What? This is not what your mealtimes look like at home? Let's get something straight...if it were this simple, I might not have a job. The reality is that eating is a very complex task. If you are new to supporting children and families with mealtime struggles, please get additional training from the SOS (Sequential Oral Sensory Approach to Feeding) and AEIOU (Acceptance, Exposure, Independence, Observation, Understanding) feeding programs. Links to both of these can be found under EI Power Links tab on my website.
The beginning for me is discovery. I want to know what caregivers perceive the challenge to be. Often, I ask them to feed the child something during a session. I just watch and make mental notes. No coaching, just watching. I try to keep it light and let things happen. Getting valuable information from how the child is positioned, the textures being offered, the oral skills of the child, the interaction between the child and parent, how much autonomy is present, the child's behavior, the existence of any signs of swallowing difficulties, willingness of the child to touch the food, what foods he will and won't touch, the environment and how that may be affecting behavior, focus/attention, volume of food consumed, the time it takes to eat, what type of liquid vessel is being used, if the child is getting tube feeds I need specifics about how that is being managed, etc. I will ask questions about things:
The parent's feedback and my observation of what is currently happening without interference is critical in learning what is and what is not working. Below there is a link to a parent handout that has many critical elements for families to be aware of and understand as it relates to mealtime success.
FINE MOTOR CORE STABILITY EYE-HAND COORDINATION
SENSORY PROCESSING COGNITION SOCIAL-EMOTIONAL FACTORS
ADAPTIVE EQUIPMENT ENVIRONMENTAL ADAPTATIONS ROUTINES
Knowing what is available to support the child in the areas of assistive devices including adaptive seating, special utensils, plates, cups, bottles etc is important and may be a significant game changer. Knowing how and if these items can get funded (insurance or private pay) is also necessary. Connect with your Occupational Therapist for support.
Keenly observe the mealtime environment for the following:
Discover with the families:
COMMUNICATION DIVISION OF RESPONSIBILITY COLLABORATION
Mealtimes are social times. Some things to consider are:
This is how we segregate leadership and responsibility around mealtimes. It will help with relationship building and autonomy for the child.
RESPONSIBILITIES FOR ADULT:
WHAT the child eats, WHEN the child eats and WHERE the child eats.
RESPONSIBILITIES FOR THE CHILD:
IF I eat and HOW MUCH I eat.
While that sounds simple, I often observe control issues over mealtimes. Parent counting bites, scolding for spitting food out, etc... LET IT GO... Pressure causes anxiety which decreases appetite.
All hands on deck approach: We offer the best of our knowledge and remain mindful that we need to collaborate with other healthcare professionals when the situation requires it.
Your team should include Parent, Dietitian, Physician, Speech Language Pathologist, Physical Therapist and Social Worker / Counselor.
The ultimate goal is to develop an individualized plan that supports the child/family's unique needs, uses appropriate supports, and addresses any medical concerns to ensure success.
Oral motor challenges can cause difficulty sucking, biting, chewing, and manipulating foods within the oral cavity. Severe oral motor problems can render a child unable to sufficiently manage food orally due to strength and endurance deficits, motor planning deficits, swallow delay, and/or sensory differences causing installation of gastrostomy appliances. Perhaps one of the best courses I took to gain better insight into how the oral structures function and the importance of the oral/motor process is the Deborah Beckman Oral Motor course. She now has a website and on it is an Oral Motor Evaluation Protocol.
A primary take-away from the SOS Approach to Feeding course presented by Kay Toomey, PhD is the construct that it takes all of your senses to navigate a mealtime. These include the following sensory systems:
These all need to be functioning in concert for feeding to go well.
I am seeing more and more often, children with a mouth full of decay. Know that a painful mouth is impactful from a sensory standpoint due to the negative reinforcement it offers the child. If possible, take a look in the mouth and ask if they have ever seen a dentist. You will likely not make progress with feeding if the child hurts when he uses his teeth.
If you are concerned that part of the mealtime challenges revolves around sensory differences, consult an Occupational Therapist with sensory experience to support the child/family.
There is a magical synchrony between our sleeping and eating routine.
Usually, a child with differences in mealtime routine will also have trouble with sleep. The prevalence of sleep disturbance in children with ASD is 50-80%. These challenges include delayed sleep onset, frequent nocturnal awakenings, reduced sleep duration and early morning awakenings. **Short duration REM sleep is important to learning and memory consolidations. Effects of poor sleep will manifest in the following behaviors:
And contributes to parental stress.
See: The effect of mild sleep deprivation on diet and eating behaviour in children: protocol for the Daily Rest, Eating, and Activity Monitoring (DREAM) randomized cross-over trial : Ward et al. BMC Public Health (2019) 19:1347 https://doi.org/10.1186/s12889-019-7628-x
I always ask the caregivers to detail what and when the child eats only to find that there is very little solid food consumption and a bountiful number of calories consumed in juice or milk or Pediasure. This is grazing too. When a child is allowed to move about the home with a cup of juice or milk all day long that they can sip on, it will have a major impact on solid food consumption. Here is a suggestion:
STEP 1: Offer the calorie laden drinks as part of the meal (4-5 oz). (And this is a good time to practice drinking from something other than a bottle or sippy cup.)
STEP 2: Put only water in the cup between meals.
STEP 3: Encourage the child to place the cup in the kitchen when it is not needed. **I remind parents at this stage that when the child gets to school, they will not be allowed to travel about with a sippy cup. It is best practice to set the child up for success in the future rather than beginning a formal school setting with challenges in basic habits and routines.
I have the privilege of working with families who have been abundantly blessed and with families who struggle to make ends meet. I often encounter situations where there is no highchair or special positioning for the child who needs additional support. Often, it is important to discuss with caregivers how posture and positioning can affect feeding and swallowing and the concept of building autonomy in the feeding process. In addition, for the children I work with that have feeding tubes, I often find that interventionists may be the only person in their medical world that suggests getting a child to a developmentally appropriate position while the tube feed is running. With all that said, where a meal happens is often in unexpected places such as the sofa, at the coffee table, on the floor in the living room, etc. The only thing I really care about in these situations is that it works for the child and the family. So, if the family eats in the living room and we are trying to work toward increased independence, I will try to manipulate a way for the child to be seated near the caregiver in a position that is functional for the child and comfortable for the family. Suggest use of toddler chairs, booster seats, towel rolls and pool noodle to make this happen and when low tech devices are not working, the child's insurance may pay for adaptive positioning equipment.
The rule of thumb is that it should likely take an infant 20-30 minutes to complete a bottle. For toddlers, it should take about 20-30 minutes to eat a meal and 15 or so for a snack. Requiring a child to sit for longer durations than this can cause unwanted behaviors. If the child has significant oral motor issues, it may take longer than the 20-30 min timeframe, but you should use sound professional knowledge in making this call.
When a child is unable to sit for this period of time to complete a meal, it may be necessary to come up with some solutions that are do-able for the family. When behavior is all that is being addressed because the child will not sit to eat, then re-think the plan. Perhaps start will a shorter goal to complete 50% of the meal, allow the child to get up and move for about 5 -10 minutes then resume the meal. Try to make these durations longer and longer until the child is sitting for the entire meal.
This is another area that I often find myself discussing with parents. Now, I am not a nutritionist, so I usually do not get into a specific number of calories. According to the Dietary Guidelines for Americans 2010, 2-year-olds usually need about 1,000 calories, while 3-year-olds require 1,000 to 1,400 calories a day, depending on activity levels. Two- and three-year-olds should be getting the majority of these calories from solid foods and not milk or juice. The three food groups they should be eating from is protein, carbohydrates, and fruit or vegetable. Based on recommendations from the SOS Approach to Eating, the standard is 2 Tbsp per year of age from each of the three food groups.
Example: 2 yr old breakfast (4 Tbsp Yogurt, 1/2 a biscuit, handful of blueberries)
The common variable here is how often this should happen and why mealtimes are so challenging to families when mealtime challenges exist. Meals occur at a frequency of about every 3 hrs in toddlers: breakfast, snack, lunch, snack, dinner and snack. I came across an excellent resource to help families gain insight into "what" would be good food for their toddler.
In most cases, I also help families explore new foods by bringing things from my own house and I also help them discover the joys of cooking with their toddler to build confidence around food and to make food fun. Another book I would suggest is "Food Play" by Amy Palanjian.
Sprout Pediatric Therapy Services, LLC does contract with a Nutritionist, VALERIE CRILE, RD, LDN, IBCLC, CPT-NASM, CHC.
**Important: A child can be overweight and still be malnourished. Pay attention to where all the calories are coming from and make appropriate referrals to address this. 8 oz milk bottles all day long can make for a very plump toddler, but not a well-nourished one.
Whenever I work with clients who have significantly impaired nutrition and eating habits, I seek the support and guidance of a nutritionist.
These are some of the ways a dietitian can help your clients:
It is critical for interventionist to discern what behaviors are being reinforced during a meal. When children are praised for an act or behavior, we usually see more of it because they want to please. You are positively reinforcing a behavior to continue. Any time you give a child attention for a behavior you DO NOT want them to do, it is negatively reinforcing, and you could see more of it just because you give it attention. We must be good observers in determining what may be causing a child to "not eat" or "not eat sufficiently". If there is pain or fear associated with eating, the eating behavior is negatively reinforced and eventually the child may stop eating.
Example 1: A child has severe diarrhea and projectile vomits every time he has a milk bottle.
Example 2: There are difficult social situations in the home and a lot of yelling at the table during mealtimes and the child has sensory challenges.
Example 3: Parent uses the highchair as a "time out chair" or fastens the child into the chair for long periods to manage his behavior.
Example 4: The child throws food off the table to watch the dog eat it.
**RULE OF THUMB:
1. Reward the positive and ignore the negative.**
Positive phrase to remember: "You can." or "You can do it when you are ready."
2. Control what you can. Examples from above...Seek medical advice for diarrhea and vomiting, reserve your quarrels for private time away from children, find another place to "time out" your child, and pick up the animals at mealtimes.
Here are some signs/symptoms that the child may have a food allergy:
These are the typical foods a child may have an allergy to:
If you have never heard of EoE, please look it up. Eosinophilic esophagitis is a chronic immune system disease in which eosinophils (a type of white blood cell) builds up in the lining of the esophagus due to an allergic reaction to foods, allergens or acid reflux. Damaged esophageal tissue can lead to difficulty swallowing or cause food to get stuck when you swallow. Signs of EoE in children include:
Read more about how allergies affect behavior:
"Is This Your Child?" By Doris Rapp, MD
Is the fight worth it?
This is where you need to decide what the primary objective really is...
If it is critical for the child to eat more volume and using utensils is being rejected by the child, I would suggest you use whatever means necessary to support volume and that might mean putting "your" goal of utensil use on the back burner for a while. There will always be time for learning a fine motor skill, but it could take years to undo a child's poor relationship with food and their caregiver because they were forced into using a utensil. On the flip side, NOT offering utensils is not what I am suggesting. Utensils can be used at the meal through co-feeding or with serving or incorporated into snacks or play activities where you can have a little more fun and lighter mood surrounding the activity.
Know your adaptive equipment or get with an Occupational Therapist or Speech Pathologist that does. From the Haberman Special Feeders/Bottles to Honey Bear Cup to build ups on handles, curved or plastic-coated utensils, suction plates and lip blocks on straws... there are special things to support differences in feeding that will improve success for the child.
REFLUX MEDICATIONS:
Routines are important to all children, not to mention the strong benefits of routines in children with special needs. One of the most basic concepts I try to instill in the lives of the families I service is that we raise our children to become independent, self-thinking, capable individuals. In doing this, it is our job to teach them all the parts of a task. Getting food to the mouth, chewing and swallowing is the major highlight of the mealtime process; however, we have the opportunity to work on so many other things in this one activity:
-Location of the kitchen (cognitively "mapping" the house)
-Getting seated (either climbing into the seat or turning to get self-seated in a toddler chair)
-Practicing patience (learning a social skill of waiting).
-Sitting to eat (socially appropriate position)
-Using utensils and open cup (self-care and independence)
-Exploring food (health and nutrition and sensory tolerance)
-Cooking (self-care and independence)
-Handwashing / Face-washing (self-care and independence)
-Communication (language both verbal and non-verbal/ receptive and expressive).
My go to for explaining this is that parents usually feel less anxious about a child going to school when the child can take care of him/herself. At school, our little ones are expected to know to sit in the cafeteria, to keep their hands on their own plates, to place the cup back in a safe place between sips, and to wash hands before and after eating. Additionally, it is important to me that families try to have a beginning, middle and end to activities. Going full circle of handwashing at the beginning and handwashing at the end gives a definite beginning and ending to the meal.
Shopping for food, preparing to cook, and cooking and cleaning skills are excellent way to teach little ones about food and life skills and to build in language/communication and cognitive concepts.
Shopping: Stroll down the aisles and point out different foods. Talke about the different vegetables and fruits. Pick something out together to explore. Let them push the buggy, ride them in the car cart, try not to be in a hurry so you can use it as a learning experience.
Preparing & Cooking food means you let them learn how to peel a banana or mandarin orange. Put a plastic knife in their hand and help them learn how to cut up soft fruits or vegetables. Let the child stir up mixes. Show them how to crack an egg or to spread butter on toast or put sprinkles on a cupcake. There are some excellent books on cooking with kids and "food play".
Cleaning up at the end of a meal could involve having the child bring dishes from the table to the sink or emptying the uneaten food from the plate into the garbage. Many Head Start programs do this at the end of the meal.
Remember to praise the child for the help.
Ark Therapeutic products has a line of oral motor tools, feeding and drinking aids along with speech therapy items.
This tool kit is designed to help families affected by ASD understand eating behaviors, give guidance on how to address feeding issues, and review some common questions that families have about eating problems.
Disclaimer: **These materials are the product of on-going activities of the Autism Speaks Autism Treatment Network, a funded program of Autism Speaks. It is supported by a cooperative agreement UA3 MC 11054 through the U.S. Department of Health and Human Services, Health Resources and Services Administration, Maternal and Child Health Research Program to the Massachusetts General Hospital. Its contents are solely the responsibility of the authors and do not necessarily represent the official views of the MCHB, HRSA, HHS, or Autism Speaks.”
If you need reinforcement about feeding and mealtimes from a source families will recognize, try this one...https://healthychildren.org. It is supported by the American Academy of Pediatrics and offers real concrete information about feeding including daily calorie needs based on age, gender and activity level, sample menus, discontinuing the bottle, juice & water, toddler snacks and many other things families may have questions about.
The best way to feed your child is to follow the Division of Responsibility. The division of responsibility in feeding encourages you to take leadership with feeding and give your child autonomy with eating. • As a parent, you provide structure, support, and opportunities to learn. • Your child chooses how much and whether to eat from what you provide. This resource is from Penn State University. It also contains a page of "Troubleshooting" (best way to respond to challenges).
A cookbook designed to help kids explore, build confidence, and have fun with food!
If you want to know where stresses lie for a family, look at the tasks they do with their little ones repeatedly during the day. When there is a challenge in one of these areas, it can make the day in and day out life of parenthood an overwhelming proposition. Did you know infants & toddlers eat every 2-1/2 to 3 hours?
Occupational Therapy practitioners have the education, knowledge, and skills necessary for the evaluation of and intervention with feeding, eating, and swallowing problems. Speech Pathologists are also a vital part of the feeding process when complex swallowing issues exist. Just a shout out to my daughter Lillian and granddaughter Evynn
Occupational Therapy practitioners have the education, knowledge, and skills necessary for the evaluation of and intervention with feeding, eating, and swallowing problems. Speech Pathologists are also a vital part of the feeding process when complex swallowing issues exist. Just a shout out to my daughter Lillian and granddaughter Evynn in this picture. We love tea parties at my house!
Lillian is a Speech-Language Pathologist working with children in the Louisiana EarlySteps program.
"DIR is the Developmental, Individual-differences, & Relationship-based model It was developed by Dr. Stanley Greenspan to provide a foundational framework for understanding human development. It explains the critical role of social-emotional development starting at birth and continuing throughout the lifespan. It also provides a framewor
"DIR is the Developmental, Individual-differences, & Relationship-based model It was developed by Dr. Stanley Greenspan to provide a foundational framework for understanding human development. It explains the critical role of social-emotional development starting at birth and continuing throughout the lifespan. It also provides a framework for understanding how each person individually perceives and interacts with the world differently. The model highlights the power of relationships and emotional connections to fuel development.
Pediatric feeding disorders are common. 1 of every 4 children are reported to have some sort of feeding disorder. A smaller number have symptoms severe enough to cause big problems or need specific treatment. The rate of feeding disorders is much higher in children with developmental disabilities. As many as 8 of every 10 children with a disability has a feeding disorder. Feeding Disorders - Developmental and Behavioral Pediatrics - Golisano Children's Hospital - University of Rochester Medical Center
"Best available research indicates that feeding problems are seen in 25 to 45 percent of the general population, in as high as 80 percent of children with developmental disabilities, and in 40 to 70 percent of children with chronic medical conditions. " (Society of Pediatric Psychology)
Know your team members: It is important to know who your team members are on the feeding team. They may include some of the following:
While many of these are not available in the home environment or attend team meetings, the information gained from such providers is invaluable and can support the assessment and intervention process. Engage the parent in discussions about how other providers on her team view the existing issues and communicate with them via telephone or via written notes. I sometimes offer the parent a letter to take with her to the doctor when I have concerns, and I am not sure the parent will articulate well enough to engage the clinician to action.
Assessment - Problem based assessments are common in all disciplines. The insurance companies want to know what the problem is. Early Intervention wants a "strengths based" assessment. While these seem conflictual, it is because they are at either ends of the spectrum. It is important to know what is typical for age and to identify where the child is falling off the tracks, but........knowing where they are remaining on the tracks gives you a great place to begin. That means, find the problems and trace back to where you have some strengths.
Feeding disorder has been divided into six sub-types:
1. Feeding disorder of state regulation
2. Feeding disorder of reciprocity (neglect)
3. Infantile anorexia
4. Sensory food aversion
Eating exposes us to a significant number of sensory inputs (visual appearance of food, smell, temperature, taste and texture). Eating is a demanding experience from a sensory perspective. Some children are over (or under) responsive to the sensory elements of food and eating. This can mean gagging at the sight or smell of certain foods. It can also be refusing to touch food, vomiting or spitting food out.
Sensory food aversion can occur for many reasons, but often it is the result of difficulty processing the sensory aspects of eating. Children with an aversion are often labeled as picky or selective eaters.
5. Feeding disorder associated with concurrent medical condition
There are so many medical reasons why a child may have difficulty with food intake. Here are just a few I have encountered over the years:
6. Post-traumatic feeding disorder
Post traumatic feeding or eating disorders are behaviors exhibited when an infant relates a painful or frightening experience with eating. This disorder is also known as choking phobia, swallowing phobia and functional dysphagia.
Use Strengths/ Preferences/ Interests while you are targeting skills for instruction: The guiding light of any intervention is the ability to gear your instruction to the strengths, preferences and interests of the child. This supports engagement and most of the time, if you let them take the lead you will find that sometimes they will let you be the leader so that you can explore new interests, activities, and expand creative play. Here is an example of how to put this to practice in a feeding environment:
Example: Goal is to expand the texture and tastes the child will accept during mealtimes due to limited food preferences but remaining at the table is difficult for this child and he always wants toys or the TV on at the table when eating. There are many opportunities here for instruction and guidance to the parent especially with "in seat behavior", but we need to make being at the table more appealing for the child.
These are some things to try:
-Bring a mirror to the table so the child can see himself (not to touch...to watch)
- Try to use utensils in play activities and begin to transition the child to having utensils at the table rather than toys
- Ensure the child is sitting in the "perfect place" at the royal table (sometimes what they can see or not see matters) and make sure the parent is one of those things they can see.
-When the child is highly anxious and has difficulty being without his familiar caregivers, they tend to leave the table to follow them. Encourage the parent to sit with the child and stay there throughout the meal. This will give the child staying power.
-Model how to engage with the child at a meal (there are so many things to talk about and explore at the table). If your talking is too much, be quiet (knowing when and when not to talk is important).
-Have the child help with prep or cooking or setting the table if they are able. There are many fun ways to engage a child in a cooking experience.
-Help the parent understand the importance of routine and show what a pre-and post-meal routine might look like (sensory readiness, handwashing etc.)
-Use a timer and educate the parent on how long is "long enough" for a child to be expected to sit.
-Try to find ways to incorporate the child's "fantasies" into the mealtime. (Dinosaur pancakes, car shaped vegetables, etc). I have even seen spoons that look like excavators.
Environment: Children eat constantly throughout the day and in a variety of environments and potentially with a variety of different caregivers.
1. When we consider the "environment" it means we are considering the physical environment (space, equipment, materials), the social environment (interactions with peers siblings and family members) and the temporal environment (sequence and length of routines and activities). Take time to identify what challenges exist in the environment including what you hear, smell, and see.
2. We should strive to support children/families in their natural environments whether it be home, daycare or out in the community since eating happens everywhere and with a variety of caregivers. How the child functions at mealtime can be very different between environments. Figure out where he eats best or what times of the day he eats best and work toward replicating this.
3. The child's physical environment also includes what/where the child is positioned and how this supports or interferes with the success of mealtimes. We should work with families to obtain adaptive equipment or make low tech positioning modifications to meet this need. This seems to be a difficult proposition in the daycare environment. Wanting children with sensory differences, motor and balance challenges, and small statures to sit in the same chairs at the same table as their peers is "their goal", but........it may not be good for the child. Education is critical and often accommodations necessary.
4. Assistive Technology may be necessary to support the child and interventionists may be called upon to recommend, trial and obtain devices needed to facilitate success. I personally like to try items I recommend to ensure it is a good fit for the child and family before asking the state or other funding source to purchase it.
Family: Families are the leaders of this intervention process and should be called upon to participate in the decision making for the child. The interventionist's role is to support them with achieving the goals they have for their child/family.
1. Keep your interventions individualized, flexible and responsive to the unique circumstances of the child/family. I have worked with families who eat in the living room every evening, this is THEIR routine. My intervention addressed how we could support the child with positioning in a seated position at the coffee table and arranged the adults in a way to help ensure more control over "in seat behavior" to ensure maximal consumption.
2. Allow caregivers to practice the interventions while you are present to build their capacity to support their child. Our goal is to enhance the capacity of the parent to meet the child's unique needs. If you try sidelying for bottle feeding and it works well for the infant, then the parents who will be feeding the child 6 feedings/7days per week needs to be comfortable with how to do it too. If a caregiver has difficulty with making this happen, you may need to go back to the drawing board to find another option or it will not benefit the child at all.
3. Build a relationship with the family that is respectful of their culture and beliefs and is mindful of their socio-economic circumstances. Careful about asking families to "buy" this or that. Parents really want to do all they can for their child. However, we can't make an already stressful situation even more stressful by asking them to spend money they don't have. I also have found over the years that different cultures use bottles longer than others and offer milk more liberally.
4. We need to be responsive to a family's changing circumstances and how that may impact mealtimes. These can include a caregiver illness, divorce/separation, challenging siblings and other social factors that change the dynamics of a family. I worked with a child who was cared for by a grandmother who passed away. The grandmother had lived with the family for over a year before her death. Grandma was the mealtime social partner, and the child didn't know what to do without this component of the meal. This may sound crazy, but we found videos of the grandmother with the child, and this was just what he needed to remain at the table to eat until we could slowly fade that way. It took time, but was a way to meaningfully address his loss.
5. Interventionists should strive to enhance the caregiver's knowledge and understanding of the challenges at mealtimes while supporting their capacity to problem solve. Often, I find myself pointing out the obvious (to me) but for caregivers without equal training and experience these are NOT OBVIOUS. When I help the family do a food log and we plot the proteins, carbs and fruits/veggies accepted they are often astonished by the fact that the child is only eating dry crunchy tan/white/beige foods. This is an excellent way to discuss sensory properties of food and how we can use food chaining to help gain new foods.
6. Help families learn to advocate for their child by knowing and understanding their rights. This seems to be most critical for our kiddos in daycare settings who need additional supports to nourish themselves for the 8 hours they spend in the center all day. Advocating for accommodations and understanding how profound it is to know if the child ate at meals and snacks is important to their growth and development. I can't imagine the trauma of being dropped off at a place every day and being hungry the entire day because there is nothing served that is a preferred food. There MUST be provisions put in place to support that child including allowing the parent to bring in preferred foods so that they are consuming something.
Instruction: This is the cornerstone of early intervention. It involves what we teach, when we teach and how we teach. Interventionists are asked to use the term "instructional practices" because it is the term predominant in literature and research.
1. We should always consider the learning styles of the child and family as we provide education. Simply ask the caregivers how they learn best. They know! I would surely say, I need a visual. For some, they need it all written down. Others do fine with watching you and trying it themselves.
2. Interventionists should strive to provide information embedded in natural learning opportunities where the child and caregivers are active participants.3. Embed instruction across routines (ex: pre-meal handwashing is the same as handwashing after a messy craft activity). 4. Utilize peers to support learning opportunities for children. 5. Each child and caregiver has a unique pace of learning. Be mindful of the needs of the level of support needed to build the family's capacity to meet the child's needs/goals. 6. When working with families who have dual languages, try to find information in their preferred language. Some websites have informational PDF's in multiple languages.
Add a build up to a utensil to make it easier to hold. Flat handles and skinny shafts tend to flip and twist in developing hands. The buildup helps to stabilize it by making it easier to grasp.
Used to teach straw drinking to support transitioning off the bottle or sippy cup. Also promotes bringing lips together (lip rounding) to build lip strength. Parent can squeeze the cup to ensure success while learning how to suck the liquid up the straw.
This cup has the same benefits as the Honey Bear Straw Cup but can be found at most retail stores and is much less expensive. It comes with 5 cups, 5 straws, and 5 lids.
Sometimes called straw topper. Primarily used to keep the straw from going too far back but has different length spouts that can be used to grade the amount of lip rounding needed. Find at Ark Therapeutics or Amazon.
The suction base prevents the plate from sliding across the table while scooping and the scooper lip on the edge of the plate flips the food back into the spoon instead of allowing it to fall off the edge of the plate.
This utensil supports arm stabilization when tremors are present or when the child is lacking or proprioceptive awareness (where the extremity is in space). Some utensils are fixed for right- or left-hand users while others can be bent either way.
This is the Eazy Hold Universal Cuff and comes in a variety of sizes to fit most tools that kids need to hold. This 5 pack is for children and is found on Amazon. It supports maintenance of grasp so that repositioning is not required as frequently or at all.
This is a silicone handle that can be added to many cups. It offers the user a slot for the hand to fit to prevent the cup from slipping out of the hands. This can be important for kiddos who have difficulty molding one of the hands around the cup. Consider dual handle cups for difficulties with both hands.
The cup is not weighted, the device inside the cup is weighed and moves to different angles so that kids to tip a straw cup back can still be successful drinking.
This spoon has ridges that offer the child more oral awareness during feeding. The spoon is smooth at the top and has a shallow bowl so that weak lips can still clean the spoon.
The real benefit to this oral stimulator for speech and feeding is that it helps provide tactile clues and sensory awareness for the mouth, which may decrease food aversions and sensitivities.
This cup has a recessed lid with 3 small dots to promote learning open cup drinking with a manageable flow speed for new learners. The 2 handles make it easy for young children to hold. It aids in developing oral-motor skills like tongue retraction and lip rounding.
There are a variety of different suction plates and bowls on the market, and some are great. My favorites are the BABELIO shown here and the EZPZ brands. I have literally lifted a table trying to lift this plate up.
This is a recessed lid with small holds all around the recess to allow the liquid to go through and limits flow speed to prevent the child from getting overwhelmed when learning. It is used to teach open cup drinking. One of my favorite training cups.
This special feeding bottle controls flow speed depending on orientation in the baby's mouth. The white disc (one way valve) and requires priming. This bottle doesn't require sucking, compression of the nipple makes it work. This bottle doesn't build up a vacuum and has a constant flow when the nipple is compressed. The nipple opening whe
This special feeding bottle controls flow speed depending on orientation in the baby's mouth. The white disc (one way valve) and requires priming. This bottle doesn't require sucking, compression of the nipple makes it work. This bottle doesn't build up a vacuum and has a constant flow when the nipple is compressed. The nipple opening when not compressed will close to allow the infant time to take a breath without leaking and causing choking. Make sure to use the right size nipple for the size mouth eating.
This special feeding bottle has an insert (one way valve) and requires priming. This bottle doesn't require sucking, compression of the nipple makes it work. This bottle doesn't build up a vacuum and has a constant flow when the nipple is compressed.
The Pigeon nipple with one-way valve works by compression only. No squeezing is needed. The baby controls the flow of milk. The nipple has a firm side that goes against your baby’s gum line and a softer side that goes on their tongue. A small notch near the rim of the nipple serves as an air vent. This notch should be under your baby's no
The Pigeon nipple with one-way valve works by compression only. No squeezing is needed. The baby controls the flow of milk. The nipple has a firm side that goes against your baby’s gum line and a softer side that goes on their tongue. A small notch near the rim of the nipple serves as an air vent. This notch should be under your baby's nose when feeding. This puts the nipple correctly in your baby’s mouth.
Tightening the nipple slows the flow of milk. Loosening it makes the flow faster.
This is a low-cost alternative for feeding babies with cleft lip and palate that is squeezable.
Assessment: Practitioners are constantly assessing and monitoring beyond the phase of eligibility. This part of recommended practice drives intervention. There are so many components to consider when there are feeding and swallowing challenges and it hits every domain of development and should include their strengths, needs, preferences and interests. You are not only assessing the child, but the caregivers who support the child with this routine.
1. Practitioners who are responsible for supporting families with mealtime or feeding/swallowing challenges should have adequate knowledge of this area since the impacts of your support and strategies offered could have consequential impacts. Get educated and know your limits. Make referrals to other team members when appropriate.
2. Not only should the assessment be in the family's dominant language, but it should be in consideration of their cultural practices.
3. The practitioner should use a variety of methods to gain information about the child including standardized testing, but also observation and interview. It should consider the equipment, daily routines/activities, and environments in which mealtimes occur.
4. Since assessment is an ongoing process, the means by which we determine progress should be sensitive to even the smallest improvements that can be identified to the caregivers.
Environment: Children and families eat in a variety of places in the home and out in the community. Children may be cared for by a variety of different caregivers with different learning styles and capacities. Environmental practices include the aspects of space, materials, equipment, routines, and activities that practitioners and families can alter to support the child's learning.
1. The physical environment-space, equipment and materials.
2. The social environment-interactions with peers, siblings and family members.
3. The temporal environment- the sequence of events and frequency and durations of aspects of mealtime.
4. Knowledge of how to adapt and manipulate these environments is a critical component of your intervention.
5. Knowledge of what assistive technology is available to support the child/family and how to go about obtaining the devices needed are imperative.
Family: This area refers to our ability to promote active participation both from the child and from the family, encouraging the child and family to be involved in decision making with respect to mealtimes so that as service plans are developed it incorporates the goals and objectives important to the family.
1. Family centered practice that is individualized, flexible, and responsive to each child and family's needs is what we should strive to achieve.
2. Our job is to be building up a child's capacity to become autonomous and independent with feeding and the family's capacity to support the child to meet the established goals and objectives centered around mealtime.
3. The goal is to build a relationship with the child and family centered around mealtimes through competent and research-based support and through respectful partnerships through interactions that are "sensitive and responsive to culture, language, and socio-economic diversity".
4. Practitioners should offer feedback in a way that is constructive and that is in a manner they can understand by supporting individual learning styles so that their skills and knowledge are strengthened and improves child and caregiver competence around mealtimes.
5. Practitioners advocate for the child/family and support them with learning their rights as it pertains to mealtimes in settings such as daycare where accommodations may be required for optimal functioning and safety with feeding/swallowing.
Interaction: Responsiveness and sensitivity is what we are stiving to support here. The manner in which we interact will foster the child and family's feeling of competence in meeting the child's outcomes.
1. The way we interact with the child and family will facilitate social-emotional development. The goal is for the child and family to initiate and sustain positive interactions during daily routines like mealtimes through modeling, teaching, feedback, and other types of guided support.
2. Interventionists should promote communication by observing, interpreting, and responding to requests, needs, preferences and interests. We can also help them learn natural consequences for their own verbal and non-verbal communication at mealtimes.
3. When working with families at mealtimes we should support the child and family with probem-solving behavior by scaffolding the toward successful outcomes to build autonomy.
Instruction: DEC views this as the cornerstone of early intervention.
Teaming and Collaboration: The best work is done with a team and how these interactions and collaborations occur will drive success. Teaming and collaboration practices are necessary to see all sides of a challenge. The goal is to remain respectful and supportive to enhance capacity while being culturally mindful.
1. Mealtime affects all sensory systems and may necessitate utilizing the expertise of other team members. These may include Occupational Therapy, Physical Therapy, Speech Language Pathology, medical doctors, nurses, parents, medical supply professionals, etc.
2. Professionals, interventionists and caregivers should work jointly to achieve goals. This may mean reaching out to on another to communicate and learn from one another.
Transition: The goal for this component is for the child and/or family to be able to utilize the skills realized in different environments and in new places of service (home to daycare or Early Intervention to school-based services). A constant struggle is recognizing that a child has to be able to function in new locations and with new support people throughout many times in their lives. Interventionists need to be mindful of this and prepare the family for how this will impact the child so that there can be well thought out and successful adjustments. My concern always for children who struggle with intake in their "safe" environments is how thy will function when they go to school and are in new locations with new people, challenging environments and with new expectations.
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