric feeding and swallowing disorders as the Coordinator of the Food School feeding therapy program. Her goal for today’s seminar was to provide information about feeding principles applicable in various settings and how to promote successful oral feeding across disciplines. Kerry has generously made her PowerPoint slides available at this link.

Kerry’s talk covered a lot of ground beginning with the components of the Clinical Feeding Evaluation, which include obtaining the child’s medical history, feeding history, and goals of the caregiver.  She stressed that it is important to understand where the child is in terms of his/her skill level and use that as a point of where to begin with treatment for building feeding skills. An interesting thing to consider when evaluating a school-age child, is the importance of exploring what motivates the child…for example, does the child eat their lunch quickly so he/she doesn’t miss recess?  Another important factor in evaluation is knowing the child’s eating environment, because it is essential for feeding success.  This includes positioning in an appropriate supportive seat that supports the child’s hips, knees, and feet at 90° angles, like a Height Right Chair. When considering the mealtime environment, Kerry advocated establishing a routine so the child knows what to expect, providing clear instructions, and a visual schedule.

Evaluation may identify a number of target areas that need to be prioritized with input from caregivers.  Kerry recommended planning intervention in 10 week blocks, which provides time to target several goals and subsequently focus on the skill deficit areas when they become more apparent as treatment sessions progress. Working with the child’s team is important in a number of areas including when it comes to prioritizing what foods to introduce with the child’s dietitian. When initiating therapy, discharge criteria must be in place so that the child’s set, measurable goals can be reviewed to determine whether the therapy has been successful.

A distinctive feature of Kerry’s presentation was her discussion of two intervention models: 1) Operant Conditioning and 2) Sensory Desensitization.  She distinguished between the two approaches by discussing how operant conditioning targets behavior directly, is child focused as well as parent focused where the therapist consults with parents to help the parent change the structure of mealtime and nutrition. It involves expanding the foods a child eats, improving volume of intake, and targeting specific behavior or skills. A prompt and immediate reinforcer (like a Wind-Up Toy) is given in treatment so that the eating behavior becomes linked to the prompt and the reward. In this approach, the child builds skills but must overcome their fear associated with eating. Individual therapy is provided and “homework” is given.

In the Sensory Desensitization approach, the child develops skills while gradually adapting, with the focus being on changing mealtime behavior by using modeling and positive reinforcement. In this model, the child progresses through “steps to eating” that include: tolerating the presence of food, interacting with the food, smelling the food, touching the food, tasting the food, and finally eating the food. The end result is that the child experiences less stress around foods and is more willing to try foods. This approach can occur in either individual or group sessions.

When selecting the approach that will be most effective for a particular child, Kerry recommended bearing in mind the child’s current skills and sensory profile as well as family concerns/goals. Considerations should include the child’s nutritional status, oral motor skills, and sensory processing ability.

Kerry provided many specific examples of therapeutic activities throughout her talk. Some examples of strategies she discussed to develop chewing skills included lateral placement in the mouth of tools such as the Baby Safe Feeder filled with chewable foods, Chewy Tubes, Y-Chew, or Theratubing dipped in pureed food, progressing to placing small pieces of dissolvable food inside the hollow tubes.  Using a Chu Buddy can help the child keep track of the chewy so it is always available.

Kerry’s thoughtful, organized, chock-full presentation provided us with a practical way to approach feeding problems in young children. Her anecdotes, videos, and tidbits of interesting information gleaned from her extensive experience as a feeding specialist complemented her presentation and were greatly appreciated by all who attended her seminar.

As you can see from some the following comments, Kerry’s seminar left attendees with much information and useful treatment strategies:

“The seminar was well organized & relatable. Examples were provided. I enjoyed the contrast of therapy styles & when each were appropriate.” Lauren P., Speech/Language Pathologist

“I would recommend this seminar to a colleague! I loved the specific interventions discussed. I look forward to applying them in my practice.”  Marianna Q., Occupational Therapist

“This was a unique learning topic, and I was thrilled for this opportunity to gain more understanding and techniques.” Marisa G., Child Development Specialist

“It was very informative in many ways – I appreciated the intervention strategies given & how they should be implemented. Also, it was helpful to hear how to identify which intervention is best for individual children.”

Amy V., Occupational Therapist

“Very interesting from a teacher’s point of view. It broadened my understanding of the issue & encouraged me to reflect on how the issue can impact classroom learning.” Maura M., Teacher

Thank you, Kerry!

Filomena Connor, MS, OTR/L

Saturday Seminar: Sensory Differences and Mealtime Behavior in Children with Autism

Autism, Events, Feeding Therapy, Filomena's Corner, Sensory

Jeanne-Zobel-LachiusaEvidence based practice (EBP) involves the integration of:

  1. Clinical expertise,
  2. Scientific research, and
  3. Patient/caregiver perspective.

The goal of EBP is the improvement of patient outcomes. It holds us accountable for our treatment plans, strategies and outcomes among our peers and other health care professions. According to the AOTA, generating research in the field of occupational therapy is “critically important for advancing the field and ensuring the viability of the profession.”

Jeanne Zobel-Lachiusa, EdD, OTR/L was the featured December Saturday Seminar Series speaker, who shared her research on Sensory Differences and Mealtime Behavior in Children with Autism (AJOT September/October 2015, Vol. 69, No.5).  In summary, the study results helped to identify problem eating behaviors in children with ASD that may be associated with sensory differences. Children with ASD were compared with typically developing age-matched peers. The study concluded that children with ASD who receive occupational therapy that offers sensory strategies might result in less stressful mealtimes.  The findings supported the need for further research in this area of self-care with children who have been diagnosed with ASD.

The seminar attendees were from varied backgrounds, including occupational therapy, speech therapy, special education, social work, psychology, child care, medicine, and parents. They engaged in a lively brainstorming session on sensory strategies in the different sensory domains that might provide mealtimes with less stress for both the child and family. They shared innovative as well as tried and true ideas with the group.

Just a few examples of the many suggestions include ideas for tactile and oral sensitivity:

Hush BuddyFor auditory sensitivity Jeanne suggested:

For children with sensitivity to fluorescent lights that flicker and glare in the cafeteria or classroom, Fluorescent Light Filters, which are magnetic were recommended. Another suggestion was for the student to wear a visor to reduce vision sensitivity.

Jeanne suggested a number of resources for the group including the book, Autism Interventions, and recommended the AOTA website for its user-friendly handouts on mealtime and feeding.

Producing research is essential for validating assessment and treatment strategies. Jeanne shared that her research was motivated by the question of whether interventions are actually effective.  Her current research demonstrated that there was a statistically significant difference in sensory differences and in mealtime behaviors between children with ASD and the typically developing group she tested.  This groundbreaking research paves the way for further studies to investigate specific treatment strategies discussed today for their effectiveness in helping make mealtimes a pleasurable experience for children diagnosed with ASD and their families.

To view Jeanne’s PowerPoint slides, click here.

Following the seminar, attendees provided feedback about the seminar.  Please see a few remarks below:

“It provided an opportunity to review recent literature and share strategies with other therapists.” Kristyn S., Occupational Therapist

“Loved the topic and the format. Jeanne was great!!   Diane H., Occupational Therapist

“Informative, interactive, insightful. It was interesting listening to other OTs experiences and suggestions.”  Sylvia K., OT student

“Helpful to organize sensory treatment with a food tolerance/mealtime behavior perspective.”  Anonymous Occupational Therapist

Thank you, Jeanne!

Filomena Connor, MS, OTR/L

Feeding Therapy: What to Do When You are Stuck

Feeding Therapy, Oral Motor

By Krisi Brackett MS SLP-CCC

I get emails all the time asking for advice on how to get kids to eat. Many of these children are in therapy but are having difficulty progressing toward the acceptance of food and liquid. I have said this before but will say it again, these kids are hard, feeding intervention can be challenging and what works for one child may not work for another. As a feeding therapist, I am a believer in working on the goal of “improved acceptance of volume and variety of foods” from the standpoint of health and nutrition (kids need to eat from all food groups) and also because if a child is orally feeding then they are using and developing their oral-pharyngeal muscles which helps with oral motor skill development. I cannot stress enough that these children are all unique and need to be assessed individually but I thought I would try to come up with a top ten (really twelve) list of ideas to break the plateau. I hope these ideas help to generate some progress!

  1. Look more closely at medical reasons for refusing food. This might include gastroesophageal reflux, constipation, food intolerance, eoscinophillic esophagitis, increased work of breathing, respiratory problems, dysphagia, or poor appetite. Consider working closely with a primary care physician, developmental pediatrician or gastroenterologist to obtain further assessment and trial some medical management strategies.
  2. Refer to a multidisciplinary Feeding Team. Sometimes two or more heads are better than one meaning a feeding team may be able to assess a child who is not progressing and come up with some new ideas to jump start things. Typically you can find a multidisciplinary feeding team in a children’s hospital. We do this all the time for our kids in NC!
  3. Increase the child’s appetite. Some of the children we work with have a history of poor appetite, volume limiting, or have been tube fed and do not have a reference for hunger/fullness. An appetite stimulant may help in getting a child eating (this tends to be more effective after medical management strategies have been implemented or when you are certain the child is not in pain).
  4. Manipulate tube feedings. Many clinicians have the goal of getting a child to bolus feeds to simulate normal eating but for some children, especially those with underlying abnormal motility this will not necessarily encourage intake. Manipulating tube feeding schedules to allow a significant amount off time off the tube to develop hunger or an opportunity to orally feed or changing the type of formula to something predigested which may have a faster gastric emptying time can be effective strategies to encourage intake.
  5. Alter supplement intake. Sometimes when a child is drinking a supplement either for meals or extra calories they develop a preference for the sweet taste of the formula and may refuse food to get the formula or because they are full. Try altering how the supplement is given by offering smaller amounts during meals (example, 4 oz instead of 8 oz), giving it after meals or at snacks only.
  6. Consider an intensive feeding program. I am always surprised to hear that feeding therapists do not know these programs exist. There are intensive feeding programs around the country (in the U.S.), typically housed in a childrens hospital, ( I admit I am not sure what is available in other countries) that will provide intensive feeding intervention daily for 4-8 weeks depending on the program. Intensive feeding program are not all the same. These feeding programs have different philosophies on intervention and vary on length of treatment and follow-up. I always give advice to caregivers who are interested to pick a program based on their child’s needs and not just based on geographical location. Many insurance companies will cover these or a portion of the cost if a child has “failed” out patient treatment.
  7. Try a different therapeutic technique. There are many different therapeutic techniques and strategies some more formal than others to encourage intake. If you are using an oral-sensory based feeding approach and are stuck consider trying some behavioral strategies.
  8. Reach out to your colleagues. There are many professional involved in feeding each with a unique skill set to bring to the table. Try reaching out to a feeding therapist from another discipline, a different profession or an expert for ideas. Many clinicians will be open to discuss a client over the phone or via email to generate some ideas.
  9. Take a break from therapy. Sometimes a child or a parent may need a break especially if they have complicated medical needs, may be in and out of the hospital with illness or surgical needs, or have other extenuating circumstances. There are children where oral feeding may not be the priority. For these children we want to make sure they are receiving proper nutrition for weight gain and growth until they are ready to work on oral feeding.
  10. Work closely with caregivers and give homework. Include caregivers in therapy and have them participate in actively using the feeding techniques. Provide homework so that caregivers can practice therapy strategies daily at home with their children. This builds confidence in the caregiver that they can successfully feed their child and provides the child with positive daily practice! Additionally, if you watch caregivers feed their children you can coach them through difficult meal time behaviors. I often think of myself as a feeding coach.
  11. Match the child’s diet texture to their oral motor skills. Many (actually most) of our clients have some oral motor delay. The child’s diet (food textures) should be consistent with their oral skills. If a child is being given foods that are above their skills level, the result will often be poor intake, refusal, long meal times, food pocketing or holding, and expelling. I have seen children make immediate improvement in mealtime just by taking them back to purees or mashed foods, or making a portion of their meal purees with limited solids (determined by their stamina for chewables).
  12. Work on cup drinking. This if often a good way to move a child off of a feeding tube because it is a direct correlation in terms of calories and nutrients. If the child can drink what is going into the tube (and the child’s weight is good), then it can be deducted from the tube feeding. There are often many options for formulas or supplements to choose from. If the child will not drink the tube feeding formula (or it may be an enteral only formula or one with little to no taste), talk with a dietician and obtain samples of alternative supplements with comparable calories and nutrients or about having the caregivers make their own high cal supplement. It can be motivating for caregivers to see the tube feedings decrease.

Info about the author:

Krisi Brackett MS SLP/CCC is a Pediatric Feeding and Dysphagia Specialist with over 20 years of experience. She is currently Co-director of the UNC Pediatric Feeding Team at the NC Children’s Hospital, UNC Healthcare, Chapel hill, NC. She is also an adjunct faculty member at the Division of Speech and Hearing Sciences, UNC– Chapel Hill. Krisi publishes the popular feeding blog, www.pediatricfeedingnews.com and is co-author of the first chapter in Pediatric Feeding Disorders: Evaluation and Treatment, 2013, published by Therapro. Krisi lectures nationally, sharing information on medical management and therapeutic strategies for handling this special population.