The Feeding Family

Imagine you are at your favorite café or restaurant, enjoying a cool, rich, delicious bowl of chocolate pudding for dessert. Maybe you come to this spot every week (or more if it’s a particularly stressful week!) and indulge in this smooth, creamy treat. Now imagine that one week, you are served your pudding and it looks a little different. You take a bite and realize that the chef has changed the recipe! Your silken chocolate pudding now contains small, soft lumps of mushy brownies! This is not what you expected! Maybe you even cover your mouth with a napkin and spit out the lump to see what the heck it is. Maybe you don’t finish your pudding today because it’s just not what you wanted. Either way, you notice that you can’t just let the pudding slip down your throat anymore. Now you must swallow a part of your mouthful, chew the rest, and then swallow again. This pudding just got complicated.

Now imagine that you are 8 months old. You’ve never had a lump in your life! That lump in your food might be surprising and even a little scary if it starts to slip down your throat. You might gag to try and get it out. Maybe your eyes start watering and you start to cry. Chances are that you might be a little wary of that food the next time mom or dad brings it out.

Not all children have difficulty transitioning from a stage-2 thick puree to a stage-3 lumpy puree. If they did, the baby food companies might go out of business! But I frequently see families for feeding evaluations because their child is having a lot of trouble transitioning to textured foods. Some of these children demonstrate sensory aversions or oral-motor delays, but many are not really displaying either. How can we help our kids with this sometimes troublesome transition?

A Little More Time: Every child is different and reaches their developmental milestones at slightly different times. Some children may have no problem with lumpy textures the first time they are offered, while others may react strongly to the change. My first suggestion for families experiencing difficulty with this transition is to wait a few days to a week and try it again. If the difficulty persists, then you can move on to some of the following ideas to help your little one adjust.

Ignore the Numbers: Just because the number “3” comes after “2”, doesn’t mean that you are bound by law to offer stage-3 foods immediately. Often changing the order in which solid textures are introduced can help children transition more easily to the lumpy texture. Here is an example of a different transition plan that has helped many families make the change (see the articles on puree, soft solid, and hard solid textures for more information on the different food textures listed below) The following textures should be offered for exploration IN ADDITION TO stage-2 or thick purees and breastmilk or formula for the majority of their nutrition:

   1. Hard Munchables: Offer hard, stick-shaped foods like carrot or celery sticks. Encourage your child to dip the sticks in their pureed food and to play with the texture in their mouth. When the stick is placed in the side of the mouth, it encourages the tongue to move to both sides, a skill necessary for chewing. The hard munchable is NOT intended to be eaten. It is purely for exploration of a new shape and texture in the mouth.
   2. Small, soft cubes: Ripe banana or well cooked carrot works very well for this stage. Think of it as offering the “lumps” from the stage-3, but without the surrounding puree. The pieces should be small, but still able to be picked up with the fingers. Offering small, soft cubes on their own can help a child learn to manage the one texture before mixing it with others.
   3. Lumpy puree or mashed table food: At this point, parents have the option of trying the stage-3 jars again, or moving to mashed table foods. Both are a lumpy texture, but the mashed table foods tend to be thicker. If your child has tolerated the hard munchables and soft cubes well, the transition to lumpy purees should be much easier.

If your child still demonstrates difficulty transitioning to lumpy textures or does not tolerate the hard munchables or soft cubes, seek the advice and guidance of a feeding team evaluation. Ask your pediatrician for a referral and see our guide on what to look for in a feeding team.

Often, I will meet a family for a feeding evaluation and they will ask me this question: “All he eats are chips and crackers, but I can’t get him to take a bite of meat! Why won’t he chew?” Children with oral-motor delays or sensory aversions to food can sometimes be very particular about what kinds of foods they will and will not eat. In this article we will discuss what the differences are between different types of hard or crunchy solid foods. Previously we have discussed pureed foods and soft solid foods. With these three resources together, you should now have a fairly complete glossary of food texture types and descriptions.

Meltable Solid: This is often the first type of “hard” solid food that we offer to toddlers. A meltable solid is a dry texture that, when placed in the mouth, softens and dissolves within a few seconds. Examples of this texture are toddler “puffs”, butter crackers, and shortbread cookies. Children are able “chew” these foods a few times and easily swallow them. If you are unsure whether a food is considered “meltable”, hold a piece in your mouth without chewing. If the food begins to break apart just with saliva, it is considered meltable.

Crunchy Solid: These are often similar to meltable solids, but require more chewing to break apart. Examples are cheerios, saltines, and graham crackers. These foods require better control of the food in the mouth and more endurance for chewing. 

Hard Munchable/Hard Stick: These two terms are used to mean a hard solid that is used for food exploration or mouth exploration without the expectation that the child will actually bite off a piece and eat it. Hard sticks can be used to stir and taste purees or simply for exploration on their own. These textures can help a child “get used to” the feeling of a hard texture in their mouth without having to chew and swallow the food. Examples of hard munchables/sticks are celery or carrot sticks, jicama spears, or hard pretzel rods. Always supervise a child when they are exploring with hard munchables to make sure that they do not accidentally bite off a piece and choke.

Hard Mechanical: A hard mechanical is the same texture as a hard munchable or hard stick but one that is meant to be eaten. These are textures that are appropriate for older children with mature oral-motor skills. Some tougher meats could also be included in this category, since they require a lot of chewing in order to be swallowed.

Mixed Texture: A mixed texture is just what it sounds like! It is a food which combines one or more of the textures featured here and in the Purees and Soft Solids articles. Stage 3 pureed baby foods might be considered a mixed texture, since they combine soft cubes within a thick puree. Chicken soup is also a mixed texture which combines thin liquids with soft solids and hard mechanicals. A child should be able to eat all the textures SEPARATELY before they are expected to eat the textures together.

Now that you know all about food textures, take a look around the next time you are at the grocery store or standing at your fridge. How many soft cubes can you find? How many hard munchables? Keep these textures in mind when choosing foods for your child. Ask your feeding team for additional information if you notice that your child is have difficulty with one or more of these textures.

Many parents and caregivers might not give much thought to the differences between a puree and a soft cube until they are faced with teaching a child with an oral-motor delay how to eat. The small differences between different food textures can make a big difference for your child when they are having difficulties with chewing and/or swallowing. The terms that your speech-language pathologist or feeding team might use to describe food textures can be confusing. In our last segment, we looked at the differences between many types of purees. This week we will address different types of soft solid textures.

Soft Cube Texture: This type of soft solid allows children to appreciate the mouth feel of a formed solid, without demanding a lot of chewing skills. Examples of soft cubes include boiled or steamed potato or carrot pieces, ripe banana or mango. A soft cube texture is one which turns into a thick puree when pressed with the tongue or teeth. 

Finely Chopped: Any fruit, cooked vegetable, or meat can be made into a softer solid texture by chopping it well in a food processor. This allows for more texture in the solid food, but with less effort needed for chewing. Finely chopped foods can be softened even further by adding sauces or gravies to help keep pieces together in the mouth. 

Mechanical Soft: The term “mechanical soft diet” is most often heard in hospitals or other medical settings. This describes a set of foods with are soft enough to be easily chewed, but are not required to be chopped or diced. Sometimes this kind of texture is useful as a transition between a pureed diet (which requires no chewing) and a full regular diet for children or adults who have suffered an injury or other feeding setback. Foods which are considered a mechanical soft texture include soft scrambled eggs, flaked fish (no breading), noodles, rice, and softer fruits and veggies (NOT carrot sticks or apple slices).

“Soft” Foods to Avoid: If your child requires soft foods due to difficulty with chewing skills, there are some common foods which are “soft” to the touch, but which can be difficult to chew and swallow nonetheless. One of these foods is bread. While bread is soft, it can be very chewy and sticky when it becomes moistened in the mouth. I often advise parents to avoid bread (slices of bread, rolls, hot dog/hamburger buns, etc.) until there child is able to handle more complex, or multi-textured foods consistently. Meats are another “soft” food that might be avoided for children with oral-motor difficulties. Even if meats are tender, they require more advanced chewing and biting skills. Ground meats with some sauce or gravy can be a nice alternative to whole meats at this stage.

I've gotten more than a few questions from readers about different food textures. What is a texturized puree? A soft cube? A meltable solid? For typically developing children the boundaries between these textures are sometimes fuzzy, and therefore many parents aren't aware that a scrambled egg and a piece of banana can be two very different foods from an oral-motor perspective! Today we'll talk about purees and what those "stages" really mean in relation to your child. The focus of this article is on children with oral-motor delays or oral-sensory aversions, but the content can be applied to children with typical skills as well.

What is a puree? A puree is a consistency similar to baby food. There are many different puree textures, some can be thin and runny, while others are thick or have soft lumps.

Stage 1 or Thin Puree: This consistency is similar to a slightly thickened liquid. It coats the spoon well but still drips off easily. This consistency is offered as a first step solid food because it is considered one to two steps "thicker" than breast-milk or formula. For older children this consistency is easy to swallow quickly, however it can pose a risk for children who are known to aspirate or choke on thinner liquids and foods.

Stage 2 or Thick Puree: This consistency is considerably thicker than stage 1. It can be similar to a smooth applesauce. It should stay mounded on the spoon when scooped but fall off the spoon if you tip it upside down.

Pudding Thickness: This type of puree is similar to, you guessed it, pudding! Foods that would be considered a pudding thickness are yogurts or smooth mashed potatoes. These foods can be very difficult to swallow for children with weak oral muscles or a weak swallow.

Stage 3 or Texturized Puree: This can be a very complicated texture for children with even mild oral-motor or sensory delays or impairments. It consists of a stage 2 or pudding thick puree with small, soft lumps throughout. I would say that about 20% of my initial evaluations are for children who are having difficulty transitioning from stage 2 purees to stage 3 purees. In future articles we will discuss strategies to help children transition to texturized foods.

Almost any food that you or your family eats can be blended into a puree. Foods should be allowed to cool to room temperature and then blended in a food processor or blender with liquid until the desired consistency is reached. Adding small amounts of water, milk, or broth will make a puree thinner, while adding small amounts of corn starch can add more thickness.

The phrase “oral aversion” describes the avoidance or fear of eating, drinking, or accepting sensation in or around the mouth (i.e. toothbrushing or face-washing).  A typically developing child learns that eating and drinking are fun and positive experiences.  A child with an oral aversion has somehow learned that eating and/or drinking is uncomfortable, unpleasant or causes anxiety.

What causes oral aversion?

Oral aversion can result from a variety of medical issues or early childhood experiences. Sometimes we are not sure why a child develops an oral aversion, but it can usually be traced back to one or many of these issues.

Medical trauma:  When a child is in the hospital they may experience a wide range of unpleasant interventions around their face and mouth. These can include more mildly unpleasant experiences like bad-tasting medications or breathing treatments or can include more invasive experiences like intubation, feeding tube placement (oral, nasal, or gastric), or need for oxygen or ventilation support. 

Lack or absence of early feeding experiences: For many reasons a child may not be able to eat early in life. Lack of these early and formative feeding experiences may lead to aversive behaviors simply because a child does not know or understand what is expected of them and they may not have the oral-motor skills necessary to eat age-appropriate foods.

Discomfort: Children with gastrointestinal disorders (reflux, constipation, food allergies) or respiratory issues (asthma, chronic environmental allergies, oxygen dependence, sleep apnea) may develop oral aversions because eating is associated with discomfort. Children with GI discomfort, even if it is mild, can make associations between food and feeling bad. Children with respiratory issues can often find that eating is difficult because we stop breathing briefly during every swallow, which can make eating for these children very tiring.

Sensory integration/regulation disorders: Children with sensory processing, integration, or regulation disorders perceive sensation differently than typical children. This can include low awareness of sensory input (unaware of a messy face, stuffs mouth in order to “feel” food better) or high awareness of sensory input (intolerant of lumps or texture in food, dislikes strong colors or smells). Children with altered sensory input can become aversive to foods with the characteristics they find overwhelming or unappealing.

Choking episodes: This is a very special subset of children with oral aversion. Children who have experienced a choking episode may have a true “food phobia” rather than an oral aversion. Children who have become aversive to eating or drinking after a choking episode should include a psychologist or child therapist in their feeding team to help the child and family deal with the trauma of that event.

This is not a complete list of reasons a child may become orally aversive. However, in my experience, these are the most common. Often an oral aversion will develop from several of these scenarios together. If you are selecting a feeding team to treat your child’s aversion, see our suggestions for choosing the right therapist.

If your child has an enteral tube-feeding system (NG-tube, G-tube, G/J-tube, etc) or, if you are exploring options for a child who has a hard time eating safely or enough food, there can be a lot of new vocabulary to learn! Here are a few simple definitions and illustrations to help you or anyone else who is caring for your child.

Types of Feeding Tubes:
Oral Feeding: Food or liquid taken by mouth also goes through a "feeding tube" - your esophagus! MOST children who receive other tube feedings are still working towards eating by mouth, unless it is deemed unsafe. Any feeding tube should be considered a tool to help your child grow and learn and ultimately work towards some amount of safe, comfortable, and enjoyable oral feeding. 

NG-Tube or Nasogastric Tube: A long, thin, flexible tube (usually about the width of a coffee straw) which is placed through the nose, down the throat and into the top portion of the stomach. Intended for temporary use of 6-8 weeks, although often used for longer periods of time.

G-Tube or Gastronomy Tube: A short tube which is surgically placed through the wall of the stomach. The placement is completed without a long incision and is usually an outpatient procedure. After the placement site has healed, the G-tube may be replaced with a smaller "button" type G-tube. A G-tube is intended for longer-term use.

G/J-Tube or Gastronomy-Jejunostomy Tube: This type of feeding tube is very similar in appearance to the G-tube, but different in the way it is used and what it is used for. The G/J-tube is a tube which is placed surgically through the stomach wall. It has two "ports"; one which enters the stomach, and one which enters the jejunum. The jejunum is the second part of the small intestine. Typically, formula is given through the "J" port so that it bypasses the stomach altogether and is absorbed directly by the small intestine. A G/J-tube is often considered for children with severe GI discomfort. Feedings given through the "J" port must be run slowly and continuously through most of the day, although some children are able to tolerate feedings only overnight.

Feeding Types and Schedules:
NPO: No food or liquid allowed by mouth. I have also seen hospitals use this to mean no food or liquid by mouth OR tube if a child is getting ready for a surgery.

Continuous Feedings: Pretty much exactly what it sounds like! Feedings are given at a continuous rate over many hours, sometimes overnight. 

Bolus Feedings: A bolus is a set amount of food or formula given at one time, much like a bottle of formula or a jar of food. Your doctor or dietitian may calculate how many calories your child needs in one day and divide that into 3, 4, 5, or more feedings per day. Each of these is called a "bolus".

Gravity Feedings: This is a way of giving a bolus. Formula is poured into a large syringe (without the plunger) and allowed to drain into the tube via gravity. The flow can be stopped by pinching the tube with the provided clip or with your fingers.

Syringe and Pump Feedings: These are both ways of feeding which slow down the rate of food or liquid entering the tube. By using a large syringe with a plunger, the feeder can push small amounts of formula into the tube, rather than all at once. A feeding pump can slow down the rate even more. Feeds through a pump can be given over 1-2 hours or more if needed. Continuous feeds are given via a feeding pump.

Venting: This is a way to let gas bubbles out of your child's stomach. Often tube feeding can lead to increased gas which can be very uncomfortable. Venting can be accomplished by simply attaching an empty syringe to the end of the tube and providing some gentle massage to the stomach. There are other devices which can be attached to the feeding pump to allow gas to escape while the feeding is run.

Making Choices:
The choice of when, how, and what kind of feeding tube to place is a decision that should be made with the input of your child's medical and therapeutic team. Don't be afraid to ask questions! The team is there to help you make the best choice. Always communicate with your doctor and/or dietitian before changing the way you feed your child through their feeding tube. Every child is different and requires a specialized plan for health and nutrition.

More Resources:
Mic-Key Low-Profile G-Tube Website
Feeding Tube Awareness: Family Support
New Visions Clinic: More Info and Resources

"What do you do?"
"I'm a speech pathologist"
"A what?"
"A speech therapist"
"Oh, my sister/brother/mom/cousin had a lisp/stutter/couldn't say their 'r' sound! Do you work in a school?"
"No, I work at a children's hospital"
"Wow. Why do sick kids need speech therapy?"
"Well I work with kids who were preemies, or who have had head injuries, and they need help with communication. Actually, mostly I work with the babies"
"But babies don't talk."

This is how most cocktail party conversations go. If anyone out there is a pediatric SLP  working with children under the age of 3, you've probably had the same conversation. The simple fact is, no one really knows what an SLP does until they need one. The same is true for most other rehabilitative services as well. So, what does an SLP do exactly? And why do SLPs work on feeding and swallowing disorders? Do other therapists work on feeding and swallowing? How do you find the right person to work with your child?

Speech and Swallowing? What's the Connection?
A speech-language pathologist, or SLP, works with patients from birth through old age on communication and swallowing disorders. Communication includes the understanding and production of the sounds that make up words (speech) and the understanding and production of sentences and stories (language). Other communication disorders that an SLP would address include stuttering, social language impairments (such as with autism spectrum disorders), and voice disorders. Because communication is controlled by the brain, the mouth and throat, and the respiratory system, it makes logical sense that the SLP would also address feeding and swallowing - which uses the same structures and systems.

Does Every SLP Treat Feeding and Swallowing Disorders?
This is a great question, and one that every parent or caregiver should ask. The answer is NO. While every SLP receives some amount of training in swallowing disorders during their graduate school training, not every SLP has skills or experience in this area. The key is to find out how much and what kind of experience your child's SLP has in the areas of feeding and swallowing. How many years of experience is a place to start, but it's not the whole picture. Here are a few questions to ask your SLP to find out about their experience level:

1. What kinds of feeding and swallowing disorders have you treated before?
2. How many patients with feeding and swallowing disorders are on your caseload right now?
3. Do you have any certifications or continuing education in specific treatment approaches? (some of these might be S.O.S., NDT, Mealtime Partners, or VitalStim)

As always, if your SLP tells you about anything you don't understand ASK QUESTIONS. The more you understand, the better advocate you can be for your child.

Do People Other Than SLPs Treat Feeding and Swallowing Disorders?
Yes, there are other types of therapists who treat many aspects of feeding and swallowing disorders. However, an SLP is the only discipline to specifically address feeding and swallowing disorders in their required graduate education and in their standards of clinical practice. Occupational therapists, lactation consultants, and even some nurses and dietitians treat feeding and swallowing disorders from different perspectives. While these specialties bring unique information to a feeding and swallowing treatment plan, it is again best to ask the question about experience. 

A good friend and colleague of mine is an occupational therapist who is also pursuing her lactation consultant certification. In addition, she has a degree in early childhood development and 5+years of experience in a NICU (Neonatal Intensive Care Unit) setting. Do I think that she is qualified to treat feeding and swallowing disorders? Absolutely. In a perfect world, the many specialists who address feeding and swallowing would work in collaboration and share their specialized knowledge.

The Team Approach - Building a Feeding Family
Sometimes it can feel that finding the one perfect person to provide therapy for your child is a daunting task. How could one person possibly have all the answers!? The answer is that they don't. The best approach is to find an SLP with a good amount of experience who is willing to work as a part of a team of specialists. This team could include any or all of the following:

• Pediatrician
• Dietitian or Nutritionist
• Occupational Therapist
• Developmental or Early Childhood Specialist
• Lactation Consultant
• Social Worker or Family Counselor
• Nurse

Don't forget that the most important person on this team is YOU, the parent or caregiver. YOU are the one person on the team who knows your child the best. YOU are the person who will be coordinating follow-through of the team's recommendations at home. Make sure that you build a feeding team who values your input and listens to your suggestions and concerns.