Autologous Gastro Intestinal
Reconstructive Surgery
CREATIVE CARE
Therapeutic & Specialised Play Service Study Day
Manchester, 30th September, 2014
Food aversion and Messy play
therapy
Mrs Sarah Wood (Consultant)
and
Miss Tracy Warburton (Health Play Specialist)
Tracy.warburton@cmft.nhs.uk
Sarah.wood@cmft.nhs.uk
Food aversion and Messy play in SBS
Objectives
• To describe food aversion with reference
to SBS
• To describe published literature
concerning weaning and food aversion
• To describe and experience messy play
• To discuss PABRRU experience
• Questions
Food aversion in SBS
‘excessive or extreme and consistently negative reaction or
oral fluids or diet interfering with normal nutritional
requirements’
Total or partial/ selective
Why?
 NBM/ dietary restriction – sepsis/ surgery/ management
plan
 ‘norms’
 NG – hypersensitivity (gag and sensation)
 Oromotor skills not developed (0-4 and 4-6months) (Illingworth
et al 1964)
 Suppression of appetite
 Dislike of messiness
Food aversion and weaning
• Multidisciplinary
• Rapid weaning with starvation + Intensive therapy
(Wilken et al
2013)
• Trabi
describes starvation + food/ play picnic
• Behavioural manipulation/ parental treatment (Gutentag et al 2000,
(2010)
Williams et al 2007, Byers et al 2003)
• Messy Play
Why?
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Reduce cholestasis
Encourage adaptation
Reduce overgrowth
Social integration
Maternal identity and reduction of PTSD (Wilken 2012)
Cost less (Williams 2007)
Food aversion and Messy play
A Holistic Approach
 For many of our children with Short Bowel Syndrome,
the first year of life can be physically and emotionally
challenging, for both the child and the family.
 From birth, babies often endure many medical and
surgical interventions requiring long term hospitalisation,
this can continue for many years. The resulting impact
on the child and the family can be quite devastating.
 Holistic care is essential for these families to provide
not only medical and physical input but also emotional
support.
 This is where the role of The Healthcare Play Specialist
as part of a Multi-disciplinary Team comes into place.
Food aversion and Messy play
The Role of the Play Specialist
Initial intervention begins with a referral from the consultant
or Ward Manager.
On transfer from Neonatal Intensive Care Unit to Ward, Play
Specialist will introduce self to patient and family.
Liase with Physiotherapy and Occupational therapy sevices with
regard to developmental assessment and formulation of play
programs.
Liaise with the Speech and Language Therapy and Dietetic Team
regarding the introduction of oral diet and weaning.
Child accepting oral diet well
Continue to monitor progress with
the Multi-Disciplinary Team to
discharge
Child experiencing oral
defensiveness and or food
aversion
Formulate specific individual
messy-play feeding programs
Provide intervention and support
alongside the family. Notify MultiDisciplinary Team about progress.
Attend discharge planning meeting.
Short Bowel Clinic – continue support around overall
developmental progress including feeding, behaviour and
emotional Issues.
Continue liaison with Multi-disciplinary Team both in the
Trust and in the community regarding patient progression
and any other interventions required.
Food aversion and Messy play
Oralmotor programme
• Session 1: face/ facial features/
inside my mouth
• Session 2: Lips/ Teeth and
Tongue
He then cleaned the door.
Mr Tongue’s House
(Lick along the bottom lip and then
across the top lip slowly.)
Food aversion and messy play
Practicalities/ Case
Food aversion and Messy play
Sensory/ Texture programme
Sensory environment critical including sensations
of:
Sight
Taste
Touch
Texture
Smell and taste
Food aversion and Messy play
Sensory/ Texture programme
 Stroke and touch
 Peek a Boo
 Hide and Find
 Sensory Box
 Baby Massage
 Auditory play
Food aversion and Messy play
Sensory/ Texture programme
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Sensory Box
Filling and Pouring
Vegetable Printing
Collage (paper and dry foods)
Games with Pretend Food and Real Food
Making Necklaces
Egg Heads
Teddy’s Tea Party
Playdough Modelling
Dinosaur World/Swamp
Build a Model Village
Splatter/Finger Painting
Food aversion and messy play
Results/ demographics
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12 children (diagnosis <1month),1 dev delay
Gestation 26-36/40
Birth weight average1.87kg
Bowel length preop 37cm (average) by 27% to 42.5cm
(average)
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All safe oromotor skills
All receiving PN from diagnosis
Main enteral nutrition NG (7), gastrostomy (5)
4 fed orally from diagnosis
GROWTH VELOCITY UNAFFECTED
Food aversion and messy play
Feed tolerance
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Commenced messy play 4-52 months (27)
Duration 3-17 months (10)
1/12 inpatient alone
All tolerating bland (cat a) and liquid diet (cat 1) pre
therapy. 7 tolerating puree (cat 2)
Post therapy:
 100 % increase in mashed/ roughly mashed/ food
with separate and hard lumps (Cat 3,4,5,7)
 11/12 increased mixed texture food (p=0.001)
 Increased tolerance to savoury (p=0.001) and sweet
food (p=0.002)
Food aversion and messy play
Conclusion
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Fun
Creative
Individualised and holistic
Involves family
Does NOT involve starvation
Can be delivered as in/outpatient
multidisciplinary
Success between 83-100%
References
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Byars KC, Burklow KA, Ferguson K, O’Flahert T, Santoro K, Kaul A. (2003) A
multicomponent behavioural program for oral aversion in children dependent on
gastrostomy feedings. J Pediatr Gastroenterol Nutr 37 (4): 473-80
Illingworth RS, Lister J. (1964) The critical or sensitive period, with special reference
to certain feeding problems in infants and children. J Pediatr 65(6): 839-848
Gutentag S, Hammer D. (2000) Shaping oral feeding in a gastrostomy tubedependent child in natural settings. Behaviour Modification 24(3): 395-410
McCurtin A. (2007) The Fun with Food Programme. Speechmark publishing ltd
(Milton Keynes)
Trabi T, Dunitz-scheer M, Kratky E, Beckenbach H, Scheer PJ. (2010) Inpatient tube
weaning in children with long term ffeing tube depenecy: A retrospective analysis.
Infant mental health journal 31 (6): 664-681
Wilken M, Cremer V, Berry J, Bartmann P. (2013) Rapide home-based weaning of
small children with feeding tube dependency: positive effects on feeding behaviour
without deceleration of growth. Arch Dis Child 98; 865-861
Wilken M. (2012) The impact of child tube feeding on maternal emotional state and
identity: A qualitative meta-analysis. J Ped Nurs 27: 248-255
Williams KE, Riegel K, Gibbons B, Field DG. (2007) Intensive Behaviourla Treatment
for sever feeding problems: A cost effective alternative to tube feeding? J Dev Phys
Disabil 19: 227-235