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Foundations to Management
Feeding Development:
1
!! Basic but it is not simple
!! Rarely caused by only environment or only behavior
!! Often exacerbated by environment
!! Not just oral-motor and swallowing
!! Top complaint of parents of young children
!! Learning is in direct relation to experience
!! Learning requires active participation
!! Sometimes the only indicator of a medical condition
or a sign of family relationship/attachment disorder
!! “Shared Control” supports development
2
Stevenson & Allaire; 1991
!! Complex process dependent on:
Anatomic/Structural integrity
Neurophysiologic maturation
!! Learned progression of behaviors influenced by:
Oral sensation
Fine and gross motor development
Experiential opportunities
!! Complexity of feeding compounded by:
Child’s temperament
Interpersonal relationships
Environmental influences
Culture
Prematurity
Respiratory Complications
3
4
!! Physiologic flexion
!! Supplemental oxygen
!! Low muscle tone
!! Endotracheal tube for ventilation
!! Reflexes
!! Resuscitation
!! Passive behavior
!! High risk of asthma into adulthood
!! Disorganized state/attachment
!! Medication effects
!! Risk to every organ system
!! Increased neurodevelopmental risk
!! Iatrogenesis
!! Growth and nutrition
!! High risk of parental mental health issues
Digestive Complications
Allergies/Malabsorption
5
6
!! Aversive Conditioning
!! Surgery
!! Respiratory Congestion
!! Medications
!! Effect on weight gain
!! Delayed oral feeding
!! Aversive Conditioning
!! Diet restrictions/parental compliance
!! Caregiver compliance
!! Physical competence
!! Resources
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Environmental Factors
BBCDBCDEEF)
Assessment Clues
8
History
!! Impact on Diet and Appetite
!! Shared Control
Parental
!! Interaction/Management
Schedule
Concerns
!! Child/Caregiver Support
!! Resources
!! Need for Referral
!! Where to Begin
Diet
Interaction
Parental Concerns
Schedule/Diet
9
10
!! Complaints of “food fights”, child is difficult to feed,
child eats for others better than caregiver
!! Do complaints match clinical observations?
!! Is parent in denial, grieving, distrustful, avoidant,
unaware?
!! Complaints of picky eating/restricted diet (less than
20 foods; food jags); gagging; vomiting
!! Won’t transition to baby food purees by 10 months
!! Won’t transition to any table foods by 12 months
!! Won’t transition to cup by 16 months
Interaction
11
!! Ability to read cues
!! Connection/attachment
!! Responsive? Appropriate?
!! Autonomy vs. Control
!! Does your child feed himself?
!! Make a mess?
!! Need help with eating?
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!! Mealtime Routine/Structure
!! Knowledge/feeding
practices/expectations
!! Is child allowed to eat/drink
between meals?
!! What kind of schedule is
child on? Is there a
schedule?
!! Where does child eat?
!! Does child need
distractions/watch tv?
!! Nutrient deficiencies
!! How often do you try new
foods?
!! How many ounces of fluids
(include all!) per day?
!! What kinds of foods does
your family eat?
!! Does child eat a variety of
carbs, proteins, fruits/
veggies?
When To Treat
12
Support Services
(in place of or prior to intervention)
!! Home visits/Parent Training
!! Counseling (individual, couples, family)
!! Service Coordination
!! Advocacy
!! Respite Care
!! Family Assistance
!! Child Protective Services
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When To Treat
When Feeding Is Contraindicated
13
14
Priorities
!! Respiratory Status/Cardiac Function
1.! Address attachment/communication environment
2.! Stimulate NNS
!! Nutrition/Hydration Stability
3.! Maintain/Normalize sensory processing
4.! Maintain/Normalize oral-facial sensation
!! Swallowing Function
5.! Establish feeding/mealtime experience
6.! Normalize hunger/satiety cycles; develop
association with feeding
!! Postural Stability
How To Treat
How To Treat
15
16
1. Rule Out Medical Reasons
!! Consult Pediatrician
!! Screen For Contraindications
!! Suspect GERD, Allergies
!! Refer to Specialists
!! Comprehensive History
!! Minimize medical influences
2. Establish Environmental Support
!! Caregiver “Buy-In”
!! Attachment/Bonding/Interaction
!! Resources/Support
!! Learning Environment
!! Structure/Schedule/Exposure
!! Consider hunger/satiety cycles
The Teaching Loop
17
Feedback
NCAST; Norris-Shortle & Cosgrove
Alert
Eye
Contact
Performance
Instruct
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How To Treat
18
3. Address Postural Stability/Positioning
!! Collaborate with PT/OT/Assistive Tech
4. Address Sensory Processing
and aversive conditioning
!! Normalize response to sensory stimuli
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Sensory Processing
How To Treat
19
20
Sensory Responses to Food
!! Won’t look at food;
!! Hand/finger splaying
covers eyes/face
!! Turns head away,
pushes food away
!! Throws food
!! Attached to colors of
food
!! Closely “inspects” food
!! Holds nose vs. intense
smelling
!! Wiping hands
!! Makes faces; body
quivers; squints eyes;
startles
!! Gagging; vomiting;
coughing
!! Pockets food; stuffs
food
!! Anterior loss of food
5. Address Oral-Motor and Feeding Skills
!! Normalize the feeding experience
!! Consider child’s autonomy/independence
!! Consider child’s skill level
!! Consider modifications (food, equipment)
!! Target skill deficits
Teach Expulsion !
Signs of Distress/Disengagement
Signs of Major Distress
21
22
!! Sighing; Crying;
!! Fussing; Cry face
!! Straining; Bowel
movement
!! Coughing
!! Irregular respiration
!! Sneezing; Sweating
!! Multiple swallows
!! Choking
!! Bradycardia
!! Hiccups; Trembling
!! Halt hand
!! Spitting up; gagging
!! Arching back
!! Startling; Gasping
!! Saying no
!! Retching
!! “posturing”
!! Facial grimacing
!! Increasing high/low tone
!! Color change
!! Falling asleep
!! Lateral head shake
!! Respiratory pauses;
!! Yawning; Squirming
!! Spitting
!! Gaze aversion
!! Covering eyes/face
!! Tray pound
!! Pulling away
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