Alison Spurr

August 2014

Play Picnics as a Solution for Fussy Eaters

o Normal Development Food continuum Role of sensory skills

Problem Feeders – Prevalence Data Picky Eaters vs Problem Feeders

Feeding Therapy Play Picnics SOS Approach

OUTLINE OF PRESENTATION

NORMAL FEEDING DEVELOPMENT

DEVELOPMENTAL FOOD CONTINUUM

Breast/bottle 0-12 months

Thin Baby food cereals 5 months

Thicker Baby food cereals 6- 7

monthsand purees

Soft Mashed Table Foods 8 months

DEVELOPMENTAL FOOD CONTINUUM

Hard Munchables 8 months

Dissolvable Hard Solids 9 months

Soft Cubes 10 months

Soft Mashed Table Foods 11 months

Soft Table Foods 12-14 months

Hard Mechanicals 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 % Major Feeding Issues

GERD 51 Food refusal

Neurological 30 Oral/dysphagia

Cardiopulmonary 27 dysphagia

Food allergy/intol 21 selectivity

Constipation 15

Diarrhea 6

Anatomical anomal 6 oral motor

Delayed emptying 4

Renal Disease 3

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 Problem FeedersDecreased range/variety of foods but Restricted range or variety of foods, usually

will eat > 30 foods <20 foods

Foods lost due to “burn out” usually 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 Problem Feeders

Adds new foods to repertoire in 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 minutesChildren 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 # : FOOD: Apple puree

Biscuits Oranges Jelly Cordial          

  

TOLERATES

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 1                  

Tolerates food on plate or in personal space                    

 INTERACTS

Touches food with napkin/utensil       1            

Touches food with another food                    

   

TOUCHES

Touches food with 1 finger 2                  

Touches food with 2 or more fingers     1              

Touches food with whole hand                    

Picks up food to wave/tap/manipulate                    

Places food on back of hand, arm or shoulder                    

Puts food on chest, neck, head or ears                    

 SMELLS & MOUTH AREA

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                    

   

TASTES

Licks lips or teeth: Scant taste from lips or teeth                    

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     2              

 EATS

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

  1 2   2 1 2          

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’ 80-

90% of the time, if presented with new food Child is on growth curve in which child’s length-

weight 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 re-

gain 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 own structure at home Regularly attend Be 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