Changing Colors: The Blog of Spectrum Pediatrics

Posts Tagged ‘responsive feeding’

September 19, 2018

Tube Free Superstar: Meet Benji

Benji was born 41 weeks with no complications during pregnancy. Due to umbilical cord asphyxiation and meconium aspiration at birth, he went to the NICU. While there, Benji showed limited interest in eating and an inability to coordinate his suck, swallow, breathe reflex.  He stayed in the NICU for 25 days and transitioned home with an NG tube due to poor weight gain and continued food refusal. While at home, Benji’s parents attempted to feed him the bottle but he continued to be inconsistent. In July 2017, Benji received a G-tube. After having his G-tube placed, Benji’s parents worked hard on his feeding schedule and relationship with the bottle. His skills improved and there were some days that Benji did not need the tube.  Unfortunately,this did not last and Benji became aware of his pump and his oral aversion grew. Although Benji would eat around 2 oz purees with meals, he would gag on any other consistency and he regressed to only being interested in the bottle while drowsy or asleep. Prior to starting the program, Benji was receiving 75% of hydration via G-tube. Due to Benji’s strong aversion to the bottle, all of his bottle feeds were done while he was falling asleep or sleeping.

Benji’s family decided to do a supported tube-wean through Spectrum Pediatrics. Benji’s journey began at 12 months old with the team at Spectrum Pediatrics in his natural home environment in New York. Benji’s pediatrician worked closely with his therapist and family throughout his tube weaning journey. During the hunger induction period, Benji’s overall volume was reduced – allowing him to feel hunger and he began to show more interest in eating.  His parents observed that he seemed more interested in eating and being spoon fed. Benji began exhibiting signal cues for acceptance such as opening his mouth or reaching for the spoon. During the transition between hunger induction and intensive treatment, Benji’s dream feeds were dropped. Although formula was offered through the bottle, as well as other cups, while awake, Benji preferred to drink milk through a straw! During the first few days of intensive treatment, Benji’s interest in various purees and finger foods such as puffs or meltable solids grew tremendously. Benji began to show interest in cups that he saw his caregivers using and would accept a few sips from an open water bottle or cup. Benji’s oral motor skills continued to improve as he began feeding himself crackers and veggie straws, however he still wouldn’t accept the bottle.

Throughout the intensive portion of the program, Benji’s oral intake continued to increase as did his comfort with spoon feeding. Benji started to dip his own crackers or veggie straws into the puree to feed himself! When a straw cup was introduced, Benji required assistance at first, but within a few days, he was able to independently drink milk from his straw cup! Benji was consistently eating fruit and vegetable pouches, along with any type of cheese! We quickly learned that Benji loved mascarpone and ricotta cheese! Benji quickly started to increase his oral intake with liquids and solids and did not require his g-tube for any supplementation after the 8th day of intensive treatment. Over the course of 15 days including hunger induction and intensive treatment, Benji fully transitioned from being 75% dependent on his G-tube to becoming a 100% oral eater! Benji’s therapist and parents worked together to read his cues and identify what he was attempting to communicate as his body learned how to self-regulate. Benji was now able to express when he was hungry and let his parents know when he was full.

Benji has not used his g-tube since May 16th, and it was removed on August 20th! During the follow up period, Benji’s oral motor skills continued to improve as he gained more experience and he is now able to drink water, and  milk from a straw cup! Benji’s ability to recognize hunger and learn how to regulate what his body needs has had a lasting impact on his overall development. Throughout the intensive period, Benji began to crawl and became more confident in his skills. Benji has learned to eat various foods and has started to eat larger pieces of foods such as bread with almond butter or cream cheese, spaghetti, and pancakes. Benji’s mother shared that although Benji likes almost everything, he currently loves blueberries, meatballs and turkey!

We are so proud of Benji and his entire family! Congratulations on being a tube-free superstar!

Photos provided by Benji’s family

August 29, 2018

The Pressure of Praise: What else can I do?

By: Heidi Liefer Moreland, MS, CCC-SLP, BRS-S, CLC

As a feeding therapist, I always thought that I was being helpful when I “coached” children through their bites, cheered, and “whoo hoo-ed!” for all their eating attempts. I also observed well-meaning parents, grandparents and caregivers cheer, clap, and praise any attempts at eating, but we often did not see a consistent increase in eating as a result.

“‘Positive’ pressure is still pressure and turns many kids off from new foods.” – Katja Rowell, MD

Kids hat have little or negative experiences with food have limited experience with the smells, tastes, and textures of foods, and any new sensation or movement can make them even more anxious.  Attempts to “help,” can actually bring so much pressure to the situation that they have difficulty participating.  What adults may view as positive reinforcement, may actually sound like  “noise” to a child in an already challenging situation. It might also feel like you are taking on different personalities during mealtimes.

Natural reinforcers for eating are satiation of hunger, enjoyment of tastes and textures, and socializing in a relaxed and supportive environment.   Mealtimes are naturally meant to be social.  Nevertheless, the social interaction during mealtimes in families with a child with feeding challenges often becomes unnatural, scripted, and clinical.

Here are a few suggestions on what to do in place of praise during mealtimes:

  1. Remember to talk about things other than food and feeding at meal times. Check out the Family Dinner Project website for some great conversation starters!
  2. Reduce the number of questions you are asking your child.  Mealtimes should not feel like an interrogation.  Imagine a waiter standing over your table asking a bunch of happy questions as you are trying to eat.  No matter how good the food is, the questioning would likely ruin your appetite.
  3. When chatting with your child at mealtimes use a speech pattern, talking volume, and rhythm of speech that is more “Mommy”or “Daddy” and less “Cheerleader” or “Therapist.” Be yourself, and think about how you interact with your child when it isn’t a mealtime.
  4. Read your child’s cues.  If they are telling you they don’t want the spoon, honor it.  Take a pause and set it down nearby.  This gives the child the sense of security that comes with feeling understood and the space to initiate when the child is ready.
  5. Enjoyment is the name of the game.  Children that feel safe and relaxed at the table are more likely to develop healthy eating skills and try again at future sittings.  Quality leads to quantity.
  6. Sometimes, when safe, it is helpful to have a midday “snack” period where your little one is allowed to play with foods without obviously being watched.  Playing with their food is crucial for development and building trust during mealtimes. 
  7. Everything in moderation:  Be careful not to give extra attention or praise to food, but also remember to praise the non-feeding accomplishments of your child. For example, “I love how your sitting” or “Thank you for listening!”

 

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August 6, 2018

Responsive Feeding: Reflection Time

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

It often seems easier to find exact guidelines on how to help your child. Responsive feeding is a great structure, but it can feel like there are a lot of gray areas when it comes to application.

Picture helping your child learn to walk. In the beginning you hold them upright, and even help them move their feet! As they mature in their skills, you progress to holding two hands, holding one hand or, just using a finger. Eventually, you let them walk to your outstretched hands and you catch them if they wobble. Sometimes you need to let them fall in order to allow them to develop their balance independently. Once they are running on the playground by themselves, you will probably forget all of the months of practice and many steps that you went through!

You can apply the same idea to other skills. We created some questions to ask yourself to guide you through the gray areas of the mealtime relationships:


Enjoyment

  1. What does my child think about food (or drinking) right now? How do they communicate this?
  2. What does my child think about family mealtimes right now? How do they communicate this?
  3. Is his or her response to mealtimes different than other areas of structure? (For example, 2 year olds often do not like to be confined, and would rather explore than eat. This does not necessarily mean that he doesn’t like food, but may dislike sitting for more than a few minutes.)

Abilities

  1.  What do they do at about 80% of mealtimes with ____________ ? No one is 100% at anything, especially toddlers and preschoolers, so 80% is a good measure of mastery. This can be any skill, such as drinking from a cup, sitting at the table, using a spoon, or just taking bites without spitting them out. It can also be behaviors, manners, and food challenges like sitting at the table or tasting new foods.
  2. What do I hope they will do at mealtimes?

Shaping rules and expectations

  1. If you do an assessment of their enjoyment and find that there is no enjoyment at all, you may need to back up your expectations until they are more relaxed at mealtimes.
  2. Once you have some enjoyment of food and mealtimes, you can begin adding structure a little bit at a time.

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August 6, 2018

Responsive Parenting: Why is this important for mealtimes?

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

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: This 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.

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.

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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