Changing Colors: The Blog of Spectrum Pediatrics

October 20, 2017

Spectrum at NPC-QIC: Lessons from a Tube-Weaning Program

Our wonderful feeding therapist and clinical coordinator of our Tube Weaning Program, Heidi Moreland, is presenting at the National Pediatric Cardiology Quality Improvement Collaboration conference in Chicago this weekend. Throughout this presentation, Heidi discusses the philosophy behind Spectrum Pediatrics tube-weaning program and provides a glimpse into what the program looks like for children and their families!

Check out Heidi’s presentation here along with helpful resources for the tube-weaning program:

References for Spectrum Pediatrics Treatment Program

Spectrum at NPC QIC Presentation

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October 4, 2017

How does Responsive Parenting Apply to Feeding?

By: Heidi Moreland, MS, CCC-SLP, BCS-S, CLC

The mealtime relationship is extremely dynamic and should evolve over time. In the beginning, the parent’s role is more permissive and supportive with food. Children are allowed to explore and branch out. This allows their tentative interests to develop and stabilize. However, we have found that being too permissive can actually lead to pickier eating and more mealtime “stand-offs,” and even impact weight gain. We also know that being too authoritative or involved can also lead to refusals and difficulty with self-regulation.

We realize this is a hard line to walk. Here are a few thoughts to help with this process.

• The child should be comfortable with saying “no” to foods if they aren’t hungry or don’t feel safe, without fear of reprisal.

  • Learning that they are loved despite the fact that they said “no” is extremely important. However, it doesn’t mean that they shouldn’t experience the consequences of “no,” such as being hungry.
  • They may show interest or refusal in a variety of ways that will change over time. You will need to pay attention now and as they mature.
  • If the child is consistently refusing, the adult may need to re-consider the environment or expectations, so that they are both appropriate and achievable.

• The adult should also be comfortable with saying “no” to behaviors and requests

  • If the situation isn’t safe, it is always appropriate for you to set limits. Playing with knives, standing on the table, or eating non-food are clear examples of appropriate limits. There are others that are less clear, but still important. Eating only at the table is a tricky one, but if that is the rule, it is important to reinforce it.
  • As hunger and trust are more established, mealtime expectations should begin to line up with expectations outside of meals. Ask yourself, “what would I do if this wasn’t food?”
  • There are very valuable lessons that children learn from consequences. Protecting them from consequences of “no” by always setting up the situation so the answer is “yes” deprives the children of learning important lessons. ▪ For example, getting the child to eat every day by only serving highly preferred foods deprives the child of learning the feeling of hunger, as well as the possibility that some new foods are good.

• Just as you wouldn’t expect an infant to drive a car or read a book, you would be disappointed if your teenager waited for you to change their clothes or put food in their mouths. It is appropriate to change your expectations as children mature.

  • If your child is a new or hesitant eater, their abilities with food may look different than their abilities in other areas.
  • Until their trust of food and eating becomes more stable, you may have different sets of expectations for food and for other areas, but it helps to be aware of the discrepancy and make very small steps to make them more similar.
  • If a behavior is new and fragile, it needs more support. Taste, variety, volume, texture, situation, etc., may time to stabilize.
  • Once a behavior is more established, parents and caregivers can begin to shape it or incorporate it into an expectation. For example, in the beginning, the “eating only at the table” rule, may be suspended, but once that behavior is more stable, eating at the table should be consistent and not open to negotiation except for special circumstances.
  • Patterns of interest and response will help you make future choices and determine when your child is ready for the next step.

Source 1

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Darling, N., & Steinberg, L. (1993). Parenting style as context: An integrative model. Psychological bulletin, 113(3), 487.

Hughes, S. O., Power, T. G., Fisher, J. O., Mueller, S., & Nicklas, T. A. (2005). Revisiting a neglected construct: parenting styles in a child-feeding context.Appetite, 44(1), 83-92.

Landry, S. H., Smith, K. E., & Swank, P. R. (2006). Responsive parenting: establishing early foundations for social, communication, and independent problem-solving skills. Developmental psychology, 42(4), 627.

August 23, 2017

Trick of the Trade from Tracy Magee,M.Ed., CCC-SLP

Visuals for Toddlers in Their Everyday Lives

All people benefit from visuals. Just think of how your daily planner or agenda helps you feel less anxious about your day if you can see all that needs to get done. Toddlers are no different than adults. Visuals aid them in feeling calmer about what is ahead, particularly since they may not understand all the language adults are using. Here are two visuals that I find helpful with the toddlers:

1. Visual schedules: Visual schedules can be cumbersome, but they don’t have to be. Pick a few categories that can give your child a general idea of the activities depicted. An example would be: 1. Breakfast 2. Bathroom (represents shower, brushing teeth, etc.) 3. Play 4. Snack 5. Park 6. Nap

Visual schedules can be used for a whole day, part of a day, or just an activity. Kids feel a sense of accomplishment when they take off the sticker card for each activity and “complete” the task. It’s a win-win for the child and the parent!

2. Sand Timers: I have been using sand timers for quite some time with the kids I work with and my own kids. We use it as a visual way to give kids an idea of time. My own children try to “beat the clock (sand timer)” when cleaning up their toys at night. I also use it before we are about to leave the house. I will put out a three minute sand timer to mentally prepare them for the upcoming transition. A parent could just use words, but the visual of seeing how much sand is left is so much more powerful to a toddler. You can order sand timers here ) or check out a local teacher-resource store.

Check out our post on SoundingBoard, a great app for visual schedules here. We also shared a favorite visual timer app that all of our therapists love! Check it out here!

August 23, 2017

What is Responsive Feeding?

By: Heidi Moreland, MS, CCC-SLP, BCS-S, CLC

Responsive Feeding: Mealtime guidance that depends upon the feeder’s ability to read the eater’s cues in order to make the meal manageable, enjoyable and successful for the eater, without giving up developmentally appropriate structure and expectations.

Every parent has a parenting style which is formed by their own personality, the way their own parents interacted with them, the community in which they live, and how the child’s personality responds and interacts to that style. Their interactions are characterized in part by how they respond to their kids and their views on how to set limits, with some parents leaning more towards being more permissive, others towards being more authoritarian.

The truth is that both responsiveness and limits are important. Responsive parenting includes a balance between being the authority, while still recognizing their children’s cues and responding positively to them. Parents acknowledge the child’s needs and desires, and may provide developmentally appropriate reasons for the rules, but have high expectations for their kids and expect that rules will be followed. Research has shown that kids of responsive (also called “authoritative”) parents have higher levels of attachment, are more secure and have more self-control.

This role evolves over time. When children are infants, the parents’ primary job is to notice the child’s needs by responding promptly. However, in order to mature past the demanding nature of infancy, children need to develop the ability to safely and successfully interact with a changing world independently. This means that parents can’t just respond to the child’s needs and expect them to mature, they must also teach their child to cope with stress and novelty (Landry, Smith, and Swank, 2006) by allowing them opportunities to be independent, even if they struggle a little. This should look different for each child and family, and your expectations should change over time as your child matures, but it will continue to follow the same process.

This style of parenting seems to work well for developing healthy eaters. Most research that looks at parenting style and eating finds that kids of responsive (authoritative) parents are more likely to develop self-regulation, be less picky, and have less food battles than parents of authoritarian or permissive styles.

Most parents do this naturally in many areas, but struggle with applying this to the mealtime relationship. Check in next week for a little bit more on how this applies to feeding and the mealtime relationship.

Sources:

Darling, N., & Steinberg, L. (1993). Parenting style as context: An integrative model. Psychological bulletin, 113(3), 487.

Hughes, S. O., Power, T. G., Fisher, J. O., Mueller, S., & Nicklas, T. A. (2005). Revisiting a neglected construct: parenting styles in a child-feeding context.Appetite, 44(1), 83-92.

Landry, S. H., Smith, K. E., & Swank, P. R. (2006). Responsive parenting: establishing early foundations for social, communication, and independent problem-solving skills. Developmental psychology, 42(4), 627.

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August 21, 2017

Back to School Time

By: Tracy Magee,M.Ed., CCC-SLP

It is nearing the end of the summer, and we all know what that means…school is going to be back in session soon! If your child is going to a new school this Fall, here are some ways to make sure they feel comfortable before the first day arrives.

1. Go to the school’s playground NOW – If your child is in preschool or elementary school, take him/her to the playground a few times before the school year starts. This will get your child familiar with the school grounds and play equipment in a low-stress setting with a trusted person (You!). This will make it easier to navigate the school grounds the first few days because the child will already feel like the area is familiar and safe.

2. Attend school functions – Does your school have an Open House day to meet new teachers and tour the school? Be sure to take advantage of this opportunity if it is offered! Attending any pre-season games is also a great way to meet people and familiarize your child with the school grounds.

3. Talk about it! – Make sure that you are talking often with your child about the big changes coming up. Discuss what a typical day will look like, and maybe even brainstorm with your child what to do if something doesn’t go quite as planned. Preparation is always a good idea, and it makes everyone feel more at ease with big transitions, like a new school.

Every student is going to be nervous on their first day at a new school, but hopefully, we, as parents, can help calm those nerves as much as we can by using a few of the strategies above. Wishing everyone a great start to their school year!

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August 18, 2017

Feeding Friday: Tube-Free Superstar Rusty

Rusty was born full term, yet had many complications during his hospital stay such as noisy breathing, poor feeding, and poor growth. Rusty was initially breast fed, but due to difficulty with weight gain, Rusty received an NG tube for primary nutrition at 1 month old due to concerns of aspiration. Rusty then was diagnosed with significant retrognathia and has mandibular distraction surgery in July at 2 months old. Although his breathing improved, Rusty continued to have difficulty with feeding. While at home, Rusty’s parents continued with tastes of puree and allowed Rusty to explore with solid foods through the baby-led weaning approach. Although Rusty did well with eating for a few weeks, his parents observed more crying and refusing feedings. His oral intake dropped and he again had difficulty with weight gain. Rusty received a G-tube in September when he was 4 months old. After this G-tube placement, Rusty would take a few bites from the spoon, but relied 100% on his tube for nutrition and hydration. During the time prior to the tube wean, Rusty was diagnosed with DiGeorge Syndrome, also known as 22q syndrome. He underwent brainstem decompression surgery at 7 months old.

Following multiple failed attempts to increase oral feedings via different methods, Rusty’s family decided to do a supported tube-wean. His journey started at 9 months old with the team at Spectrum Pediatrics at the Virginia location. Due to Rusty’s history with aspiration, his swallowing was closely monitored and the first few days of treatment focused on allowing Rusty time to explore and demonstrate interest in food. Rusty’s parents describe him as a generally happy baby and he could not have been happier to be in a new place and meet new friends! Rusty initially showed interest in pouches and reaching for foods that his parents were eating such as crackers and bananas. Rusty quickly learned to love to eat oatmeal for breakfast while his mom spoon-fed him. Rusty also demonstrated a need for independence, he loved to munch on puffs, cheese crunchies, and strawberries. Rusty quickly learned how to drink independently from a pouch and eventually a straw cup with milkshakes and smoothies!

Rusty also started to enjoy home made meals that his parents ate as well, such as Dad’s butternut squash soup! Rusty slowly started to trust food and learn how great it made him feel! Rusty was eating enough by day 4 of treatment to discontinue his tube use. Rusty worked very hard to learn how to finger feed himself, drink through different cups, and swallow purees and liquids. Rusty started to show clear cues to his parents during mealtimes such as pushing away the food when he was all done and reaching for his cup or the bowl when he wanted more.

During his transition home, Rusty was happy to be back having mealtimes with his older brother. Rusty quickly learned to eat various foods and became a more competent and confident eater. Rusty started to learn what he needed to make him feel good, as he continued to learn how to crawl, cruise around, and take a few steps independently. Rusty now loves grilled cheese, kielbasa, meatloaf, roasted broccoli, peanut butter toast, and smoothies! These are just a few of Rusty’s favorite foods, but he loves a wide variety of food now. During the past summer months, his family learned that he loves to eat ice cream straight from the cone and strawberries straight from the patch!

 

Rusty recently had his G-tube removed. We are so proud of Rusty and all of the things he has accomplished! Congratulations Rusty on being a tube-free superstar!

Photos provided by Rusty’s family.

August 11, 2017

Feeding Friday: Tube-Free Superstar Caden

Caden was born 37.5 weeks, with a birth weight of 6 lbs., 4 oz and was a described as a “fighter from birth” by his family. He had an extended hospital stay following a heart surgery and respiratory complications. He had significant reflux, and received his G-tube prior to discharge home at almost 2 months of age. By the time he was discharged home, he was not sucking and there was concern that any oral feeding attempts were burning additional calories. Caden’s family worked very hard over the course of the next few months to get him to eat and drink by mouth as his medical status stabilized. He would take small sips or bites of foods while distracted or tricked, showing his family he was capable however; he eventually stopped eating all foods he previously showed interest in.

Following multiple failed attempts to increase oral feedings via different methods Caden’s family decided to do a supported tube-wean. His journey started at 10-months old with the team at Spectrum Pediatrics at the Virginia location. On the first few days of treatment, the focus was to give Caden space to explore and initiate eating while his family decreased pressure to eat. Caden showed increased interest in some foods he ate previously like his grandmothers meatloaf by eating small bites and picking pieces up to throw them on the floor. Caden was curious but unsure about food during the first few days of treatment. He slowly became more comfortable putting more pieces in his mouth instead of the on floor but was very reluctant to allow his family to help him. To his families surprise he soon started enjoying milk at meals too! At first, he let a lot of the milk fall out of his mouth but eventually he used his straw cup with greater efficiency to swallow liquids and keep his clothes dry. By day 5 of treatment, he was drinking enough milk and taking small amounts of purees and solids to discontinue his tube use. Eventually, he began drinking yogurt pouches and found a new love for fettuccini and alfredo sauce. Caden worked hard learning how to use his hands to get enough food in his mouth eventually allowing his family to help him with a spoon too! He started to communicate at mealtimes by using reaching, new sounds, and screams to get what he wanted. He also got much better at letting his family know he was finished at a meal. In the weeks following he continued to build his skills and became very fast at eating his favorite foods.

Now just a few months after his 10 day intensive treatment, Caden loves mini pancakes, alfredo (of course), chia pudding, veggie straws, oreo cookies, and trying to steal whatever his older brother is eating. His favorite activities are dancing to “Hand Clap” by Fitz and the Tantrums, playing with Tupperware containers, climbing everything, and yelling “mamamamamama!”

Caden celebrated his first birthday, learned how to walk, and was able to get his G-tube removed. We are so proud of Caden and all the things he has accomplished, he is a tube-free superstar for sure!

Photos provided by Caden’s wonderful family!

July 23, 2017

Feeding Friday: The Impact of Unwanted Guests

By: Heidi Moreland, MS, CCC-SLP, BCS-S, CLC

Do these personalities show up at your family table?

It is important to interact with your child at the table and respond to their attempts to communicate.  However, if you are always trying to “push” food and eating, you are probably having the opposite effect than what you hope.  Despite your good intentions, pressure can turn you and your mealtime into an endurance event for you and your child, which is unpleasant for everyone present.

  • The Mafia – Force feeding with a smile
  • The Rodeo Clown – Offering a distraction for every bite so they don’t notice what you are really doing
  • Pushy Waiter – Hovering over the meal
  • Papparazzi – Cheering and taking pictures with every bite
  • The Voice-Over Narrator – Self-talking every bite in hopes of drawing attention to eating
  • Home shopping Network Salesperson – Always displaying and showing food, utensils and plates, hoping that your child will suddenly want one.
  • Used Car Salesman – Talking only about food, the benefits of food, the tastiness of every bite.
  • Human Calculator (or actual calculator) – Keeping track of every single bite, gram and calorie.
  • Perfectionist – failing to recognize and be satisfied with small attempts such as touching or tasting because they aren’t as big or as varied or as frequent as hoped.
  • Bad First Date - Going straight to the mouth with the spoon without allowing an  “introductory period”
  • Bad Date. Always.   - Continuing to pressure after a child says (or communicates) “No.”

Do any of these look like your alter ego, or is there someone else in your child’s life who has a tendency to take on one of these personalities? Picture what you would do and feel if you were seated next to one of these people at a dinner or event.  What would your response be?

 

July 23, 2017

Trick of the Trade from Tracy Magee,M.Ed., CCC-SLP

Behavior Strategies

I have recently been learning some of the behavior philosophies of Dr. Harvey Karp. He is the man behind the successful books, Happiest Baby on the Block and Happiest Toddler on the Block. A few of his strategies for dealing with toddler meltdowns were brand new to me, and I thought they might be good to share with others, too! Here are some of his ideas about how to cope with toddler tantrums:

1. “The Fast Food Rule:” Karp suggests that before you can help another person move on from something that is upsetting, you need to acknowledge that the child is upset. You can do this by repeating back the child’s “order” to him/her. This makes the child feel heard and his/her feelings are validated. It is important that the parent use short sentences and the same emotions as the child. Karp models what this looks like by stamping his foot and saying, “I want the bus! I want the bus! I want the bus!”

2. “Feed the Meter:” This idea from Karp suggests that we all need to hear praise from others (i.e. “feed” our ego meter). He also brings up the point that everyone enjoys overhearing this praise from others. We all would love to overhear our boss singing our praises to another boss. Karp says that toddlers are no different. He states that one adult should cup their hand, as if whispering, to another adult to give the toddler praise. This way, the child thinks he/she is overhearing the compliments about his/her behavior. Karp believes this praise is very effective in continuing that positive behavior, and it may even be more effective than praising the child directly.

These are just a few ideas from Dr. Karp, but I have found them to be very beneficial with toddlers I am working with lately. It has also been a success with my own two year old at home!

If you want to learn more about Dr. Karp’s behavior ideas, you can find his book HERE and his website HERE.

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July 12, 2017

Trick of the Trade from Jamie Hinchey, M.S., CCC-SLP

DIY Kitchen

There are many different play kitchen sets on the market today for young children. As a speech therapist, I often see children in their home where there may be limited space. I recently had a family share with me their version of a Do-It-Yourself kitchen to help save space. Pretend play is such an important part of development, it is crucial that your child has the ability to use their cognitive and play skills to engage in activities such as pretending to clean, cook, or copy what they may see you do around the house. To create this DIY kitchen you need two things: a plastic  container (size may vary) and a sharpie marker. On the top of the plastic container, this parent chose to draw a stove, similar to the one they had at home. You can customize this kitchen to look like your stove or oven so your child is familiar with it.

To help with storage of all of the various “kitchen toys”, the container opens up and is able to fit all of the accessories, even while fitting under the bed! In this version, there are toy pots, pans, and utensils. Feel free to use your own pots or pans that may be in your kitchen. This DIY kitchen would also be a great way to work on safety directions and helping your child recognize what is “safe”. For example, you could use the pretend stove to work on what it means for something to be “hot” or what it looks like when the stove is on or off. I hope you enjoy this DIY kitchen as much as this family does! Time to get cooking!

Picture credit from one of our Spectrum families who created their own kitchen!