SPEECH PATHOLOGY INSERVICE Paediatric Ward Flinders

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Play Picnics as a Solution for Fussy Eaters
Alison Spurr
August 2014
OUTLINE OF PRESENTATION
o
Normal Development
Food continuum
 Role of sensory skills


Problem Feeders –
Prevalence Data
 Picky Eaters vs Problem Feeders


Feeding Therapy
Play Picnics
 SOS Approach

NORMAL FEEDING
DEVELOPMENT
DEVELOPMENTAL FOOD CONTINUUM
Breast/bottle

Thin Baby food cereals

Thicker Baby food cereals
0-12 months
5 months
6- 7 months
and purees

Soft Mashed Table Foods
8 months
DEVELOPMENTAL FOOD CONTINUUM
Hard Munchables

Dissolvable Hard Solids

Soft Cubes
8 months
9 months
10 months

Soft Mashed Table Foods

Soft Table Foods

Hard Mechanicals
11 months
12-14 months
16-18 months
DEVELOPMENTAL FOOD CONTINUUM

The developmental progression in learning to eat
various food textures requires advancing BOTH
oral-motor functioning and sensory processing
Taste
Balance
 Smell
Proprioception
 Sight
Interoception
 Sound
 Touch
Sensory processing requires the ability to take in
information from all of the senses, process that
information and then produce an adaptive response.

Eating is the most difficult
sensory task that children
do
SENSORY MEAL

Eyes – visual information changes with every bite
and every chew

Smell – closely linked with preferences

Touch- fingers, mouth ,tongue, internal

Taste – pre, during and after swallow

Sound – crunching, slurping etc.
Causes of Feeding Problems
FIELD, D., GARLAND, M. & WILLIAMS, K
(2003) N = 349 CHILDREN
Medical diagnosis
GERD
Neurological
Cardiopulmonary
Food allergy/intol
Constipation
Diarrhea
Anatomical anomal
Delayed emptying
Renal Disease
%
51
30
27
21
15
6
6
4
3
Major Feeding Issues
Food refusal
Oral/dysphagia
dysphagia
selectivity
oral motor
ARE FEEDING PROBLEMS CAUSED BY
PARENTS?
Gueron-Seal et al. (2011)
 N=55, ages 1-3 years, mean = 2 years
 27 children in the feeding disorders group
 28 children in the control group (Matched by age,
gender, birth order, maternal education)
 “having a child with a feeding disorder puts the
mother-child relationship at risk for more negative
feeding interactions” p833
 more intrusive and less structured
 The more worried a Mother was about her child’s
weight, the more her interactions with her child at
mealtimes were impacted

Are Feeding Problems Caused by
Environment?

Pridham et. al (2001)





47 full-term; 52 preterm infants
Videotaped at 1, 4, 8 and 12 months
Looking at Mother’s working model of feeding her child,
along with Mother’s positive affect, sensitivity and
responsiveness.
As the child’s weight became less deviant, a Mother’s
feeding affect and behaviour BECAME more positive
There were NO significant associations with Mother’s
symptoms of depression in either group or across afes
on the Mother’s feeding affect of behaviour
WHAT DOES A FEEDING
PROBLEM LOOK LIKE?
EDMOND ET AL(2010) FEEDING SYMPTOMS,
DIETARY PATTERNS, AND GROWTH IN YOUNG
CHILDREN WITH AUTISM SPECTRUM
DISORDERS, PAEDIATRICS, 126, 337-342
Avon Longitudinal Study of Parents and Children in
England
 14,062 live births: 13,971 survived to age 5 years
 Food Frequency questionnaires at 6, 15, 24, 38 and
54 months of age
 Content of diet assessed at 38 months
 Weighed and measured at 7 years of age

PICKY EATERS VS PROBLEM FEEDERS

Picky Eaters
Decreased range/variety of foods but
will eat > 30 foods
Foods lost due to “burn out” usually
Problem Feeders
Restricted range or variety of foods, usually
<20 foods
foods lost are NOT re-acquired
regained after 2 weeks
Tolerates new foods on plate and
cries/tantrums with new foods
usually can touch or taste them
Eats > 1 food from most all food
refuses entire categories of food textures or
texture groups or nutrition groups
nutrition groups
PICKY EATERS VS PROBLEM FEEDERS

Picky Eaters
Adds new foods to repertoire in
Problem Feeders
Adds new foods in > 25 steps
15-25 steps
Typically eats with family, but frequently
Usually eats different foods than family and
eats different foods than family
often eats alone
Sometimes reported as “picky eater”
Persistently reported as “picky eater” across
at well child checks
multiple well child checks
Parental Practices for Problem feeders
Force feeding – associated with lower child weight
status in both cross-sectional and prospective
studies (Farrow & Blissett, 2008; Keller, Pietrobelli,
Johnson, & Faith, 2006)
 Distraction feeding – using toys, TV, and movies,
and feed while child is distracted
 Use food as a reward
 Punishment feeding – taking rewards, toys away for
poor feeding
*Parents do what they are doing because it works for
them on some level

FEEDING THERAPY
Play Picnics
 SOS
 Applied Behavioural Analysis (Behavioural
modification)
 Inpatient Intensive Fussy feeding
 Tube Weaning

Graz
 Inpatient tube wean
 Day patient program

Unfortunately limited studies comparing different
approaches to feeding therapy especially post
discharge.
PLAY PICNICS – PRIMARY GOALS

Allow the child to lead, regain control and
enjoyment of the feeding process

To teach parents to allow the child to lead in feeding
(and other areas)

To promote the child’s curiosity in food by providing
positive, non threatening, oral experiences. This,
along with hunger, will provide internal motivation to
eat and drink.
PLAY PICNICS - SECONDARY GOALS

Promote a positive carer-child relationship
developing attachment,
 giving child better emotional health and
 relationship building skills.


Reduce the severity of feeding problem.

Increase the parent’s capacity to cope with child
with severe feeding problems, due to both the
treatment and the opportunity to meet other parents
with issues in common.
PLAY PICNICS - INCLUSION CRITERIA
Age between 8 months to 18 months.
 Safe swallow for some type of oral intake
 Must have primary carer attend each time.
 Capable of self feeding- gross motor skills to
access food/ fluid in exploration. Parent can then
hold/support as necessary.
 If tube fed: Tolerating bolus feeds during the day,
ideally at minimum of 3 hours apart. (ie child has
sense of hunger)

PLAY PICNICS - EXCLUSION CRITERIA

NBM or high aspiration risk

Infection

Parents who can not commit to attendance

Carefully watch and plan for Food Allergies
FACILITATOR’S ROLES
Coach parent re cue reading – child’s sensory
preferences, aversion, preferences, enjoyment
 Select oral experiences/ available options for
children- foods, textures, equipment.
 Look at oral defensiveness, oral hypersensitivity,
coordination and strength of oromotor movements
and swallow strategies (?referral to SP).
 Look at positioning (?referral to PT).
 Look at sensory aversion (?referral to OT).
 Conduct pre and post assessments

PLAY PICNICS - PROCESS
Age and allergy appropriate food placed on clean
floor
 Children are placed on the floor with parents sitting
around the outside
 Parents are not to intervene unless there is a safety
issues
 Therapists provide support for parents and help
with learning to read their child’s cues

LET THE CHILDREN PLAY

Anything goes
Children define the rules
 All initiative is in the children’s hands


Nothing has to happen
No playing, just observing
 Not touching, just smelling
 Not eating, just playing
 No play picnic


It is the child’s choice
SOS approach
Sequential – Oral - Sensory
 Dr Kay Toomey and Dr Erin Ross

Designed to assess and address all the factors involved
in feeding difficulties (examines and treats the “whole”
child)
 Multi-disciplinary approach
 Based on normal development of feeding, accessing the
cognitive development of the child and play-based
therapy
 Systematic Desensitisation


The use of competing relaxation responses during exposure to
a graduated hierarchy of anxiety producing stimuli to help a
patient learn to overcome their fears.
SOS
Treatment of feeding problem is based on the belief
that the child is having a stress response because
they can not manage the task.
 Therefore we try to teach the skills in a manner that
respects the child’s readiness for the task
 There are 32 steps to food acceptance and children
are encouraged to move up the hierarchy one step
at a time
 If a child can not tolerate an exposure level, he/she
“signals” the therapist who drops back to a “safe”
level of interaction which allows the child to “relax”

STEPS TO EATING – 32 steps to food
acceptance
6 broad acceptance levels
Eating
Taste
Touch
Smells
Interacts with
Tolerates
FOOD PLAYGROUP GOALS
•
•
•
•
•
Learn to have positive experiences with food
Learn mealtime routines and cues to eating
Decrease resistance to touching, tasting and
swallowing food
Increase range of foods a child will try
Increase volume of food ingested
(SKILL DRIVES VOLUME)
Individual goals developed with
parental input
GROUP SCHEDULE
Sensory Preparation– 15 minutes
Children participate in ‘obstacle course’ for
sensory organization and body awareness
Children participate in sensory ‘calming’ singing
songs (for the older children parents leave the room
and watch behind a 1 way mirror)
** ENDORPHINS COUNTERACT ADRENALINE
- We want to avoid a fear response as adrenaline is
an appetite suppressant
STARTING ROUTINE
Every child washes & dries hands & face (tactile
exercise, hygiene, facial warm up, establishes routine)
then sits at table
 Blow bubbles: oro-motor exercise, endorphins,
reinforcement
 Given a damp face washer and “clean the table” also
use to wipe hands throughout session if needed
(routine, sensory organisation)
 Each child is passed plates and napkins (social
learning, turn taking, routine)
 Each child serves themselves from a plate/bag

FEEDING
Lead Therapist presents each food, one at a time
(may also be a supporting therapist in the room to
help and a therapist in the room with parents
providing education)
 Therapists model sequence of steps to accepting
new foods (begins with visual tolerance, interacting,
smelling, touching, tasting, eating)
 Children are positively reinforced for all levels of
interaction (imitation, touch, praise, clapping,
cheering, praise of others)

CHILDREN ARE NEVER FORCED TO EAT
FEEDING
Parents and staff use positive language i.e. “you
can” rather than “can you?” and “we” rather than
“don’t” i.e. ‘we sit in our chairs’ rather than ‘don’t
leave the table’
 Rule for food presented:
 1x meltable solid (i.e. green jelly)
 1x hard munchable (ie green apple slices)
 1x puree (apple puree)
 1x drink: (green cordial)

There should also be a: starch, protein, dairy, fruit/veg
at each group & foods need to be linked in some
way (i.e. colour, shape)
FEEDING
 A recording sheet is used to track where each child
enters (#1) and exits (#2) the steps to eating &
recorded for progress
SESSION # :
TOLERATES
FOOD:
Tolerates food in room
Tolerates food on OTHER side of table
Tolerates food at MIDDLE of table
Tolerates food on table JUST OUTSIDE their space
Apple
puree
Biscuits
Oranges
Jelly
Cordial
1
Tolerates food on plate or in personal space
INTERACTS
TOUCHES
SMELLS & MOUTH AREA
Touches food with napkin/utensil
Touches food with another food
Touches food with 1 finger
Touches food with 2 or more fingers
Touches food with whole hand
Picks up food to wave/tap/manipulate
Places food on back of hand, arm or shoulder
1
2
1
Puts food on chest, neck, head or ears
Brings food/liquids in close proximity to nose/mouth or
face (eg: smells, blow bubbles)
Puts food on chin, cheek, forehead or nose
Touches food to lips
Hold food in lips
Taps OR HOLDS food on teeth
Licks lips or teeth: Scant taste from lips or teeth
TASTES
Touches food with tip of tongue
Full tongue lick
Holds food piece INSIDE of mouth
Bites pressure/gnaws on food (creates no pieces)
Bites food, THEN spits of drools out ALL (no other
breakage or chewing of piece made with bite)
Bites food, breaks/chews it in mouth, spits ALL
EATS
2
Bites food, chews/manipulates it in mouth, THEN
swallows some OF THE BOLUS, spits rest
Bites food, chews it, swallows it ALL or takes puree
/liquid into mouth and swallows ALL
12
2
12
PACK UP
Leader signals “all done”
 Each child ‘kisses’ ‘blows’ 1 piece of each food in
bin (helps to move further up the hierarchy)
 All other material thrown away
 Wash the table with cloth
 Each child washes & dries hands
 Good bye song

DISCHARGE CRITERIA
30 different foods consistently in food repertoire
 Enters the Steps to Eating hierarchy at ‘tastes’ 8090% of the time, if presented with new food
 Child is on growth curve in which child’s lengthweight ratio is appropriate, and child has been able
to maintain growth on or above that curve for at
least 4-6 weeks
 Family no longer battles at most meals
 Prefer – at least one illness with weight loss and regain pattern seen in typically developing children

SOS STUDIES
Erin Creach, CCC-SLP (2006)
 N=10, age range=17-31 months
 7 meals with same 7 foods
 SOS style therapy
 Behavioural coding system
 Results

Signif increase in positive meal time behaviours
eg.smiling, vocailizing, interactions with caregivers
 Sig increase in food interaction eg. Touch, stir, pick up
 No sig difference in self-feeding
 Sig decrease in neg meal-time behaviours

SOS STUDIES
Own data from SOS clinic
 2000-2005 (internal audit)

Average for children transitioning off G tubes, who
entered Feeding Therapy with some oral intake = 12
months from start of treatment (depends on age and
step on eating hierarchy that child entered)
 *cost for 1 x per week therapy for 12 months = approx
$9500 for individual therapy and $4500 for groups


QLD study due out next year
LIMITATIONS OF SOS PROGRAM

Parents need to be committed
 Adapting
 Regularly
 Be
own structure at home
attend
able to learn ‘lessons’ in group

Time/staff intensive – 2 therapists, 2 assistants

Handouts
Scoring
Medical notes
Planning
Shopping
Liaising with other professionals involved in care





ABA
Used with ASD for multiple social behaviours
including teaching
 Child gets rewarded for eating/trying new foods –
food rewards, or toy rewards
 Williams, Field and Seiverling (2010)
 Reviewed 38 treatment studies of Food Refusal
from 1979-2008
 218 Children across 38 studies (average= 5.7
children)
 190 of 218 on supplemental tube feedings (87%)
 113 of 190 (59%) weaned from tube feedings by
study end = weeks to months depending on study

INPATIENT FUSSY FEEDING
Fay et al, (infants and young children, 9, 26-35,
1997)
 Study of 19 patients at Baylor Medical Centre with
NG and G tubes
 3 weeks inpatient


Issues
12 out of 19 successful (failures = premature, Developmental
delay and GORD)
 All children on pureed foods (no discussion about
developmentally appropriate foods)
 Cost for 3 week intensive stay = $33,000

TUBE WEANING PROGRAMS

Graz

Inpatient wean

Outpatient day service
EARLY REFERRAL =PREVENTION
Encouraging positive feeding relationships
 Ideas to provide pleasant oral experiences
 Assist in transition from tube to oral feeding
 Information about transitioning to solids

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