The Bigger Picture—How Attitudes Can Affect The Mealtime Experience

I think the best practice for all of us, whether we have a child with food aversions or not, is to put ourselves in their little (or big) shoes. The Big Picture, always about the Big Picture. Our own anxieties and fears as parents feed directly into our children---how does this play out in a child with feeding complications? You want so badly for them to try a food, to eat a certain amount so they can reach a desired weight for their age, but sometimes ignore the fact that eating in itself is not enjoyable for them! Therefore the act of “trying a food” can be a really far-fetched idea in many instances. Not only that but there is often not one, but two or three people surrounding the dinner table coaxing the child to try the food and once again, our own anxieties set in and result in an overall stressful mealtime experience for everyone! There definitely needs to be a shift in the thinking here, and not only in the caregivers but also in many therapists treating children for pediatric feeding disorder (PFD), ARFID, or all related struggles related to mealtime and food.

Bear with me as I enter into story telling mode for a few minutes to share this example. When my daughter was a toddler we had family in town to celebrate her 3rd birthday. During their visit we went to a great little seafood place and had some delicious food! Keep in mind that this dinner wasn’t specifically our daughters "birthday celebration” night, but rather a night on the town for all of us, mostly adults,  to try a new place.  Her dad was really wishing for Adalyn to try the grilled shrimp but everything on her face said “No!”…thus the coaxing begins, “Just try it, you’ll love it” “Just one bite and then you can__(fill in the blank here)”  Others joining in on occassion "yeah, you might like it!".  We all know this scenario, right? I interuppted, half jokingly saying  “Hello? Do you not know anything about what I do for a LIVING, treating very selective eaters? Please don’t worry about her not trying the shrimp, its fine". I said we’d just plan a seafood or shrimp night one night and approach something new with some preparation.  Which is exactly what we did! We started talking about it the night before and mentioned it a few more times the next day,  brought her along with me to the store and started calling out  “Popcorn Shriiiimp, where are you?” having a little cheesy bit of fun.  We even got some hush puppies since that is always a nice addition to any seafood! We came across some yummy looking breaded butterfly shrimp in the frozen food section and went that route instead of popcorn shrimp. I showed her the tails (on the picture on box) and asked if I could take them off for her, she thought that was the most generous act and thanked me in advance right there in the store “Oh, thank you mommy!”

That night we had a great meal of baked tilapia (this was already an accepted food of hers) with butter, lemon, mint from the garden and lots of parmesan cheese, a few new shrimp and some hush puppies! She immediately asked for her ranch—her favorite choice for dipping, especially with new foods, but I asked her if she would try some mango preserves for a sweet dip for our shrimp. She tried it, seemed to enjoy it, but politely declined any additional dips! Only 3 or so bites of the shrimp, but you know what? That’s ok! What a different reaction than the night in the restaurant! She was not prepared for trying shrimp, she shuddered at the thought and there was not much that was too familiar about it to her.

I do realize that different personality types make it easier or more of a challenge to come to grips with inconsistencies in life. Especially when dealing with the health and nutrition of our children. I am considered an “Idealist” (according to the Myers-Briggs personality test anyway), and I know my ability to really empathize with another person in combination with some other "weird" qualities help me to help others and I have a strange knack with the most rigid of "pickiness" and beyond with anxious eaters. It is a challenge but I do love it—at times I find it harder to relate these mealtime concepts and beliefs to the parents of these children, but I do believe a shift in attitudes toward mealtime is needed. This is why I am content with what ended up being a "1 bite shrimp night" and the fact that she may have eaten a third of what she did the day before. With the children we work with, as therapists, the details of caloric intake are much more important and have been taken into account following assessment and collaboration with the child’s physician and often a registered dietician.  I am a big believer in finding calorie packed foods that can be added to current accepted foods, I learned this from the beginning of my career and it is a perfect way to continue to allow a child to choose what they will eat and how much they will eat…it just so happens that some of their choices have more calories in them! The outlook I have in many situations is the same, “This too shall pass”, or many small steps toward the bigger picture. And like I said, it’s all about the Bigger Picture.

** This was adapted from the original 2009 post on my feeding blog Fun with Food, but all very much remains applicable. Our not so little anymore Adalyn will now occasionally try shrimp but it is not and never will be her first choice!

Heightened anxiety and Sensory based feeding aversions

Many of the children I see for feeding therapy have increased anxiety surrounding new foods and many will "shut down" so to speak at the very sight or mention of a new or undesired food. When working with families I ask them to list their child's favorite foods and then I examine the various properties and help plan which foods to introduce based on the similarities. Pairing desired foods with new or undesired foods has been helpful with many children...you do not want to be 'sneaky', but rather discuss the similarities and provide opportunities for exposure and for your child to build trust and familiarity with the new foods.

It is not uncommon to see a child with a limited diet Love foods that are crunchy, sweet, salty, even spicy. What is the common factor in those type of foods? They all have an increased sensory value and give more feedback! A child who loves barbeque chips for example, may love the idea of having chicken tenderloins coated and baked in her favorite bbq chips. This is a way you can expand on a food. Children who prefer these types of foods often Overstuff foods, usually the foods that are a little softer. Here is a great article by Suzanne Evans Morris regarding overstuffing: Mouth Stuffing.

Yesterday I discovered a great blog written by the co-authors of Food Chaining. I did not realize that the treatment approach I use with many children is similar to the concepts and plan in Food Chaining. Please check out the site, it is a great resource and lists many others! I plan to order the book and incorporate some of the examples in my own therapies! I spoke with a very sweet, very concerned mother of a 5 year old son who has a diet limited to 4-5 'staple' foods. Her story is like many others--she knows her sons anxiety and panic surrounding new foods is not typical of other children his age but she is having trouble seeking treatment. A speech-language pathologist or occupational therapist specializing in pediatric feeding disorders is sometimes difficult to come by but we are out there! I hope to continue adding to this site and eventually have a list of treatment centers and speech and occupational therapists working in the field of pediatric dysphagia; so if you happen to be reading this and are a professional in the field or have a recommendation for other families, please leave a comment below! Most Children's hospitals have a feeding/swallowing program and will offer outpatient treatment. You can also check with any company that offers speech or occupational therapist and ask if there is a therapist/therapists who works in the area of feeding.

Below is an example of introducing a new food, discussing its properties, presenting it in a new form (puree for dipping) and pairing it with a like colored desired foods.

ARFID, selective eating and PFD—where to start?

If you suspect ARFID and you are researching and starting there I also suggest you seek out a therapist specializing and treating pediatric feeding disorders. Your child or teen or yourself may likely need a psychologist or psychiatrist and a cognitive behavioral therapy plan in conjunction with other therapy, but I can personally attest to what I know as an SLP working primarily with feeding since 2003 and that there is rarely a one factor root to very selective eating.

Maybe I shouldn’t mention ARFID at all but rather the fact that there are certain criterion that send a red flag for noticing a difference in what could be typical vs atypical or just a difference that is affecting lives in a way that is less than ideal or optimum. Whether struggles in the arena of eating and mealtime began due to this or that there WILL often be accompanying oral motor feeding patterns, sensory disturbances and associations that have been created likely without the person or their caregivers absolutely knowing that those inefficient patterns or differences in anatomy were present. 

It can be as “simple” as a history of early feeding difficulty, a slew of “wait and see” mindset determined by yourself or a medical professional, etc, but the bottom line is that a thorough evaluation can at least look into background history and help identify patterns and along with that comes the feedback from someone with experience of knowing what other patterns including oral motor function and sensory and a whole body mindset to further investigate all possible influences and where a starting point should be At the TIME of assessment.

There is no need to fixate on why “this was overlooked” or “why didn’t I or they identify this or that” aside from having a newfound perspective or new information. This may be opinion but I also feel it is helpful in making strides in the present. What do you know now, today, that could lead to a direction of a plan and progress? Stay there and know that if you haven’t considered or haven’t been aware of the possibilities, that now you are and you can get started right away on seeming solutions and implementing a plan. Sometimes the “plan” is simply letting all of the new information soak in and allowing empathy to root in the ways that you will certainly find are necessary. We are an interconnected web of information and if you start somewhere that can lead you to the next step then you are already making progress in the journey to increased awareness and action. There’s a lot to be said for that! I am opening this up to hopefully allow connections to be made in whatever location you are, there are numerous resources available and sometimes it is just a matter of logistics and experience and people connecting with each other so that the journey can begin for you.

I encourage you to check out the Feeding Matters resources provided in this link! https://www.feedingmatters.org/pfd_and_arfid/

Cups!

Q: What type of cup or sippy cup should I be using with my 12 month old son?


Hi! I would first begin working with open cup and straw drinking. I use yogurt drinks, baby food puree mixed with formula, milk, or water and sometimes powder pudding mix for beginning cup drinking. Thickening slows the flow allowing some independence while learning as well as practice with lip closure. You can gradually thin the liquid as he becomes more efficient.

As far as sippy and transitional cups, I like to recommend this one first https://reflo.net/   It flows slowly and limits the risk of surprising dumps of liquid on the face that often happens with beginning cup drinking!  I also like this one without the valve, playtex tumbler....http://www.amazon.com/Playtex-Coolster-Tumbler-Sippy-Girls/dp/B0011E4HBM as it is similar to open cup and does not require as much suckling when valve is out. Also the toss and go cup he was using at school was fine too as well as straw cups...You should allow him opportunities for open cup drinking and sippy without valves. The suction required for sippy cups, especially with valves, often results in the same suckle pattern with manipulation of foods requiring a consecutive lateral munching pattern. I also like these:  

https://www.amazon.com/TalkTools-Recessed-Lid-Cup-Handles/dp/B08RMXRLQN

https://www.munchkin.com/splash-toddler-cup.html?color=89&gclid=CjwKCAiA2rOeBhAsEiwA2Pl7Q7vXMRX5-h2ACIOU76ZCDo_qXI7ddlRsnwNBWWK_X6e3aohEFxETGRoC4eEQAvD_BwE

Likely outdated since original post; however, if you’ll notice the idea behind all of these cup choices is to move away from a spouted valve. 

http://citikids.com/ProductImages/24026.1.jpg http://usera.imagecave.com/loveski777/Munchkin%20Dora%20Big%20Kid%20Cup.jpg You can also take valves out of this one as well.

Here is a link to a great article by Melanie Potuck related to this blog topic:
https://www.google.com/amp/blog.asha.org/2014/01/09/step-away-from-the-sippy-cup/amp/

**The cup options are plenty, overwhelming at times and since the original date of this blog there have been numerous changes including discontinuation of cups, new products and other options.  I'm including some pictures as examples of some cups currently available!  My go to practice cups in therapy are still often the very basic open cup with a thickened liquid to slow the flow and straw practice! I love the spoutless options available and you can never go wrong with the basic disposable coffee cup and lids that you would receive at most restaurants, drive thrust or find at the store. I recently bought a cup at the dollar tree (also pictured). My oldest daughter has claimed this one as you can see by the artwork :). Tervis lids are also ideal.

Please feel free to Share your finds!   A child who is having a lot of difficulty transitioning from bottle to any other cup is a different scenario in my opinion. Often the anxiety is very much escalated at the idea of any new presentation and in those instances and other child specific examples, there may be acceptance of the silicone sippy cups and straws and this can open the door for other changes to take place!  It's difficult to cover all of the challenges and different scenarios in one post, but finding what you have to work with is essential and taking things one step at a time to reach the long term goal is often the key to success!

The challenges of sensory processing differences

Why are pediatric feeding disturbances difficult to treat in children with sensory processing disorders?

By Kristina Starnes, M.S. CCC-SLP

Pediatric feeding disturbances are not only common in children with sensory processing disorders (SPD) but are often more difficult to treat due to the many factors that contribute to feeding aversions. Children who experience sensory processing difficulties frequently have increased anxiety and aversion to accepting even small variations of a favorite food, whether it be a sandwich cut in a different way, a colored goldfish cracker instead of a solid goldfish they have come to know and expect, or their drink in a different cup. Take the child’s usual and accepted meal to a new setting, possibly a babysitter’s home or a restaurant, and discover that even when presented in the way the child always eats the food at home or in school, he simply cannot bring himself to take a bite of the food. The frustration and difficulties surrounding mealtime and eating may also be an indication of difficulties in other areas of function.

If these patterns sound familiar to you as a caregiver, then you are likely to also relate to the following anxieties and frustrations that countless parents have expressed to me over the last 12 years while working with pediatric feeding. Here are some concerns I have heard from parents:

-All of the other kids at the birthday party get so excited about the cupcake and ice cream, and my daughter cries and wants to go home.

-I just wish he would eat chicken nuggets!

-He will only eat the chicken nuggets from chick fil A and only in the box. If they are taken out of the box, he throws a tantrum.

Now, if you are anyone other than a family member experiencing this on a daily basis, you may assume that these feeding behaviors have developed solely as a result of parents falling into some typical power struggles to which we can mostly all relate if having raised children or grandchildren at any point. So parents are often told by well-meaning friends and relatives:

-You have to make him eat.  

-If she is hungry enough she will eventually eat that. 

-Or maybe, “He does that because you let him. He’s holding out,and he knows you will give him what he really wants in the end.   

Although some of these statements may indeed be a part of the problem behavior, they are likely just that – a part.  

In order to address eating concerns, you must break down the entire pattern and identify contributing factors, as well as what clinical experience and research have shown us. In order to change thesepatterns and get from point A to point E (eating!), we must pay attention to B through D in the process. A feeding assessment helps to bring the pieces of the process together by identifying typical vs.atypical oral sensory-motor development, feeding history, patterns used with types of foods eaten, as well as the child’s relationship with eating and those who are the mealtime partners or doing the feeding with a baby or those needing assistance.  Even when strong sensory aversions are identified, these may be indications of respiratory, gastrointestinal discomfort, family eating patterns, as well as food allergy or intolerance that are actually exacerbating existing hypersensitivities. Therefore, forcing or bribing will likelylead to deepened feeding aversions and increased anxiety.  

Children with the feeding complications of accepting only certain foods in certain ways along with a number of other factors for each accepted food may have learned to expect that the same foods will be offered at each meal in the same way. Additionally, the reason they may be eating something at home and not in daycare or vice versa is because the routine in the new environment had not been adapted to their predictable routine wherever that may be. The stress surrounding mealtime may have become too much for the parent to handle when they have repeatedly tried introducing new foods unsuccessfully. Without an understanding of the overall condition and factors contributing to refusal, parents and caregivers can become stuck in a cycle without support and, at the end of the day,we all do what we need to do to get by especially under stress.

These children typically progress with feeding goals and expanding foods by establishing a predictable, consistent routine in therapy as well. This allows for the new changes to be introduced within that framework. Bridging the progress into other environments may come much later but can be accomplished also by establishing a predictable routine in which these new skills and foods can then be incorporated (See Establishing Predictable routine at http://notjustpicky.blogspot.com/2010/01/email-responses-to-families.html?m=1)

I often hear the question, “What causes this?” in regard to a child’s feeding complications.  Rarely, there is only one factor. In children with SPD, it is common to find inadequate oral sensory-motor feeding patterns leading to disorganized and undeveloped chewing skills, difficulty with food bolus preparation within the oral cavity, and, in turn, difficulty and discomfort initiating the swallow. Which came first, the chicken or the egg? This saying comes to mind when stepping back to look at the big picture. 

Did sensory concerns contribute to oral motor feeding delays, or did the oral motor feeding delays contribute to the sensory issues with feeding? There is not right or wrong answer because both can be true. Visualize yourself feeling nauseous and you don’t want to look at a certain food, much less put it in your mouth. If you do put it in your mouth and something feels off because you are already feeling queasy, you might gag and even vomit. 

Sometimes chewing skills have never developed because a child has never actively chewed food. Therefore, the organization and patterns needed to chew were never developed. Food scattered across the tongue can feel especially undesirable, just downright gross, to the person already hypersensitive to certain food textures. Developing the needed oral sensory-motor feeding skills and systematically decreasing hypersensitivities can help eating become enjoyable and manageable for a child. When sick, or if there is underlying reflux, food sensitivity, or allergy then it is difficult to progress with feeding. This is why addressing each component of a child’s feeding is necessary.

A checklist from http://www.sensory-processing-disorder.com/provides helpful information regarding signs that may indicate that a child has a sensory processing disorder or specific needs that should be further assessed. “The purpose of the "SPD Symptom Checklist for Infants and Toddlers" is to help parents and professionals who interact with children become educated about particular signs of sensory processing disorder in the youngest children and babies. It is not to be used as the absolute diagnostic criteria for labeling children with sensory processing disorders, but rather, as an educational tool and checklist. Professionals (usually occupational therapists) who diagnose this disorder have their own tools in addition to checklists to observe and test for SPD (formerly called SID or Sensory Integration Dysfunction).”

ABOUT THE AUTHOR  

Kristina Starnes, M.S. CCC-SLP is a Speech Language Pathologist who specializes in pediatric feeding and swallowing disturbances. Kristina lives in Fayetteville, Arkansas where she and her daughters spend time together enjoying their college town and the Ozark Mountains. She is the owner of Therapy Tree, LLC and also enjoys writing and sharing information related to pediatric dysphagia on her blog, Fun with Food, and Facebook support pages. 

She has a passion for promoting awareness, treatment and prevention of feeding and swallowing disorders, connecting with others who share the same vision and strives to help others overcome negative associations surrounding food. 

‘Tween “toddlers”---Twoddlers?

 
Twoddler food!  This is the first grouping of a hopeful growing list of “In between” puree and table food stage for all of our babies, toddlers and older children who are wishing for grown up food but not quite ready with their oral motor feeding skills. Just remember that you will need to be very aware of allergens in these recipes and check with your pediatrician or dietician before introducing ingredients that have not yet been introduced. I will include store bought and homemade. Think soft on inside and texture on outside, like McCains Potato smiles :)

Caulitots
http://cupcakesandkalechips.com/2013/10/01/baked-cauli-tots/ http://yourlighterside.com/2010/03/caulitots-baked/

Homemade soft Nuggets
http://www.momables.com/lunchbox-wars-4-chicken-nuggets/

https://notjustpicky.blogspot.com/2012/04/ch-ch-ch-chia-chicken-bites.html?m=1

https://notjustpicky.blogspot.com/2009/10/turkey-nuggets.html?m=1

Tasty Veggie patties

https://notjustpicky.blogspot.com/2013/07/avocado-cakes-with-banana-and-basil.html?m=1

 https://notjustpicky.blogspot.com/2009/08/crunchy-spinach-cakes.html?m=1

http://pickytots.blogspot.com/2009/09/squish-your-squash-indian-style.html

Bread Lovers Beware

https://notjustpicky.blogspot.com/2013/12/cinnamon-pumpkin-banana-yummalicious.html?m=1

https://notjustpicky.blogspot.com/2009/03/savory-veggie-waffles.html?m=1

https://notjustpicky.blogspot.com/2009/01/chicken-bopps.html?m=1

https://notjustpicky.blogspot.com/2009/11/easy-dairy-free-pumpkin-cupcakes.html?m=1

The Sweeter side of Protein
https://notjustpicky.blogspot.com/2012/07/power-packed-cookie-dough-bites.html?m=1

Five Signs that Your Toddler May Benefit from Feeding Therapy

5 Signs that Your Toddler May Benefit from Feeding Therapy Thank you Melanie Potock from www.mymunchbug.com for the very helpful information. Please spread the word!