Category Archives: feeding

Helping Baby with Gastroesophageal Reflux Disorder (GERD)

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One problem that impacts a large number of young children in Gastroesophageal Reflux Disorder (GERD).  Statistically, babies who have GERD are at risk for feeding issues during childhood.  It is important that parents be given tools to recognize GERD, address GERD, and promote future eating habits.

When the lower esophageal sphincter has poor closure, stomach content can regurgitate back up into the esophagus.

When the lower esophageal sphincter has poor closure, stomach content can regurgitate back up into the esophagus.

The best indicator of GERD is the infant’s symptoms, which may include reoccurring vomiting, fussiness during feedings, inconsistency with intake of milk or formula volume, gagging, swallowing with effort, arching the back or refusing to eat despite appearing hungry.  Many caregivers  of children with GERD report that they have been feeding baby while they are sleeping, since baby is refusing feedings while awake.  Medical tests cannot rule out GERD.

As an occupational therapist, my expertise is education on positioning, during and after feedings:

  • Use the log roll technique while changing babies diaper or clothes.  Many caregivers lie babies on their back and lift their bottom by their legs in order to change diapers or clothing.  This position puts a great deal of pressure of baby’s stomach and promotes stomach contents to reflux into baby’s esophagus.  Instead, roll baby from side to side like a “log”.  Avoid twisting baby’s trunk by keeping shoulders and hips aligned.
  • Feed baby on their side with head up above feet, versus flat on their back.  Place a pillow under your shoulder, ensuring that baby is on their side and with an upright incline.
  • For babies 6 months or older, feed baby on their left side.  Stomachs are positioned on your left side.  Infants have a vertical stomach, with very little curvature.  If your baby is 6 months or older (around the time most babies learn to sit upright), their stomach is beginning to be compressed  into the shape of a kidney bean.  Due to the position of the stomach, many babies who are 6 months are older, will reflux less when feed lying on their left side.  If your baby is breast feed, you can use the football hold technique in order to nurse from the left breast and keep baby on their left side.
Football Hold

The “football hold” is a great breastfeeding position to nurse from the left breast and positioning baby on his left side.

  • After baby eats, keep baby upright or on their tummy for 20 minutes.  My personal favorite was using a baby carrier after feedings.

Caregiver’s should also be aware of common feeding patterns of infants or children with GERD.  The symptoms of GERD can cause children to cycle back and forth from being in pain and refusing food, and being very hungry and overeating.  After regurgitating stomach content up into the esophagus, the area becomes inflamed, irritated and painful, and many children will avoid eating.  Then, after sometime, the physical, painful symptoms subside and the child is again ready to eat.  Since the child has been avoiding food, they are very hungry.  At this stage, many children will overeat and overfill their stomach.  This causes the stomach content to regurgitate again, which cycles back to avoiding food again.

If a caregiver suspects that a child has GERD, they should track the child’s feeding time (time of day and duration) or bottle intake.  Look for patterns of poor feedings and overeating.  The caregiver should also track the time of any observable symptoms, and look for patterns of discomfort after feedings with a larger volume.

In order to prevent this cycle, caregivers should consult with the child’s pediatrician to discuss strategies to prevent overeating.  The plan needs to be specialized for that child.

Finally, it is important to discuss strategies for promoting future healthy eating habits.  It is understandable that a child would be at risk for eating problems when their first experience with food is pain and discomfort.  While baby is nursing or bottle feeding, the caregiver should be aware of their own body language and tone of voice.  Are your shoulders tight?  Is your voice strained?  Take a deep breath.  Sing a sweet song to baby.  Coo and giggle with them.  Your calmness will carry them through a difficult time.

As the caregiver introduces solids (which is less likely to regurgitate because of their thicker texture), they should make a point to emphasize the joy of eating.  Play with food! Get messy, squeeze, paint, draw, lick, splat, make “animals”, make car noises, and most importantly SMILE while eating together.  Little ones are designed to learn and change.  Together, caregivers and children can build new, fun experiences with food.

Introducing Solids: Food Stages

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During the early stages of introducing solids, the goals are to improve oral motor skills, establish safety, maintain positive associations with eating and to develop a diet with a wide variety of foods.

Development of oral motor skills for feeding are dependent on the qualities of the foods given to the child.  The qualities of the foods (such as meltable or non-meltable) determine the level of oral motor skills required to prepare the food for swallowing.  The following is an outline of foods organized by the typical progression of feeding skills.

Typically introduced at 5 months:

  • Thin Baby Food Cereals

Typically introduced at 6 months:

  • Stage One Baby Food Purees/Single Food Item Purees
  • Thicker Baby Food Cereals

Typically introduced at 7 months:

  • Stage Two Baby Foods, Mixed Food Purees
  • Mashed Table Foods, such as banana, avocado, sweet potato…

Typically introduced at 8 months:

Typically introduced at 9 months:

  • Hard Solids that Melt, such a graham cracker, Gerber’s cereal squares, Snap Pea Crips, Krinkle Sticks, Towne crackers

Typically introduced at 10 months:

  • Soft Foods cut into Cubes, such as avocado, kiwi, cooked squash, cooked potato, peas, banana, vegetable soup ingredients without broth, Gerber Graduates fruits

Typically introduced at 11 months:

  • Soft Chews, Same Texture, such as fruit breads, muffins, small pastas, cubed lunch meat, thin deli meats in small squares, barley, scrambled eggs, soft meat soup without broth

Typically introduced at 12 months:

  • Soft Chews, Multiple Textures, such as macaroni and cheese, chicken nuggets, french fries, spaghetti, lasagna, fish sticks

Typically introduced at 15 to 18 months:

  • Hard Chews, such as cheerios (and most non-meltable cereals), pretzel sticks, ritz crackers, saltine crackers, sticks of hard raw fruits and vegetables,

It is suggested that non-meltable cereals and crackers be introduced at approximately 15 to 18 months, which is much later than popular belief.

Please note, the provided ages are a suggestion, as different children develop at different rates.  My general suggestion is to wait approximately one month before proceeding to the next stage.  Signs that a food is too difficult for your child include coughing, watery eyes, gagging, turning head away or spitting out more than 50% of the food.

If you have concerns regarding your child’s feeding development, do not hesitate to consult your pediatrician or an occupational or speech therapist who specializes in feeding.

Family Meals

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One of the most essential tools for learning feeding skills is modeling, which is best done by having regular family meals at the table.  Most parents agree that sitting together for meals is important.  I would like to advocate the value further from a sensory-motor perspective, and provide tips to make family meals more successful.

Children develop their perceptions of food over time through their senses: seeing, smelling, touch and taste.  Exposure at the table to other’s plates is a great first experience to new foods.  For example, a baby or young toddler who is not yet eating mature foods, is still learning about these foods through sight and smell while sitting at the table with family.

Also, as young children are developing food manipulation skills, including finger feeding, use of fork and spoon, drinking from a cup and straw and cutting with a fork and knife, consistent modeling from caregivers is crucial.

Adding routine and creating a supportive environment will greatly improve the eating experience, such as:

  • Children should sit at the table for meals, with other eaters, three times per day.  If your child is not yet sitting three times per day, gradually increase daily meals over time.  It will take time and consistency, but your dedication will pay off in the end.
  • Children 12-months-old and older should assist in setting the table and cleaning up in order to add structure to mealtimes.  Very young children can place spoons or napkins in the table to set up and can drop spoons into the sink and wipe the table for clean up.  Older children should pay a large role in setting up and cleaning after meals.
  • Starting at 6-months of age, children can be expected to sit a the table for meals for 20 minutes.  If children are learning to sit at the table for 20 minutes, redirect escape attempts with “it’s not time to clean up”.  A visual timer may be a good tool to trial with your child.  Young children who need to be strapped into highchairs or booster chairs should not sit more than 20 minutes.  Children who are sitting in regular chairs may be allowed to sit more than 20 minutes, but should not be expected to sit more than 20 minutes until early adolescence.
  • Children should be positioned so that they can observe others eating during mealtimes. I prefer smaller feeding chairs that position the child at eyelevel with the rest of the family, versus large, stand alone high chairs.

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  • Conversations and interactions should stay positive throughout.  It is essentials that the family table be associated with a positive and safe environment.  Many parents may inadvertently create a negative environment by venting about their day at the dinner table.  Also, if children are demonstrating undesirable behavior at the dinner table, redirection with a calm, yet assertive tone is best.  Time outs are not ideal since they can reinforce escaping from the task of sitting at the table.
  • Parents should focus on the enjoyment of eating instead of volume.  This is by far one of the hardest principles for parents.  In my own home, I frequently catch myself focusing on the short term accomplishment of volume.  This leads to power struggles, frustration and the child having a high arousal state.  Children’s appetites are suppressed by adrenaline (the “fight or flight” hormone) when they enter a high arousal state.  Instead, as parents, we need our behavior and parenting decision support the enjoyment of eating.  In those moments I remind myself that in the long term, children will eat more volume and have better nutritional variety if the enjoyment of eating is always the first priority.

 

What is typical feeding behavior?

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A recent study revealed that almost half of parents describe their child as a “picky eater”.  Many parents and professionals struggle to identify if a child is a “picky eater”, or a “problem feeder” that requires intervention.  Dr. Kay A. Toomey, a pediatric psychologist and feeding specialist, has developed a list of specific observations to assist in differentiating commonplace feeding behaviors and feeding difficulties that require intervention.

PickyEaters-VS-Problem-Feeders

Dr. Toomey has also outlined feeding “red flags”.  If a child presents with one of these, they should be seen by a feeding specialist.

Red-Flags

If you have further concerns regarding you child’s feeding, do not hesitate to discuss it further with your pediatrician or contact me at 760-685-7694.

Kids in the Kitchen

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Children learn about food qualities through their eyes, hands, nose and tongue. Interacting with food before the demand of eating promotes success.

Children develop their perceptions towards various foods differently than adults.  We perceive food with a cognitive lens, in which we recall past experiences, categorize foods and reason our way through choosing which foods we are going to eat.

Children perceive food with a sensory-motor lens, in which they decide which foods they are going to eat through there eyes, hands, nose, in addition to their tongue.  Many children are highly aware of changes in food’s shape, size, color, smell, temperature and texture.  In some cases, children will refuse foods that appear slightly different than their preferred choices.

There are many reasons why a child may have a limited food repertoire and prefer to eat the same few foods again and again.  All children benefit from interacting with food in more ways that just eating.

My suggestion: Invite your children into the kitchen.  Scoop, pour, shake, stir, open, close and mix.  As a bonus, you’ll be engaging in activities great for sequencing, imitation, attention, planning and fine motor development.  Most young children are thrilled at the chance to join their parents in the kitchen.  Also, it’s a better use of time than the parent occupying or distracting the child away from the kitchen so that the parent can hurry up and get the cooking done.

With son #1, before he could walk, every morning we would make smoothies and my coffee together.  I helped him scoop the protein powder, pour the milk and kefir, peel the banana and scoop the ice.  Next I helped him scoop the coffee grounds (“one, two, three”) and pour the water. Then we washed the dishes together, in which he played in the water with his hands while I loaded the dishwasher.  And yes it was always a mess.  And yes it took three times longer than if I just did it myself.  You need to rethink your kitchen time as more than just preparing food.  It’s a place to develop your child’s lifelong relationship with food.

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For a little parenting humor, check this out this diagram from the “Honest Toddler”:
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Starting Solids: Hard Munchables

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Baby is improving his oral motor skills in preparation for eating.  His tongue reflexively moves towards the carrot during a munching chew pattern.

As babies transition from milk to solids, hard munchables are a great food to introduce around 8 months old, after purees and before crackers. Baby won’t actually swallow this beginner food, but will engage in oral motor play to prepare for chewing.

Hard munchables are firm foods, appropriately shaped into a stick form.  They are long enough so that baby can easily grasp the food and reach the back of the gums.  It’s important that the food be firm enough so that it won’t break, and thin enough so that it will fit between the gums.  Also, it is crucial that the food is at least 5 inches long and that baby is supervised, in order to prevent choking. My favorites are carrots, celery, jicama, fruit leather, bell pepper strips and bagel strips.  My sons always preferred their hard munchables cold from the refrigerator (probably felt good on their gums).

Placing objects in the mouth (in a safe manner of course) is a crucial preparatory activity for eating.  Hard munchables encourage the gag reflex (which is present at the front of the tongue in newborns) to move to the back of the tongue and throat.  They also inhibit tongue protrusion (movement pattern used for sucking at the nipple), promote tongue tracking (needed for managing solids) and support the emerging munching pattern.

Coordinating lip, tongue, jaw and throat muscles for eating is hard work for little ones.  Providing hard muchables while introducing solids will help give your baby a good start.

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Addressing Feeding in Occupational Therapy

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My two areas of specialty in occupational therapy are sensory-motor processing and feeding therapy.  Often the two areas are related.

I have been trained in the Beckman Oral Motor Protocol for assessing and treating oral motor skills, which are foundational for manipulation of food by the lips, tongue and jaw.

The approach that I have been trained in and use during feeding therapy is the SOS approach developed by Dr. Kay Toomey.

http://www.sosapproach-conferences.com/

If you have concerns regarding your child’s feeding skills, do not hesitate to contact me.