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.

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.

Sarah’s family was like many families of children with feeding disorders. They had a happy, healthy baby girl who just wasn’t eating like the other babies. She spit up more. She fought the bottle at feeding times. And, she just didn’t seem to enjoy being fed. Her brother had been a great eater and never had a problem growing and gaining weight. Her parents just couldn’t figure out what was wrong with their baby. Would she grow out of it? Were they doing something wrong?

So, Sarah’s parents did what any family would do; they asked their pediatrician.

He referred them to the state’s 0-3 early childhood program for an evaluation and also to our feeding clinic for an evaluation. The 0-3 program physical therapist (PT) found Sarah to have a moderate delay in her gross motor skills. The PT and the feeding team recommended weekly therapy. After 3 months of weekly therapy, a developmental therapist (DT) and occupational therapist (OT) completed a re-evaluation and suggested adding weekly DT and OT to the family’s services. After about 6 months of therapy services, the family was referred by their GI doctor to an out-of-state intensive inpatient feeding program. The program staff included a team of psychologists, another speech therapist, a dietician, another GI doctor, and an ENT (ear, nose, and throat doctor). So, let’s review. Sarah and her family were then seen by the following specialists:

• 1 Pediatrician
  
• 2 Pediatric GI doctors
  
• 1 ENT
  
• 1 Psychology team
  
• 2 SLPs
  
• 1 PT, 1 OT, and 1 DT
  
• 2 Dietitians

In summary, that is 12 specialists at 4 hospital systems. What started as a small
concern for this family quickly spiraled into a much larger problem with many
different systems to navigate. As with many families of children with feeding delays, Sarah’s parents were thrust into the role of telephone operator. We spent the beginning of many sessions just catching up on the multitude of recommendations and changes made by the many other members of the feeding team. Sarah’s family was often confused or uncertain when given conflicting recommendations by different team members.

Lesson #3: Build a core team, preferably with members who are willing and able to communicate frequently.

When a child is diagnosed with a feeding delay or disorder, some families respond by wanting as much information as possible. Second and third opinions are an excellent idea and trying a few therapists can be essential in finding someone who you and your child feel comfortable working with. But, eventually it’s best to build a core team of doctors and specialists who can help create a treatment plan encompassing all aspects of your child’s development. If needed, additional specialties can be added as consultants to the team, with the core team members integrating the new recommendations into the common treatment plan. The members of the team should be willing to communicate frequently with other team members, whether in a monthly staffing of your child’s case or via telephone/email communication.

Building a solid team that communicates well will lesson the pressure on families and parents to pass along recommendations. Parents are able to focus on the content of each session without furiously taking notes they can pass on to the next therapist or physician. Also, understanding what each member of the team is focusing on can help you, as a therapist, better design your treatment activities and home program to mesh within the global treatment plan.

"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.