Katie Hein M.S. CCC-SLP Jaime Stover M.S. OTR/L Julie Stefanski MEd, RD, LDN, CDE

1. Katie Hein M.S. CCC-SLP Jaime Stover M.S. OTR/L Julie Stefanski MEd, RD, LDN, CDE Mealtime Fear Factor:Helping children when food becomes a fight

2. Not a Happy Bedtime Story • “Brian eats Cheerios and not much else. For nearly two years, we haven't been able to get him to eat meat or fruits or vegetables. None of his pediatricians we go to seem all that concerned since he’s a healthy weight for his height and his energy level is normal, but it’s gotten to the point that we need some help. • Brian will have a cup of calcium enriched OJ when he wakes up. He eats about a cup of Cheerios- dry of course and drinks another cup of OJ before we take him to preschool. His teachers tell us he generally turns down the snacks unless it is Goldfish, pretzels, or other crunchy-salty foods. Back at home for lunch he’ll eat cashews and drink a cup of milk. He also might have more cheerios. Later in the afternoon he’ll eat Goldfish or the like. For dinner he eats another cup of Cheerios. • We’ve tried refusing him foods other than what we’re serving for dinner– but he calls our bluff and just doesn’t eat. We’ve tried that approach for a couple of days at a time. We’ve tried making it a game. We’ve tried introducing different colors, textures, etc. But nothing works. Please help us!”

3. Feeding Difficulties • Incidence of feeding disorders is estimated to be 25 to 45% of typically developing children and 80% of children with developmental disabilities • In a study of 349 children referred for feeding evaluation- • Cerebral Palsy : 12.6% • Oral Motor Delay: 68% • Dysphagia: 32% • Down Syndrome: 6% • Oral Motor Problems: 82% • Selectivity by texture: 45% • Autism: 7.4% • Food Selectivity: 93% Field, D., Garland, M. & Williams, K. (2003); Linscheid et. Al (2003)

4. Preterm births have increased 20% since 1990. The survival rate of preemies, micropreemies, low birth rate and children with complex medical conditions has impacted the increase in the incidence of swallowing and feeding disorders. Followed normal sucking pattern at 35 weeks and dysfunctional sucking pattern at 35 weeks Parent reports of feeding problems at 6 months: Force feeding Gagging Vomiting Coughing Parental Experience: Feeding Patterns of NICU Graduates Hawdon et al., 2000

5. Disorganized Feeders • 6 months: 6 times more likely to vomit & 3 times more likely to cough • 12 months: 4 times less likely to tolerate textures in purees • i.e. Stage 3 baby foods • 9 times more likely to cough during a meal • 50 % of these children did not enjoy the meal • More than half of the parents did not enjoy mealtime • Feeding Behaviors in Very Low Birth Weight (VLBW) Infants • 21-46 months of age through parental questionnaire with 70% response rate • 58% exhibited food refusal • 51% used food rewards • 69% used coaxing/bribing Hawdon, et al., 2000; Cerro, et. al., 2002

6. Feeding Behaviors in Children with Autism Spectrum Disorder (ASD) • Effects 1 in 100 individuals. Estimated that 79% may have undiagnosed GI issues. • Parent survey of child with ASD • 67% picky eaters • 69% will not try new foods • 60% won’t eat new foods Williams,et al., 2000

7. Feeding and The Body Toomey, Kay., & Ross, E., 2010 • All Organs • Digestion, breathing, etc. • All Muscles • GI muscles for peristalsis, postural muscles • All Senses • All need to work together and readjust during feeding activity • Learning • Feeding is a learned activity • Hunger is instinctive eating is not

8. Feeding and the Body Toomey, Kay., & Ross, E., 2010 • Development • Increased developmental issues is directly related to increased feeding concerns • Nutritional Status • Get child to age appropriate diet • Weaning off feeding tube • Environment • 92-95 % of the time, parents are not the reason for feeding trouble

9. Eating is a learned behavior. Typical toddler food refusal and food jagging is an annoying, but normal part of child development. Picky eaters: Eat fewer than 30 foods Eat at least 1 food from almost every type of texture Tolerate new foods on their plates. Willing to touch or taste new foods Willing to eat a new food after they’ve been exposed to it 10 or more times Will eat the same favorite every day and may burn out on it. Often will start back eating their favorite food after a two to three week break. Approximately 50% of children age 18 to 23 months are “picky eaters”

10. Negative Nutritional Impact • Children with feeding and swallowing problems are at risk for malnutrition. • Poor nutritional intake has been linked to decreased alertness, attention, brain development (especially in infancy and early childhood), cognition, emotional and social development, and readiness for learning. • Past research has shown that the food and beverage choices of American children are not meeting daily requirements. In children with selective acceptance of nutrient dense foods subclinical nutrient deficiencies are likely. Bryan et al., 2004; Grantham-McGregor and Baker-Henningham, 2005; National Health/Education Consortium, 2006;).

11. Picky Eating goes Extreme • Problem feeders lack variety in their daily food choices which may lead to vitamin, mineral, calorie, and protein deficiencies. • What are the foods problem feeders are typically willing to eat?

12. Problem feeders: • Eat fewer than twenty foods. This number can decrease to < 5 to 10 foods • Refuse to eat entire categories of textures • Will burn out on favorite foods and not replace them with new foods • Cry and/or throw tantrums when offered a new food • Have a need for rituals surrounding mealtimes/foods • Can be brand specific/inflexible about particular foods- ie. Only McDonalds chicken nuggets • Are still unwilling to eat a new food after 10 exposures.

13. Patient A – At Initial Visit Comment from doctor’s office staff to help to get insurance approval for therapy- “What is the problem? Oatmeal is healthy.” Diagnosis of Autism 4 years old Consuming only smooth/creamed oatmeal with smooth fruit puree and smooth yogurt added to mixture Drinking milk, tea, and soda Consuming 3 bowls of oatmeal and 3 cups of milk per day Not sitting at table during mealtime

14. Feeding Assessment • Were there any problems with breastfeeding or bottle feeding? • When were solids introduced? Were there any problems transitioning through stages of infant food? • Is there any difficulty chewing or swallowing? • Can the child feed himself? • Does the child have normal hunger cues? • How is the child’s appetite? • Is food or candy ever used as a reward? • Is the child able to age appropriate feeding and drinking utensils? • Does the child receive any therapies, including feeding therapy?

15. Interdisciplinary Evaluation of: • Positioning - maximize body tone and control for improving food intake • Gross and fine motor control of the trunk, head, neck, arms, hands and fingers. • Oral structures need to manipulate food and coordinate respiration with feeding and swallowing. • Oral motor skills including tongue lateralization, mastication, jaw strength • Condition of dentition, gums, tongue, palate and mucosa • Presence of mechanical devices (e.g., braces, palatal appliances), history of brushing teeth and tongue, flossing, use of rinses; • Oral sensorimotor function related to food awareness, control of food and saliva during oral preparatory and oral phases of swallowing, self-protection from aspiration • Assistive needs for seating and feeding.

16. Physical Causes of Feeding Issues • A Pediatric GI consult can help determine physical diagnoses which may be impacting feeding problems such as • GERD • Eosinophilic Esophagitis EoE OR Eosinophilic Gastroenteritis EoG • Chronic Constipation • Chronic Diarrhea • Food Allergies/ OR Food Sensitivities

17. Comprehensive Feeding Evaluation • Addressed the functioning of the multiple systems that are involved in feeding and swallowing. • Assessment reviews: • Extent to which the difficulties stem from food preferences (the child’s or family’s) • Behavioral issues • Medical, physical or cognitive problems (including anatomic, neurophysiologic, sensorimotor and medications) • Child’s nutritional status and needs • Food delivery system (oral or non-oral or some combination of these), feeding schedule • Quantity and texture of food to be offered at meals and snacks

18. Nutrition Assessment • Altered nutrient and/or calorie needs due to a medical condition; • Gastrointestinal problems such as constipation, diarrhea and vomiting that affect absorption • Poor appetite or food intake; • Poor growth/weight gain or excessive rate of weight gain • Oral sensitivity that can affect toleration for a variety of food types and textures • Drug/nutrient interactions • Supplementation (with or without prescription/physician recommendation) • Parental stress regarding feeding that can result in the child refusing food • Impact of special diets that may be explored in treating other disabilities (e.g., elimination diet or • gluten-free or lactose-free diet for autism). • Review of food diaries, growth charts, and laboratory tests

19. Likely deficiencies in problem feeders • Protein • Calcium • Magnesium • Omega 3 Fatty Acids • Zinc • Carnitine • Vitamin and mineral supplementation is vital. Any supplementation the child is willing to try is the first option. • Liquid vitamin or mineral supplements added to juice, pudding, etc. should be started at 1/8 or 1/16th dose needed so as to not increase food rejection.

20. Sensory Integration Dysfunction • Children may have difficulty responding appropriately to sensory information from their environment. • Eating requires integration of visual, tactile, smell, taste, and auditory stimuli. • Visual- Children may prefer or reject foods of a certain color. May have a tantrum if foods touch on the plate. • Auditory- May prefer soft foods or liquids to avoid the sounds created by hard, crunchy foods. • Tactile- May be unwilling to touch foods with his hands. May choke, gag, or vomit which reinforces fear of certain foods. • Smell- May become fussy or overwhelmed by odors of food preparation. • Taste- Strong flavors may trigger gag reflex. May prefer bland foods or specific flavors.

21. Primary Motor Dysfunction Insufficient sucking at breast or bottle Taste differentiation noted with liquids in bottle Inefficiency or incoordination with all textures Food swallowed whole when given mixed textures Difficulty maintaining bolus of food on tongue; loss of food out of mouth or pocketed in cheeks Vomiting- not texture specific Gagging noted after food moves through oral cavity Gagging with liquid or solid after swallow initiated or triggered Toleration of others’ fingers in mouth Acceptance of teething toys, but not able to bite them or manipulate them in mouth No problems with toothbrushing Primary Sensory Disorder Nipple confusion from breast to bottle feeding Lack of taste differentiation of liquids in bottle despite intact sucking Efficiency with liquids better than with solid foods Sorts out food of different textures- ie. Fruit piece in yogurt Food held under tongue or in check to avoid swallowing Vomiting- certain textures Gagging noted when food approaches or touches lip or tongue Gagging prominent with solids; normal swallow with liquids Toleration of one’s own fingers in mouth, but not others No mouthing toys Refusal of toothbrushing Characteristics of Primary Oral Motor Disorder vs. Primary Oral Sensory Source: Palmer and Heyman (1993); Arvedson et. al. [2002] p. 295

22. SOS Approach to Feeding • Sequential Oral Sensory (SOS) • Design to assess and address all factors involved in feeding difficulties • Examines and treats the “Whole Child” • Philosophically based on the idea that “the child is always right” • A child knows what works best for him or her • We as feeding specialists need to figure out the reason for the feeding difficulty and base treatment on that Toomey, Kay., & Ross, E., 2010

23. The Basics of SOS • Myths about eating • Interferes with understanding and treating feeding problems • Systematic Desensitization • Is the best FIRST approach to feeding treatment Toomey, Kay., & Ross, E., 2010

24. The Basics of SOS • Normal Development • Follow normal developmental milestones of eating is the best course of action • Food Hierarchy/Choices • Play is an important role in feeding treatment • Child achieves sensory and oral skill progression with food choices rather than “doing to” the child • Food hierarchies help sensory systems shift slowly into accepting new foods Toomey, Kay., & Ross, E., 2010

25. 10 Myths of Mealtime • Eating is the body’s #1 priority • Eating is instinctive • Eating is easy • Eating is a 2 step process • It is not ok to play with your food • If a child is hungry he or she will eat. They will not starve themselves • Mason et al., 2005 Toomey, Kay., & Ross, E., 2010

26. Myths of Mealtime Continued 7. Children only need to eat 3 times a day. 8. A child who won’t eat has EITHER a behavioral OR an organic problem. 9. Certain foods are eaten only at specified times of the day, and only certain foods are “healthy for you” 10. Mealtimes are a solemn occasion. Children are to be seen and not heard • Manikam & Perman, 2000 • Field, Garland, & Williams 2003 Toomey, Kay., & Ross, E., 2010

27. Steps to Eating • Tolerates • Interacts with • Smells • Touches • Tastes • Eats Toomey, Kay., & Ross, E., 2010

28. Step 1: Tolerates • Being in the same room with food • Sitting at the table with food on the other side of the table • Sitting at the table with food halfway across the table • Sitting at the table with food approximately in front of the child • Looking at the food when directly in front of child Toomey, Kay., & Ross, E., 2010

29. Step 2: Interacts With(vestibular, proprioceptive, kinesthetic tasks) 6. Assist in preparation/set up with food 7. Uses utensils/container to stir/pour food/drink in other containers 8. Uses utensils/containers to serve self directly 9. Touches food with a napkin 10. Touches food with another food Toomey, Kay., & Ross, E., 2010

30. Step 3: Smells 11. Odor in the room 12. Odor at the table 13. Odor directly in front of child 14. Child leans down or picks up to smell Toomey, Kay., & Ross, E., 2010

31. Step 4: Touches 15. Fingertips, fingerpads 16. Whole hand 17. Chest, shoulder 18. Top of Head 19. Chin, cheek 20. Nose, underneath nose 21. Lips 22. Teeth 23. Tip of tongue, full tongue Toomey, Kay., & Ross, E., 2010

32. Step 5: Tastes 24. Licks lip, licks food 25. Bites off piece and spits out immediately 26. Bites pieces, holds in mouth for “x” seconds and spits out 27. Bites, chews, “x” number of times and spits out Step 6: Eats 28. Chews, partially swallows 29. Chews, swallows with drink 30. Chews and swallows independently Toomey, Kay., & Ross, E., 2010

33. SOS Treatment Strategies • Social Modeling • Structuring Meal/Snack Times • Reinforcement • Accessing the Cognitive Toomey, Kay., & Ross, E., 2010

34. Social Modeling • We learn by observing others receiving consequences for their actions • Humans have a “mirror neuron system” and when an action of another is observed, the same mirror neuron fires in the observers brain as if they were actually completing the task themselves Siegel, D., 2004

35. Social Modeling: Teaching the Social Experience of Eating 1. Family meals: 1:1 ratio between adult and child at each meal time 2. Model good feeding behaviors: talk about how the food feels, taste, etc. Put on a happy face. Toomey, Kay., & Ross, E., 2010

36. Social Modeling: Teaching the Social Experience of Eating Cont. 3. Food is the focus of the meal/Discuss properties of food: conversations about pleasant topics and the food, not pressure on the child to eat. 4. Overexaggerate the correct motor movements: chewing with an open mouth Toomey, Kay., & Ross, E., 2010

37. Social Modeling: Teaching the Social Experience of Eating 5. Imitate the child’s eating: make the food fun, make pictures of the food, turn food into interest driven items 6. Do not punish the child: increasing adrenaline suppresses appetite 7. Involve child in all aspects: setting the table, cleaning up, etc. 8. Child needs to stay at the table: do not use timeout to deal with behaviors Toomey, Kay., & Ross, E., 2010

38. Structuring Meal/Snack Times: Keeping Child at the Table 1. Seat the child at the same place at the table 2. Create a routine to meals/snacks: transition activity, sit at the table, serve family style, eat, clean up 3. Follow same time schedule Toomey, Kay., & Ross, E., 2010

39. Structuring Meal/Snack Times: Keeping Child at the Table Con’t 4. Present food in manageable bites: based on oral motor abilities, not age. 5. Every meal should include 1 starch, 1 protein, 1 fruit, and 1 vegetable 6. Rule of thumb: a tablespoon per every year Toomey, Kay., & Ross, E., 2010

40. Structuring Meal/Snack Times: Keeping Child at the Table Con’t 7. One preferred food at every meal 8. Several foods on the table for exposure (Skinner, et al., 1998) 9. Allow spitting into chosen containers only 10. Limit meals and snacks to 15-30 minutes (Reau, et al., 1996): Mean feeding time was 20 minutes Toomey, Kay., & Ross, E., 2010

41. Reinforcement 1. Verbal praise: in appropriate amounts works best (Skuse, D. 1993) 2. Create parent reinforcement value: stay away from all negative words 3. Reinforce siblings eating 4. Reinforce any positive food behavior: looking at it, touching it, smelling it Toomey, Kay., & Ross, E., 2010

42. Reinforcement Cont. 5. Use food as the reinforcer 6. Can very carefully use preferred foods as reinforcers: do not want to create a valence split (Newman, J., & Taylor, A., 1992) 7. Use “disappearing object” reinforcers if an object reinforcer is the only option Toomey, Kay., & Ross, E., 2010

43. Assessing the Cognitive: Unique to the SOS Approach • Utilizing whatever cognitive functioning the child has to help them understand the food and their bodies • Sensorimotor: visual, smell, and tactile comparisons. Demonstrate physical changes of food. • Pre-Logical: compare food to known objects (play with a purpose) using all the above mentioned senses • Concrete Operations: incorporating all senses to improve tolerance Toomey, Kay., & Ross, E., 2010

44. Management of Food Jags Definition: eats the same food prepared the same way every day or at every meal or brand specific Problem with food jags: children eventually burn out on these foods and foods are permanently lost out of child’s food repertoire For typical eaters food jags can be decreased by changing the physical property of foods each time they are offered. Altered the size, shape, color, texture, or temperature of the food jag food. If a child will only eat mac & cheese out of the blue box have them begin by putting the ingredients from the box into plain sealed plastic bag. Next the preferred noodle shape could be cut in half, etc. Toomey, Kay., & Ross, E., 2010

45. SOS Therapy Meals: Learning How to Eat Goal #1: Skill development Goal #2: Experience with a wide variety of foods Goal #3: Movement up the “steps to eating” hierarchy SOS uses systematic desensitization vs flooding Toomey, Kay., & Ross, E., 2010

46. SOS Session Structure/Routine • Group or individual • 12 week increments • 45 minute sessions • Session co-treated with OT and ST • OT addresses sensory aspect • ST addressed oral intake and management Toomey, Kay., & Ross, E., 2010

47. SOS Session Structure/Routine • Sensory Preparation (5 minutes) • Child participates “obstacle course” for sensory organization and kinesthetic awareness • Child participates in sensory “calming” or “jazzing” Toomey, Kay., & Ross, E., 2010

48. SOS Session Structure/Routine • Transition • Child and parent march to therapy room while singing (proprioceptive input helps with handling transition, increases endorphins through deep breathing, and decreases adrenaline • Child is helped into seat by parent or therapist • Blowing bubbles: reinforcement for coming into the room Toomey, Kay., & Ross, E., 2010

49. SOS Session Structure/Routine • Starting Routine • Every child uses washcloth to clean up bubbles • Every child washes and dries hands/face (tactile exercise, hygiene, facial warm up) • Plates, napkins, and cups handed out with child involvement if possible • Child helps serve themselves from baggy/plate (moving up the hierarchy, fine motor, and sensory) Toomey, Kay., & Ross, E., 2010

50. SOS Session Structure/Routine • Feeding • Lead therapist presents each food one at a time • Therapists model the sequence of steps to accepting foods (begins visual tolerance and gives a child a choice of where to enter hierarchy) • Children are positively reinforced for all levels of food interaction Toomey, Kay., & Ross, E., 2010