Feeding Struggles and Therapy

When your child does not eat or struggles to eat, it can be heartbreaking.  You want nothing more than for your child to succeed and live a happy healthy life, but without proper nourishment that is not possible.  There is a wide spectrum of feeding struggles, which affects up to 45% of typically developing children and up to 80% of developmentally disabled children.  At any level, it is difficult for both families and the child to transition to solid foods and self-feeding.  It is just not fun…for anyone!   The gagging and vomiting are tough on everyone.  Thankfully most children get the hang of eating relatively quickly with constant exposure to food.  However, it is not as “easy” for everyone.  There are many different factors that lead to feeding disorders, but regardless of the road that led you to this struggle, it is a hard, long journey.  At the end of the day, I would fly Gavin to the moon if I could to get him to eat one Oreo Cookie!  We just want him to eat. 

Eating is such a natural thing for all of us, it is hard to understand why or how someone could not just eat.  We take for granted how many muscles and senses are involved in that perfect bite.  It is not a factor of just finding the right food that the child may enjoy.  Trust me, we have tried pudding, ice cream, mac & cheese, pickles, pickle juice….you name it, we have tried it!!!  When it comes to severe feeding struggles, these kids are not refusing to eat for behavioral reasons (although that does start to play a role as they get older). These kids are not eating because something hurts or their body is telling them not to.  Most of these kids have passed the age when they should have hit that developmental milestone where our body naturally figures out how to handle food in our mouths and swallow.  As a result, they have negative feelings associated with eating.  They are scared and every brain pathway that has formed tells them that food hurts.  One woman I met compared feeding struggles to post traumatic stress syndrome.  Many of these kids have been to hell and back as a baby; they are lucky if feeding is all they are dealing with!  Our therapist described feeding struggles like putting a bowl of spiders in front of us and telling us to eat it.  No thank you!

This is where therapy comes in.  Again, I am not a doctor and I am not a licensed therapist…I have learned from one of the best though, so I feel I am closeJ.  The goal is to show these kids that eating is not a scary experience by breaking the eating process down and teaching them every little step.  The child needs to be brought back to that feeding level that he or she failed to reach, which is typically with purees.  This stage cannot be skipped as it is when we develop much of the tongue movement and is the natural building block to eating solids.  It is important to build up and stretch muscles around the mouth and tongue.   Then, comes teaching how to chew, move the food around the mouth with the tongue and swallow.  Hopefully, after enough positive experiences, they will begin to forget all of the negative feelings he associates with food and eat!

Here is a little exercise for you to understand the chewing and process that we take for granted:

      1.       Take a stick of chewing gum.  Fold it into a square and put it in your mouth like you are going to chew it but don’t chew it yet!  Where is the gum?     (In the back of your mouth on one side.)

      2.       Chew the gum on that one side.  Now, move the gum from one side of your mouth to the other.  What did you do to do this, and how did the gum travel from one side to the other?    (You use your tongue to move the gum from the back, up to the front of your mouth, and then the gum is pushed to the back of your mouth on the other side.  As you learn to eat, you figure out that food is shifted in your mouth at the front of your mouth.  If you try to move the gum over the back of your tongue, you will gag.)

      3.      Put your (clean) finger in your mouth between your teeth and check.  Chew the gum with your jaw going up and down only without moving the gum around your mouth.  Then, with you finger still between your teeth and cheek and try to chew the gum again normally moving the gum around your mouth as you chew.  What do you notice about your cheeks?    (When we chew, we engage our cheeks and use them to help move food around our mouth.)

The most important element of therapy is establishing the procedures and expectations.  Just like teachers need to provide a safe environment for their students to learn, a therapist needs to provide a safe place where the child knows what is coming at him or her.  There needs to be a level of trust developed…and an understanding that the therapist or feeder is the alpha dog!  There is a behavioral aspect involved with feeding struggles.  Remember, Gavin is two.  While he is a very good boy, he has been known to display typical two year old behavior from time to time!  Eating has never been an enjoyable event in Gavin’s life, so expecting him to always be thrilled to jump in the high chair to eat is not realistic! 

So, here is what a typical therapy session involves for Gavin:

      1.       Gavin sits in his high chair with shoulder straps safely secured with a bib tied firmly around his neck. Again, we want to avoid behavioral meltdowns!  Completely securing him down gives him the message that you are in charge.

      2.       The TV is turned on and Gavin is given toys to play with.  These are used to distract Gavin throughout the process and keep his mind off any negative feelings or anxiety he may have associated with feeding. Depending on the behavior level, these reinforcements are provided continuously throughout the meal or removed at times of refusal and presented again to reward the good behavior…stretching his tongue as told, taking a bite, etc.  I am assured there is an exit plan at the end of therapy so he does not always depend on TV to eat!

      3.       We go through a series of stretches to stimulate Gavin’s mouth and get him used to us being in his personal space.  Stretches are both on his face and inside his mouth.

     4.       Gavin practices moving his tongue back and forth prompted by a little plastic teething stick.  We have him stretch it as far as he can laterally to one side and then repeat it to the other side.

     5.       Gavin practices chewing.  We have a tri-tip chew toy that we put at the back of his mouth and prompt him the chew.  The goal is to get a good firm bite.  Then, we use food wrapped in mesh from the fabric store for chewing, just as we did with the tri-chew.  This allows food to ooze out of the bag so he can experience the taste and texture of the little food particles in his mouth.  They are too small for him to gag…hopefully!  We will also practice chewing little pieces of different solids like crackers on his own without the mesh.
     6.       The meal begins.  A timer is set for a definitive feeding time period.  Gavin starts the timer after we tell him: “Gavin, push the button to start the timer!  When the timer goes ‘Beep. Beep.’ We will be all done and you can get out of the chair!”

     7.       We present the spoon to Gavin’s mouth with the prompt: “Take your bite.”  And then we wait… Hopefully he takes the bite with the initial prompt or even without the prompt.  We are looking for a good open, not a “snapping turtle.” J Sometimes he needs a little help with a finger lightly pressed on his chin to cue him to open a little wider.  There are different ways to place the spoon depending on the texture of the food to help prevent a gag.

     8.       Lots of praise given and we have a little celebration after Gavin takes a successful bite.        

     9.       We continue this process until the timer goes “Beep. Beep.” And then Gavin is immediately removed from the chair.

     10.   Gavin gets a stickerJ 

It’s a long methodical process, but he eats!!!  Some days are better than others, but this technique has provided Gavin with confidence to eat and the ability to handle several solids.  The hope is that if we do this four times a week, five days a week, for six to eight weeks, with the help of doctors, dietitians, and therapists, it will provide enough positive eating experiences for him to come home and continue his journey to healthy eating.  You never know…he may even eat cake for his 3^rd birthdayJ