49 Years and 1 Day
1 day ago
Friday, February 24, 2012
April 27 and 28, 2012 Food Chaining II The Digestive Tract Disorders Course
We will present Food Chaining II The Digestive Tract Disorders course with Dr. Fishbein in Denver, Colorado. Register for this course at www.cepauniversity.com. Hope to see you there!
Tuesday, December 13, 2011
Estate Planning for Children with Special Needs
http://www.cincinnatichildrens.org/patients/child/special-needs/transition/estate/.
Great website with good resources for our kids. Check it out!
Great website with good resources for our kids. Check it out!
Friday, November 11, 2011
The Infamous French Fry Chain Done the RIGHT WAY
Accepted Food: McDonald’s French Fries
Initial Home Food: OreIda Crispy or Fast Food Fries (work toward baked on a baking stone for a healthier choice)
If the child likes dips/condiments explore this texture. If the child does not tolerate dip, dry dips (garlic salt, pepper, season salt, Mrs. Dash) can be explored. Take time to do this, don’t offer a new food every day of the week. Allow the child to become comfortable seeing, smelling the new food. Do not rush through food exploration. Think of every new food as you would think of food from a foreign country.
• Fast food french fries with ketchup, ranch dressing, salsa-ranch mix, BBQ, honey mustard or mayo, etc as dips. The child can explore tastes and offer at meals based on the child’s rating of the food item or condiment. Put small amounts of dip in small clear bowls. Let the child look at, smell and explore the dips. The child can choose whether or not to dip. A small paint brush can also be offered if the child wants to 'paint' the new taste on the food and offer to a parent or sibling. Preparing food for others is learning about food.
• Explore fries in different restaurants. Explore McDonald’s hash browns or Hardee's hash brown rounds. Offer a few Tator Crowns (just the tops, crunchier texture) and see if the child can tolerate crunchy tator crowns. Tator Tots may or may not be accepted. Hash browns or fried potatoes may come out of this exploration of this food in time. Do not rush.
• Keep expanding French fry options at home. Try a wide variety of fries. Cook the regular portion of what a child likes and only cook 1 or 2 of the other types of fries. Do not rapidly change.
• Steak fries or potato wedges can be explored and compared to the inside of a baked potato.
• Baked potato (let the child explore toppings and also think of other accepted foods, if the child likes bacon, try crumbled bacon over steak fries or baked potato. You are not trying to get the child to eat a revolving cycle of toppings, you are trying to explore what toppings the child likes. If the child will accept cheesy toppings, cheese can be expanded as a sauce, dip or soup.
• Learning activity: Make mashed potatoes or scalloped potatoes together.
• Work toward acceptance of mashed potatoes with butter, seasoned salt, sour cream and chives or gravy.
• Some children can also keep progressing to Shephard’s Pie or potato and meat dishes.
Language/learning activities: Teach the child about potatoes, how they grow, where they come from, the connection between Ireland and potatoes, this can also be a great geography lesson!
Food Exploration: Let the child explore the food with the senses. Tasting food is the LAST step the child will take. Let the child look at the food, smell it, feel with the fingers and take time to understand the properties of the food. This is why we only cook one or two different fries and put it in the “looking place’ of a divided plate. The child needs adequate time to explore on their own and at their own pace. No pressure approach is very important. Once the food is in front of the child, the food belongs to the child. Do not take control of the child’s eating. Foster independence.
Child Food Chaining Rating Scale:
5=I love this food and I can eat it with Mommy and Daddy at home or anywhere. My favorite!
4=I really like this and want to try more.
3=I am not sure how much I like it but I will try it again and learn more about it.
2=I don’t like this food, I want to try something else.
1=This is awful and I don’t want to eat this. I don’t feel good around this food.
Versus The WRONG way...Do you see the changes are too rapid and don't allow for the child to learn and explore?
Mc Donald's fries (no ketchup)
Fast food french fries with ketchup (What if the child does not like dips or is afraid of it or does not understand what ketchup is?)
French fries with ranch dressing (too big a change, try a lot of fries in the ketchup if the child like ketchup, let the child determine what dips they want to try. Just quickly changing dips is wrong. This is based on the child's rating, reactions and preferences).
Any french fries
Tater tots (may be too big a step, this should be a learning phase and Tator Crowns may be accepted before Tator Tots)
Potato wedges or fried potato slices
Baked potato -with anything on it (No, you can't just jump into baked potato, we teach kids what is inside french fries, steak fries so we can also teach them that this is in a baked potato. If a child can eat baked potato at Red Lobster, the family also has another restaurant to enjoy together. Think about social eating)
Baked potato with melted cheese or bacon bits
Mashed potatoes
Mashed potatoes with gravy (big big jump here...advance only as tolerated)
Pot pie (may never be possible, but Shephard's pie might where the child eats the mashed potato topping a bit of meat)
Initial Home Food: OreIda Crispy or Fast Food Fries (work toward baked on a baking stone for a healthier choice)
If the child likes dips/condiments explore this texture. If the child does not tolerate dip, dry dips (garlic salt, pepper, season salt, Mrs. Dash) can be explored. Take time to do this, don’t offer a new food every day of the week. Allow the child to become comfortable seeing, smelling the new food. Do not rush through food exploration. Think of every new food as you would think of food from a foreign country.
• Fast food french fries with ketchup, ranch dressing, salsa-ranch mix, BBQ, honey mustard or mayo, etc as dips. The child can explore tastes and offer at meals based on the child’s rating of the food item or condiment. Put small amounts of dip in small clear bowls. Let the child look at, smell and explore the dips. The child can choose whether or not to dip. A small paint brush can also be offered if the child wants to 'paint' the new taste on the food and offer to a parent or sibling. Preparing food for others is learning about food.
• Explore fries in different restaurants. Explore McDonald’s hash browns or Hardee's hash brown rounds. Offer a few Tator Crowns (just the tops, crunchier texture) and see if the child can tolerate crunchy tator crowns. Tator Tots may or may not be accepted. Hash browns or fried potatoes may come out of this exploration of this food in time. Do not rush.
• Keep expanding French fry options at home. Try a wide variety of fries. Cook the regular portion of what a child likes and only cook 1 or 2 of the other types of fries. Do not rapidly change.
• Steak fries or potato wedges can be explored and compared to the inside of a baked potato.
• Baked potato (let the child explore toppings and also think of other accepted foods, if the child likes bacon, try crumbled bacon over steak fries or baked potato. You are not trying to get the child to eat a revolving cycle of toppings, you are trying to explore what toppings the child likes. If the child will accept cheesy toppings, cheese can be expanded as a sauce, dip or soup.
• Learning activity: Make mashed potatoes or scalloped potatoes together.
• Work toward acceptance of mashed potatoes with butter, seasoned salt, sour cream and chives or gravy.
• Some children can also keep progressing to Shephard’s Pie or potato and meat dishes.
Language/learning activities: Teach the child about potatoes, how they grow, where they come from, the connection between Ireland and potatoes, this can also be a great geography lesson!
Food Exploration: Let the child explore the food with the senses. Tasting food is the LAST step the child will take. Let the child look at the food, smell it, feel with the fingers and take time to understand the properties of the food. This is why we only cook one or two different fries and put it in the “looking place’ of a divided plate. The child needs adequate time to explore on their own and at their own pace. No pressure approach is very important. Once the food is in front of the child, the food belongs to the child. Do not take control of the child’s eating. Foster independence.
Child Food Chaining Rating Scale:
5=I love this food and I can eat it with Mommy and Daddy at home or anywhere. My favorite!
4=I really like this and want to try more.
3=I am not sure how much I like it but I will try it again and learn more about it.
2=I don’t like this food, I want to try something else.
1=This is awful and I don’t want to eat this. I don’t feel good around this food.
Versus The WRONG way...Do you see the changes are too rapid and don't allow for the child to learn and explore?
Mc Donald's fries (no ketchup)
Fast food french fries with ketchup (What if the child does not like dips or is afraid of it or does not understand what ketchup is?)
French fries with ranch dressing (too big a change, try a lot of fries in the ketchup if the child like ketchup, let the child determine what dips they want to try. Just quickly changing dips is wrong. This is based on the child's rating, reactions and preferences).
Any french fries
Tater tots (may be too big a step, this should be a learning phase and Tator Crowns may be accepted before Tator Tots)
Potato wedges or fried potato slices
Baked potato -with anything on it (No, you can't just jump into baked potato, we teach kids what is inside french fries, steak fries so we can also teach them that this is in a baked potato. If a child can eat baked potato at Red Lobster, the family also has another restaurant to enjoy together. Think about social eating)
Baked potato with melted cheese or bacon bits
Mashed potatoes
Mashed potatoes with gravy (big big jump here...advance only as tolerated)
Pot pie (may never be possible, but Shephard's pie might where the child eats the mashed potato topping a bit of meat)
Wednesday, November 9, 2011
Link to the Great Suzanne Evans Morris...
Oh the great Suzanne Evans Morris...I love her therapy and I read everything she ever wrote and attended her course. Here is a link to her New Visions website therapists and parents with a long list of resources from chewing to dealing with silent aspiration. Check it out and bookmark it! http://www.new-vis.com/fym/p-feed.htm
Tuesday, November 8, 2011
Is it ever safe to cut a bottle nipple? Emphatically...NO!!
YES flow rate matters! Cutting a nipple is tampering with medical equipment in a hospital. Nipples are designed to stop or significantly slow flow when a baby stops to breathe. A cut in the nipple means there is no stopping place and the infant is forced to lift the tongue against the hard palate to try to stop the flow and survive the feeding. This must be terrifying in a reclined position with your arms tucked into a blanket. The cut is never the same and this is always the way to start a feeding disorder. This has to stop. We are smarter than this. There are products designed to flow faster for thickened feedings but there are cautions all over these products about use with thin liquids (formula or breastmilk). If a baby cannot finish a bottle, they need more time to develop their skills, they do not need you to make the feeding 5 x's harder for them to finish safely. So no to slit or cut nipples, no to poking extra holes in the nipples.
Pick the right products, such as the Dr. Brown bottles level I, Gerber slow flow silicone level 1, Parent's Choice slow flow or Evenflo Classic Response slow flow and let babies have a comfortable flow rate that allows them to maintain ventilation while feeding. Put the baby in an upright, side tilt position and pace the feeding by tipping the bottle down and giving the baby an extra ventilating breath as needed.
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2386985/
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2386985/
www.txsha.org/_pdf/Convention/...Swallowing%20and%20Feeding%20for%20NICU%20Graduates.pdf
Pick the right products, such as the Dr. Brown bottles level I, Gerber slow flow silicone level 1, Parent's Choice slow flow or Evenflo Classic Response slow flow and let babies have a comfortable flow rate that allows them to maintain ventilation while feeding. Put the baby in an upright, side tilt position and pace the feeding by tipping the bottle down and giving the baby an extra ventilating breath as needed.
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2386985/
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2386985/
www.txsha.org/_pdf/Convention/...Swallowing%20and%20Feeding%20for%20NICU%20Graduates.pdf
Friday, November 4, 2011
Infant Feeding Evaluation Summary Copyright 2011 Cheri Fraker
Infant Feeding Evaluation Summary
Parent Guide
Patient Name:_______________________________________________________________________________
Parents Names:______________________________________________________________________________
Feeding Evaluation:
o Review of parent concerns/reason for referral
o Oral Reflexes (root, suck, swallow, phasic bite, transverse tongue, gag)
o Infant Cranial Nerve Evaluation
o Non-nutritive suck (pacifier skills)
o Nutritive suck (feeding skills)
o Lip seal, bottle flow rate
o Swallowing skills for liquids (cervical auscultation of the swallow) Therapist is listening for the opening of the Eustachian tube and upper esophageal sphincter
o Positioning
o Endurance
o Respiration (before, during and after feeding)
o Spoon feeding skills
o Upper airway screening
o Allergy screening
o Reflux screening
o GI function summary
Formula/Breastmilk by Bottle
Recommendations
Before Feeding
o Stimulate root reflex by stroking pacifier or bottle nipple down the middle of the lower lip prior to placement of the pacifier or bottle nipple
o Introduce the pacifier prior to bottle, dip pacifier in breastmilk or formula
o Slight downward pressure to the middle of the tongue with pacifier to improve tongue cupping skills
o Slight upward pressure to the hard palate. This may stimulate the suck reflex
o Lightly traction the pacifier to improve lip seal and cheek strength (2-3 x when offering pacifier, twice daily)
o Swaddling/swaddle lower body only
o Boppy pillow/pillow supports
o Lower lights and less noise while feeding
During Feeding
o Recommended bottle/nipple_______________________________________________________
o Swaddled, upright positioning (gravity will have less impact on liquid flow in the mouth to the throat)
o Side tilt positioning throughout feeding
o Support to head and neck (see photos)
o Chin support (rolled burp cloth)
o External pacing (you set the pace so the baby can breathe and eat comfortably)
o Burp mid-feeding, wait 5-10 minutes after feeding for final burp
After Feeding
o Upright 15 to 20 minutes after feeding (chest to chest)
o Avoid car seat and swing after feedings
Spoon Feeding
o Recommended spoon ______________________________________________________________
o Rest spoon on lower lip
o Perfect bite size is important
o Allow an extra ‘dry’ swallow
o Flavored baby food
o Move to smooth, higher flavored food
o Texture program (chewy spoon for “chewing practice”)
o Move to meltable solids (ex. vanilla wafer, graham cracker, puffs)
Cup Drinking
o Avoid cup drinking for now
o Recommended cup __________________________________________________________________
o Start with drops of liquid in the soft spout of the cup
o Small amount of liquid in cup
o Cold liquids in cup
o Thickened liquid by cup recommended
Additional Suggestions
o Ocean Saline Spray
o Cool mist humidifier
o Elevated head of crib/bed
Treatment Plan
o Feeding product change
o Pacing and positioning program
o Improve pre-feeding skills
o Improve awareness during the swallow (high flavor, cool temperature liquids)
o Swallow study (see letter)
o Referral to RD to try a more gentle formula for better tolerance
o Constipation management program
o Discuss reflux medication trial with your doctor
o Referral to OT/PT
o Referral to ENT and/or GI
Next Appointment: ___________________________________________________________
Therapist Contact Information: ______________________________________________
Notes:_______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
Thank you,
_____________________________________________________
Therapist Signature
Parent Guide
Patient Name:_______________________________________________________________________________
Parents Names:______________________________________________________________________________
Feeding Evaluation:
o Review of parent concerns/reason for referral
o Oral Reflexes (root, suck, swallow, phasic bite, transverse tongue, gag)
o Infant Cranial Nerve Evaluation
o Non-nutritive suck (pacifier skills)
o Nutritive suck (feeding skills)
o Lip seal, bottle flow rate
o Swallowing skills for liquids (cervical auscultation of the swallow) Therapist is listening for the opening of the Eustachian tube and upper esophageal sphincter
o Positioning
o Endurance
o Respiration (before, during and after feeding)
o Spoon feeding skills
o Upper airway screening
o Allergy screening
o Reflux screening
o GI function summary
Formula/Breastmilk by Bottle
Recommendations
Before Feeding
o Stimulate root reflex by stroking pacifier or bottle nipple down the middle of the lower lip prior to placement of the pacifier or bottle nipple
o Introduce the pacifier prior to bottle, dip pacifier in breastmilk or formula
o Slight downward pressure to the middle of the tongue with pacifier to improve tongue cupping skills
o Slight upward pressure to the hard palate. This may stimulate the suck reflex
o Lightly traction the pacifier to improve lip seal and cheek strength (2-3 x when offering pacifier, twice daily)
o Swaddling/swaddle lower body only
o Boppy pillow/pillow supports
o Lower lights and less noise while feeding
During Feeding
o Recommended bottle/nipple_______________________________________________________
o Swaddled, upright positioning (gravity will have less impact on liquid flow in the mouth to the throat)
o Side tilt positioning throughout feeding
o Support to head and neck (see photos)
o Chin support (rolled burp cloth)
o External pacing (you set the pace so the baby can breathe and eat comfortably)
o Burp mid-feeding, wait 5-10 minutes after feeding for final burp
After Feeding
o Upright 15 to 20 minutes after feeding (chest to chest)
o Avoid car seat and swing after feedings
Spoon Feeding
o Recommended spoon ______________________________________________________________
o Rest spoon on lower lip
o Perfect bite size is important
o Allow an extra ‘dry’ swallow
o Flavored baby food
o Move to smooth, higher flavored food
o Texture program (chewy spoon for “chewing practice”)
o Move to meltable solids (ex. vanilla wafer, graham cracker, puffs)
Cup Drinking
o Avoid cup drinking for now
o Recommended cup __________________________________________________________________
o Start with drops of liquid in the soft spout of the cup
o Small amount of liquid in cup
o Cold liquids in cup
o Thickened liquid by cup recommended
Additional Suggestions
o Ocean Saline Spray
o Cool mist humidifier
o Elevated head of crib/bed
Treatment Plan
o Feeding product change
o Pacing and positioning program
o Improve pre-feeding skills
o Improve awareness during the swallow (high flavor, cool temperature liquids)
o Swallow study (see letter)
o Referral to RD to try a more gentle formula for better tolerance
o Constipation management program
o Discuss reflux medication trial with your doctor
o Referral to OT/PT
o Referral to ENT and/or GI
Next Appointment: ___________________________________________________________
Therapist Contact Information: ______________________________________________
Notes:_______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
Thank you,
_____________________________________________________
Therapist Signature
Wednesday, October 19, 2011
Laura and I will be joined by Mark Fishbein, MD, pediatric gastroenterologist from Children's Memorial Hospital in Chicago, Illinois for the Food Chaining II course in St Louis on December 2 and 3rd. This is the course we just taught in Alaska. It was very well received and given 100% 5 star ratings from the audience when we presented it in San Antonio. Hope you can be there! If you are interested, contact Art Moreau at www.cepauniversity.com.
Saturday, August 20, 2011
$99.00 Discount on TWO CEPA courses with the new You Choose Two Option
If you decide to attend both the Dysphagia course and our Food Chaining II course (or substitute with any other CEPA course) you will qualify for a $99.00 discount. Go to www.cepauniversity.com for more information.
Friday, August 12, 2011
PreChaining Course: Much to DO about Pediatric Dysphagia
This course will be at the Omni Hotel in Indianapolis, Indiana. http://www.omnihotels.com/FindAHotel/IndianapolisSeverin.aspx on November 4 and 5th. There is a special rate for CEPA participants. The www.cepauniversity.com website will be updated very soon with dates for both courses (PreChaining/Dysphagia and Food Chaining II/Digestive Tract Disorders). This is our new aerodigestive series for a TRUE multidisciplinary team approach. We will be joined by Sandra Ettema, MD, otolaryngologist and speech pathologist! She leads our pediatric swallowing clinic! The Chaining II course was rated 100% 5 stars by participants in San Antonio (love you guys) and for that course, our dear friend Dr. Mark Fishbein, MD, pediatric GI (Chicago's Top Docs 2011) will be with us! Hope you can be there. We are still working on location for the Chaining II course. CEPA is also offering a new option "You Choose Two" courses for participants interested in a combination of featured lectures.
Sunday, August 7, 2011
Aerodigestive Series from Fraker and Walbert
The “It Takes a Team Series” continues with two new courses from Fraker and Walbert! A complete aerodigestive approach to your most complex feeding therapy patients.
Cheri and Laura will present two new courses in fall of 2011 by debuting a new lecture with Sandra Ettema, MD, otolaryngologist and moving the Food Chaining course to an advanced level with Food Chaining II with special guest, Mark Fishbein, MD, pediatric gastroenterologist.
PreChaining Therapy, The Upper Airway and Dysphagia
“The Much to Do About Pediatric Dysphagia” course will provide instruction on Fraker, Walbert and Cox's PreChaining therapy and rehabilitation of the swallow for older children with dysphagia. This course will also provide instruction on how to write and implement dysphagia chains paired with select specific feeding products to result in effective and successful treatment programs. This powerful course teaches therapists to stop feeding aversion before it starts and how to treat the most challenging children on their caseloads. Dysphagia therapy is much more than thickening liquids and we will provide instruction for the new therapist as well as the seasoned professional. Sandra Ettema, MD is not only an otolaryngologist, but she is also a speech-language pathologist and will provide easy to understand, but vital, detailed instruction about the upper airway and the complexity of swallowing disorders. Cheri and Laura will explain HOW to treat infants and children and provide in specifics in treatment of swallowing disorders. This course is packed with case studies from this team’s work with infants and children. Dr. Ettema works with Cheri and Laura on a daily basis and directs the SIU Koke Mill Pediatric Swallowing Clinic in Springfield, IL
These two dynamic therapy packed courses will be offered in November and December of 2011. The pediatric swallowing course and the recently debuted and extremely popular "Food Chaining II" course can also be selected in CEPA's new "You Choose 2" education program.
Food Chaining, The Digestive Tract and Digestive Tract Disorders
The Food Chaining II Course: Digestive Tract Disorders and Cheri and Laura will be joined again by Mark Fishbein, MD, pediatric gastroenterologist, from Children’s Memorial Hospital in Chicago, Illinois. This course was rated a 5 by 100% of the participants at it’s debut in San Antonio, Texas. Dr. Fishbein is also a co-author of “Food Chaining: The Proven Six Step Solution for Problem and Picky Eating.” He worked with Cheri and Laura and was part of the Springfield, IL feeding team for 10 years. Dr. Fishbein was just named one of “Chicago’s Top Kid Docs” for 2011. The course will focus on treatment of infants and children with a range of gastrointestinal disorders.
These therapy oriented courses are designed for all health professionals interested in pediatric nutrition and feeding disorders. The goal of presenting this series is to provide in depth instruction and understanding of the complex, whole body challenges involved in treatment of infants and children with feeding disorders.
Cheri and Laura will present two new courses in fall of 2011 by debuting a new lecture with Sandra Ettema, MD, otolaryngologist and moving the Food Chaining course to an advanced level with Food Chaining II with special guest, Mark Fishbein, MD, pediatric gastroenterologist.
PreChaining Therapy, The Upper Airway and Dysphagia
“The Much to Do About Pediatric Dysphagia” course will provide instruction on Fraker, Walbert and Cox's PreChaining therapy and rehabilitation of the swallow for older children with dysphagia. This course will also provide instruction on how to write and implement dysphagia chains paired with select specific feeding products to result in effective and successful treatment programs. This powerful course teaches therapists to stop feeding aversion before it starts and how to treat the most challenging children on their caseloads. Dysphagia therapy is much more than thickening liquids and we will provide instruction for the new therapist as well as the seasoned professional. Sandra Ettema, MD is not only an otolaryngologist, but she is also a speech-language pathologist and will provide easy to understand, but vital, detailed instruction about the upper airway and the complexity of swallowing disorders. Cheri and Laura will explain HOW to treat infants and children and provide in specifics in treatment of swallowing disorders. This course is packed with case studies from this team’s work with infants and children. Dr. Ettema works with Cheri and Laura on a daily basis and directs the SIU Koke Mill Pediatric Swallowing Clinic in Springfield, IL
These two dynamic therapy packed courses will be offered in November and December of 2011. The pediatric swallowing course and the recently debuted and extremely popular "Food Chaining II" course can also be selected in CEPA's new "You Choose 2" education program.
Food Chaining, The Digestive Tract and Digestive Tract Disorders
The Food Chaining II Course: Digestive Tract Disorders and Cheri and Laura will be joined again by Mark Fishbein, MD, pediatric gastroenterologist, from Children’s Memorial Hospital in Chicago, Illinois. This course was rated a 5 by 100% of the participants at it’s debut in San Antonio, Texas. Dr. Fishbein is also a co-author of “Food Chaining: The Proven Six Step Solution for Problem and Picky Eating.” He worked with Cheri and Laura and was part of the Springfield, IL feeding team for 10 years. Dr. Fishbein was just named one of “Chicago’s Top Kid Docs” for 2011. The course will focus on treatment of infants and children with a range of gastrointestinal disorders.
These therapy oriented courses are designed for all health professionals interested in pediatric nutrition and feeding disorders. The goal of presenting this series is to provide in depth instruction and understanding of the complex, whole body challenges involved in treatment of infants and children with feeding disorders.
Thursday, July 14, 2011
Junk? Nope.
One of the biggest criticisms of Food Chaining is that we teach children to eat junk food. That may seem correct to those who have not been to our courses or understand the process fully. Our program was featured in The Journal of Clinical Nutrition because we lead children to healthy eating and diets that contain meats, breads/grains, dairy, fruits and vegetables. Our patients eat without being forced, coerced, pressured or stressed. We customize diets of all our patients to help them reach their full potential. I have treated children, even with autistic spectrum disorder, who now have diets that contain broccoli, spinach, fresh fruits, steak...a far cry from the days of popsicles, gummy bears, milk, crackers and chips. The reason our program works is because we start where the child IS and not only expand the diet but teach children HOW to eat these more complex foods. We use those flavor preferences and early texture preferences to design a customized feeding program and expand the diet at the child's pace. Isn't it more likely that the child who eats chicken nugget will accept fried fish, scallops, popcorn shrimp and breaded pork tenderloin before eating baked fish/chicken, roast and steak? But we use dips and condiments and seasonings to work toward those foods and help the children feel safe and confident eating these foods. Doesn't it make sense that a child who loves chocolate could accept fresh fruit dipped in chocolate until we can fade that masking flavor and help the child enjoy the actual taste of fruit? There is no "junk food" unless we are talking fried butter, food is of higher or lower nutritional value. Variety in the diet is key to breaking the patterns of picky eating. The ritual of eating the same thing over and over is much more harmful than eating popcorn shrimp. Selective eating is not just a preference for "junk food" it usually a reflection of the child's immature chewing and swallowing skills. A bite of a goldfish cracker is a very different chewing and swallowing event than a bite of filet mignon. A feeding specialist must start with success and help the child enjoy each trip to the table to avoid anxiety, fear, anger, stress and dysfunctional and destructive interactions at the table. Food Chaining works when done correctly and with eyes that see the current moment as well as a child's potential.
Friday, July 1, 2011
Magic
Dr. Fishbein's nickname for me is "Tinkerbell" a reference to my work with children being magical in nature. What a lovely and humbling compliment. Truth be told, there are few things in this world that I truly do well, but this is just something that comes easily to me.
This week, I had a session that was truly magic. A few years ago, I met a wonderful young family with a little one who had a lot of fear at the table. At the time I told them that I believed their son had a GI disorder and needed assessment and treatment to be successful at the table. Frankly, they did not buy into my assessment and we did not see them for two years. Fast forward to today and their son is not only rejecting new foods but losing foods in his food repertoire. All he wants is milk. Milk that coats and soothes an angry GI tract but in high volumes can lead to diminished appetite and health issues, like anemia. They came to clinic again and I told them I would treat him only with a multidisciplinary approach and if they would agree to follow my intervention plan with a three month review of where we were at that time. I told them that if I started treating him while he had an active, untreated GI disorder he would not make progress. They agreed and the GI assessment revealed that the child did indeed have a GI disorder. So now, we were truly in a place where I could help undo the damage that eating with pain causes. The parents had also implemented a strict behavioral approach but they had been very inconsistent in how they interacted with their son at the table. "Leaning on their own understanding" had not worked for them and they were ready to accept help from our team. We paired GI meds with a gradual decrease in milk to improve appetite but not take away what this child needed (the coating effect of milk) to ease his angry GI tract. The medication became the substitute for the milk and we were now ready to work in fertile soil, where change is not only possible, it is lasting. I just had to deal with how to bring him back from 2+ years of a very negative experience.
Both parents came to our first session. I had told them to have their son help pack a lunch box of small portions of 2 foods he liked and one he wanted to learn about, but they forgot to do that. They showed up with only a cup of milk. They were pretty overwhelmed and I told them not to worry. I went to the kitchen in our department and came back with two types of divided plates (school tray style and character plate) and a bowl. I had my cues cards of what to say at the table and what to drop from your vocabulary (do NOT say "take a bite"). I also had two little boxes of cereal, a waffle, a little cup of syrup and a variety of utensils.
The child was clinging to his dad and they both were sitting across the room from me. I sat at the little table and talked to all of them and every once in a while made eye contact with the child and smiled. I made it clear that no one would make him eat, we were just going to have fun. I asked Dad to move his chair up closer to the table and still hold his son on his lap. Mom sat in a small chair beside them at the table and I was across. Space is important, I am new to this little one and we need time to get to know each other. We opened the boxes of Apple Jacks and Corn Pops, these are new foods for him. I started putting pieces of cereal in the sections of the divided plate. I asked the child if I should put the cereal on the big tray or on my astronauts on other divided plate. He pointed to the big tray. I started trying to shoot a basket with the cereal across the table to the tray in front of him. One bounced out and he looked at me and giggled. I told him I didn't know cereal could bounce! He slid out of his father's lap and stood at the table. We started playing together putting the pieces of cereal on the tray. I told mom and dad a bit more about sensory exploration and that must happen before putting food in the mouth. We needed to learn about this new food with our hands first and I demonstrated making crumbs. I crushed cereal into tiny pieces. I put some on the astronaut and his father (who quickly caught on) said, "see we can make moon rocks!" The child and his dad started crushing cereal, breaking them in half and laughing. Bye bye anxiety, now we can go somewhere. I started stacking up the Corn Pops and I showed my new little friend that Corn Pops are sticky. I stuck one to my finger and it did not fall off. He giggled again. We put some of this cereal on the trays and continued crushing and crunching and he was exploring and interacting and learning about two new foods. I told the child and his dad that we could just put our fingers in the crumbs and taste one. Dad did it and so did the child. No one said anything or yelled "yeah" or anything, we just kept the ball rolling forward. I told his dad that it is also fun to crush the cereal with your teeth. The father picked one up and bit into it. So did his son, who said, "mmm, that is good." We decided Mommy needed to try something fun and we cut our waffle into pieces. Then we started scooping tiny amounts of syrup into each little square of our waffle. The child immediately started doing this and then put Apple Jacks on the sections. I shared with the parents earlier that sometimes I put blueberries in the sections of the waffle and someone was listening to me! We had a lot of fun scooping, dipping, crushing, crunching and then as parents and I talked more, the little boy dipped his finger in syrup and continued to eat cereal and drink his milk. We didn't "do anything" and he was eating. I just pointed over in his direction and mom and dad looked at each other in amazement. He kept saying, "mmmm, that is good" and "I like this." We got a bunch of big stickers out and selected some good ones to reward such bravery. He is going to use a new sticker to help me know when he learns about a new food. When it was time to go, he didn't want to leave. Magic.
This week he will explore the produce section in the grocery store and find a food to learn about. He can pick a color of food or find something that looks interesting to him. This week he is in control of eating, he will explore with his senses and in his comfort zone. We will expand foods like breads/grains that should be much easier for him to tolerate from a sensory standpoint. The focus will not be on taking a bite, but taking a step toward the table. Our primary goal will be enjoyment and peace at the table. One good experience leads to another good experience, making the chain of success. He will not be punished, he won't be sitting at the table for two hours, he won't be holding food in his mouth for an hour instead of swallowing it, he won't dissolve in tears at the table. The plate at mealtime will contain one food he really loves to eat in ONE section of his new divided plate. The portion will be slightly smaller than normal. He will also be given a small portion of a food he is OK with eating and one tiny portion of a new "learning" food. He will give ratings to his food 1-5 so I know how he liked it (rate appearance, smell, texture and/or taste). He will drink one serving of flavored milk in the morning (as kids with GI disorders usually don't like to eat well first thing in the morning) and he will have a morning snack later at school. He will have one Carnation Instant Breakfast at lunch at daycare as he usually cannot tolerate eating in this environment and has gone all day without food. Food will be offered but the CIB will be there as a support until he can eat at school too. I am reducing his milk and giving him micronutrients he needs. Plus a bit of weight gain will help fuel his appetite. He will be offered six mini meals per day. Food will be offered for a short time and he will not be pressured to eat. At night he will have dinner (usually a very hard meal for him) and one before bed snack. He will get his Pediasure to supplement his diet and help hold him comfortably overnight.
I think he is going to soar in treatment now. Mom and Dad understood the approach and I gave them a progression of sensory exploration activities and tips to make tasting fun, and eyes to see when their son is ready to do so. The joy of eating is truly magic and hopefully this little one will learn to enjoy not endure meals. Do you see that is so much MORE than just combining similar foods. Happy Chaining!
This week, I had a session that was truly magic. A few years ago, I met a wonderful young family with a little one who had a lot of fear at the table. At the time I told them that I believed their son had a GI disorder and needed assessment and treatment to be successful at the table. Frankly, they did not buy into my assessment and we did not see them for two years. Fast forward to today and their son is not only rejecting new foods but losing foods in his food repertoire. All he wants is milk. Milk that coats and soothes an angry GI tract but in high volumes can lead to diminished appetite and health issues, like anemia. They came to clinic again and I told them I would treat him only with a multidisciplinary approach and if they would agree to follow my intervention plan with a three month review of where we were at that time. I told them that if I started treating him while he had an active, untreated GI disorder he would not make progress. They agreed and the GI assessment revealed that the child did indeed have a GI disorder. So now, we were truly in a place where I could help undo the damage that eating with pain causes. The parents had also implemented a strict behavioral approach but they had been very inconsistent in how they interacted with their son at the table. "Leaning on their own understanding" had not worked for them and they were ready to accept help from our team. We paired GI meds with a gradual decrease in milk to improve appetite but not take away what this child needed (the coating effect of milk) to ease his angry GI tract. The medication became the substitute for the milk and we were now ready to work in fertile soil, where change is not only possible, it is lasting. I just had to deal with how to bring him back from 2+ years of a very negative experience.
Both parents came to our first session. I had told them to have their son help pack a lunch box of small portions of 2 foods he liked and one he wanted to learn about, but they forgot to do that. They showed up with only a cup of milk. They were pretty overwhelmed and I told them not to worry. I went to the kitchen in our department and came back with two types of divided plates (school tray style and character plate) and a bowl. I had my cues cards of what to say at the table and what to drop from your vocabulary (do NOT say "take a bite"). I also had two little boxes of cereal, a waffle, a little cup of syrup and a variety of utensils.
The child was clinging to his dad and they both were sitting across the room from me. I sat at the little table and talked to all of them and every once in a while made eye contact with the child and smiled. I made it clear that no one would make him eat, we were just going to have fun. I asked Dad to move his chair up closer to the table and still hold his son on his lap. Mom sat in a small chair beside them at the table and I was across. Space is important, I am new to this little one and we need time to get to know each other. We opened the boxes of Apple Jacks and Corn Pops, these are new foods for him. I started putting pieces of cereal in the sections of the divided plate. I asked the child if I should put the cereal on the big tray or on my astronauts on other divided plate. He pointed to the big tray. I started trying to shoot a basket with the cereal across the table to the tray in front of him. One bounced out and he looked at me and giggled. I told him I didn't know cereal could bounce! He slid out of his father's lap and stood at the table. We started playing together putting the pieces of cereal on the tray. I told mom and dad a bit more about sensory exploration and that must happen before putting food in the mouth. We needed to learn about this new food with our hands first and I demonstrated making crumbs. I crushed cereal into tiny pieces. I put some on the astronaut and his father (who quickly caught on) said, "see we can make moon rocks!" The child and his dad started crushing cereal, breaking them in half and laughing. Bye bye anxiety, now we can go somewhere. I started stacking up the Corn Pops and I showed my new little friend that Corn Pops are sticky. I stuck one to my finger and it did not fall off. He giggled again. We put some of this cereal on the trays and continued crushing and crunching and he was exploring and interacting and learning about two new foods. I told the child and his dad that we could just put our fingers in the crumbs and taste one. Dad did it and so did the child. No one said anything or yelled "yeah" or anything, we just kept the ball rolling forward. I told his dad that it is also fun to crush the cereal with your teeth. The father picked one up and bit into it. So did his son, who said, "mmm, that is good." We decided Mommy needed to try something fun and we cut our waffle into pieces. Then we started scooping tiny amounts of syrup into each little square of our waffle. The child immediately started doing this and then put Apple Jacks on the sections. I shared with the parents earlier that sometimes I put blueberries in the sections of the waffle and someone was listening to me! We had a lot of fun scooping, dipping, crushing, crunching and then as parents and I talked more, the little boy dipped his finger in syrup and continued to eat cereal and drink his milk. We didn't "do anything" and he was eating. I just pointed over in his direction and mom and dad looked at each other in amazement. He kept saying, "mmmm, that is good" and "I like this." We got a bunch of big stickers out and selected some good ones to reward such bravery. He is going to use a new sticker to help me know when he learns about a new food. When it was time to go, he didn't want to leave. Magic.
This week he will explore the produce section in the grocery store and find a food to learn about. He can pick a color of food or find something that looks interesting to him. This week he is in control of eating, he will explore with his senses and in his comfort zone. We will expand foods like breads/grains that should be much easier for him to tolerate from a sensory standpoint. The focus will not be on taking a bite, but taking a step toward the table. Our primary goal will be enjoyment and peace at the table. One good experience leads to another good experience, making the chain of success. He will not be punished, he won't be sitting at the table for two hours, he won't be holding food in his mouth for an hour instead of swallowing it, he won't dissolve in tears at the table. The plate at mealtime will contain one food he really loves to eat in ONE section of his new divided plate. The portion will be slightly smaller than normal. He will also be given a small portion of a food he is OK with eating and one tiny portion of a new "learning" food. He will give ratings to his food 1-5 so I know how he liked it (rate appearance, smell, texture and/or taste). He will drink one serving of flavored milk in the morning (as kids with GI disorders usually don't like to eat well first thing in the morning) and he will have a morning snack later at school. He will have one Carnation Instant Breakfast at lunch at daycare as he usually cannot tolerate eating in this environment and has gone all day without food. Food will be offered but the CIB will be there as a support until he can eat at school too. I am reducing his milk and giving him micronutrients he needs. Plus a bit of weight gain will help fuel his appetite. He will be offered six mini meals per day. Food will be offered for a short time and he will not be pressured to eat. At night he will have dinner (usually a very hard meal for him) and one before bed snack. He will get his Pediasure to supplement his diet and help hold him comfortably overnight.
I think he is going to soar in treatment now. Mom and Dad understood the approach and I gave them a progression of sensory exploration activities and tips to make tasting fun, and eyes to see when their son is ready to do so. The joy of eating is truly magic and hopefully this little one will learn to enjoy not endure meals. Do you see that is so much MORE than just combining similar foods. Happy Chaining!
Monday, May 23, 2011
Simply Thick Warning
SimplyThick: Public Health Notification - Risk of Life-Threatening Bowel Condition
AUDIENCE: Consumers, Pediatrics, Emergency medicine
ISSUE: FDA notified parents, caregivers and health care providers not to feed SimplyThick, a thickening agent for management of swallowing disorders, to infants born before 37 weeks. The product may cause necrotizing enterocolitis (NEC), a life-threatening condition characterized by inflammation and death of intestinal tissue.
BACKGROUND: FDA first learned of adverse events possibly linked to the product on May 13, 2011. To date, the agency is aware of 15 cases of NEC, including two deaths, involving premature infants who were fed SimplyThick for varying amounts of time. The product was mixed with mothers’ breast milk or infant formula. Illnesses have been reported from at least four different medical centers around the country. The illnesses of which FDA is aware involve premature infants. SimplyThick was added to the feeding regimen of those infants, who later developed NEC, to help with swallowing difficulties stemming from complications of premature birth.
The product is sold in packets of individual servings and in 64-ounce dispenser bottles. The product can be purchased from distributors and local pharmacies throughout the United States.
RECOMMENDATION: Health care providers should stop administering the product to premature infants. Parents and caregivers who have questions or concerns related to the use of the product and/or who have medical concerns should contact their health care provider. See the photographs at the link below for images of the product.
Read the MedWatch safety alert, including links to the Press Release and product photos, at:
http://www.fda.gov/Safety/MedWatch/SafetyInformation/SafetyAlertsforHumanMedicalProducts/ucm256257.htm
AUDIENCE: Consumers, Pediatrics, Emergency medicine
ISSUE: FDA notified parents, caregivers and health care providers not to feed SimplyThick, a thickening agent for management of swallowing disorders, to infants born before 37 weeks. The product may cause necrotizing enterocolitis (NEC), a life-threatening condition characterized by inflammation and death of intestinal tissue.
BACKGROUND: FDA first learned of adverse events possibly linked to the product on May 13, 2011. To date, the agency is aware of 15 cases of NEC, including two deaths, involving premature infants who were fed SimplyThick for varying amounts of time. The product was mixed with mothers’ breast milk or infant formula. Illnesses have been reported from at least four different medical centers around the country. The illnesses of which FDA is aware involve premature infants. SimplyThick was added to the feeding regimen of those infants, who later developed NEC, to help with swallowing difficulties stemming from complications of premature birth.
The product is sold in packets of individual servings and in 64-ounce dispenser bottles. The product can be purchased from distributors and local pharmacies throughout the United States.
RECOMMENDATION: Health care providers should stop administering the product to premature infants. Parents and caregivers who have questions or concerns related to the use of the product and/or who have medical concerns should contact their health care provider. See the photographs at the link below for images of the product.
Read the MedWatch safety alert, including links to the Press Release and product photos, at:
http://www.fda.gov/Safety/MedWatch/SafetyInformation/SafetyAlertsforHumanMedicalProducts/ucm256257.htm
Saturday, April 23, 2011
The Graz Method AND Pre-Chaining
I am going to be part of a tube weaning using the Graz method. The patient has seen me since age 2m and the PreChaining therapy program has been extremely successful. This child has the skills to eat above age level for solid foods and dysphagia for liquids has resolved. There were numerous challenges throughout this first year of life, yet amount of food accepted is impacted by the tube feedings. We will formally work with the Graz team over a one to two week time period. I will continue to post general information about this program that has a very high success rate. I am not anxious about it because of the PreChaining program. For more, see the link about the Graz method.
What should I DO at the table? In a word...
OK....You have had your child checked by a good and reputable team to rule out GI disorders and other medical based issues that can derail successful eating. Your child has no swallowing problems, no airway problems, no GI issues and no major nutritional issues. Maybe some mild sensory issues, but nothing major. The dietitian has told you that things are not that bad and you are actually dealing with persistent pickiness only... Now, what should you do?
NOTHING.
Let me say it again...NOTHING.
Now most of you and shaking your heads and getting ready to pull your hair out, but I will tell you after doing this for 24 years, that is the best advice I can give you. Stop thinking about it all the time. Offer food on a plate, offer a variety of food, use the ideas of food chaining of offering food similar to what your child already eats and build on tastes, textures and help teach and offer learning opportunities for your child but at the table? Do NOTHING.
You cannot, should not and will not succeed by taking control of another person's eating. You must offer food/liquids on a schedule that helps stimulate appetite and then... eat your meal, talk about anything else but how your child is eating, take the words "take a bite" out of your vocabulary and leave the child to decide what to eat or not to eat. Understand child portions and eating patterns. Most kids don't eat well and vegetables are an acquired tastes. Ultimately, it is the child's decision to eat that matters.
If he chooses poorly, he experiences hunger. There are some kids who do not feel hunger or have dysphagia, but that is why the medical feeding team is needed to identify those kids and a different set of intervention strategies are needed for problem eaters. But uncomplicated picky? Do NOTHING.
Pressure does not work. Force does not work because it will always turn around and bite you in the end. Providing is your job. Eating is the child's job. Do not give the child the spotlight at the table, don't let them pull your strings by how they eat each day. Calm yourself as much as possible. Go scream in the backyard if you need to, but don't feed into this. Pun intended.
The true picky eater without problems is out there and most of them come out of it on their own. The problem eater needs our help. There is a difference. But picky can become problematic and emotional and stress laden and behavioral. Don't let it. There is power and action in restraint. Deep breath. This too shall pass.
NOTHING.
Let me say it again...NOTHING.
Now most of you and shaking your heads and getting ready to pull your hair out, but I will tell you after doing this for 24 years, that is the best advice I can give you. Stop thinking about it all the time. Offer food on a plate, offer a variety of food, use the ideas of food chaining of offering food similar to what your child already eats and build on tastes, textures and help teach and offer learning opportunities for your child but at the table? Do NOTHING.
You cannot, should not and will not succeed by taking control of another person's eating. You must offer food/liquids on a schedule that helps stimulate appetite and then... eat your meal, talk about anything else but how your child is eating, take the words "take a bite" out of your vocabulary and leave the child to decide what to eat or not to eat. Understand child portions and eating patterns. Most kids don't eat well and vegetables are an acquired tastes. Ultimately, it is the child's decision to eat that matters.
If he chooses poorly, he experiences hunger. There are some kids who do not feel hunger or have dysphagia, but that is why the medical feeding team is needed to identify those kids and a different set of intervention strategies are needed for problem eaters. But uncomplicated picky? Do NOTHING.
Pressure does not work. Force does not work because it will always turn around and bite you in the end. Providing is your job. Eating is the child's job. Do not give the child the spotlight at the table, don't let them pull your strings by how they eat each day. Calm yourself as much as possible. Go scream in the backyard if you need to, but don't feed into this. Pun intended.
The true picky eater without problems is out there and most of them come out of it on their own. The problem eater needs our help. There is a difference. But picky can become problematic and emotional and stress laden and behavioral. Don't let it. There is power and action in restraint. Deep breath. This too shall pass.
The Advance...Food Chaining made the April 4 Cover Story
Helping Children with Feeding Disorders Expand Their Diet
By Jason Mosheim
Posted on: April 5, 2011
View Comments (0)Print ArticleEmail ArticleShare
Vol. 21 • Issue 6 • Page 6
Cover Story
When the ultimate goal of a program is to find joy in eating, who could argue? Food chaining is an approach to help children expand their diets by using their favorite foods or drinks as a launching pad to gradually beef up their eating repertoire. Developed by Cheri Fraker, MS, CCC-SLP, with Laura Walbert, MS, CCC-SLP, of the Koke Mill Medical Center, in Springfield, IL, and Sibyl Cox, RD, LD, of the Southen Illinois University School of Medicine, food chaining complies with best practices for treatment of feeding disorders.1
About 25 percent to 35 percent of children, including those developing typically, have a feeding disorder of some kind, according to Fraker. However, more than 70 percent of premature or medically fragile children have a feeding disorder, and up to 90 percent of children with cerebral palsy have a significant feeding or nutritional problem. All of these children are candidates for food chaining.
"The main goal of food chaining is to expand the diet and have children eat food from all food groups. Not necessarily all foods, but food they enjoy," Fraker told ADVANCE. "Enjoyment is one of our biggest goals."
Best practice guidelines recommend a low-pressure approach to feeding. Clinicians need to provide children with multiple exposures to food, become familiar with the swallowing aspect of feeding, and understand some children lack certain skills to eat some foods. They may appear picky, but in many cases they are probably avoiding particular foods because they don't know how to eat them successfully.
Speech-language pathologists should study carefully what the child eats-including tastes, textures and aftertastes-as well as the child's chewing patterns and expand on all of them. "My belief is children eat the crunchy crackers and chips not just because they like them, but because they only have the skills to eat those foods. They eat those foods because they can breathe around them or they are successful. I don't necessarily think they love those crackers," she said.
In food chaining the clinician put foods in an order and builds the child's oral motor skills. "We have to develop flexible oral-motor skills," Fraker said. "These kids literally do not know how to sequence the motor patterns to eat food of different textures. For example, with a challenging food like meat, you need to stabilize the bolus of food inside of the cheek, chew a piece off, and then swallow a portion of it and repeat. We teach the mechanics of eating different foods. I tell them, 'You drink soup differently than you eat a pretzel, mashed potatoes or a steak. If you use the same pattern over and over with those foods, you'll gag, choke, and be unsuccessful.'
To put food in order, speech-language pathologists first must look at a child's core diet. What do they eat? What are they good at eating? A food is considered part of the core diet if a child can comfortably eat at least a portion of it and not just one or two bites.
Clinicians also should study the child's upper airway system, too. Are the adenoids enlarged? Is the child swallowing well? Is the child handling everything well? Could the child begin to head down the right path if the clinician expanded the intake of breads and grains? For example, children can be given a banana or apple bread to expand fruit flavor in a texture they can handle. The clinician then can start working to progress the chewing process.
Ewan, who has autism, dysphagia and eosinophilic esophagitis, was eating just 10 foods when he started food chaining. He now eats all foods, including a wide variety of meat, fruit and vegetables.
"I might go after dried fruits at first. I tell them they are a little gummy or a little chewier, and I show them where to put it in their mouth, what their tongue does, and where it moves the food," she said. Fraker sometimes uses puppets to model the process.
She also may put children on a therapy ball and bounce them up and down as though they were a piece of food in their mouth. "I say, 'We push it to the side,' and I take them to the side of the ball. Then I say, 'We push it to the middle.' I teach them the big motor plan."
Food chaining also utilizes the "Get Permission" approach developed by Marsha Dunn Klein, MEd, OTR/L, as well as her ideas of "mouse bites" and "elephant bites." "I expand the flavor of food before I expand the texture of food," Fraker said. "I just want to get kids tasting something new in a way they can handle. I don't want them gagging on the texture or not being able to chew it. I want them to experience it and see what they like."
For children with feeding disorders, the introduction of new foods can be a very frightening experience, she said. "They are very scared. When you bite into an orange, you bite through skin. You have this white stuff on the outside, and all this juice comes out. They are dealing with two food consistencies, liquid and fruit, and they never stay the same. The food is complexly textured. It becomes mushy, and they don't know what to do with it."
She instructs children to bite into the fruit and drink the juice first. "I've had kids standing up, tipping their head down, trying to let the juice run forward in their mouth," she said. "I tell the parents they want the fruit; they just don't know how to do it. Once we teach them and they have the confidence, the food chaining takes off because they feel, 'I can do this, and I can be safe.' They can really explore flavor and then more textures."
At the beginning of food chaining, clinicians need to be aware of any gastrointestinal issues or food allergies children have. Can they digest certain foods, or do they experience severe constipation? Do they have reflux esophagitis or an eosinophilic disorder? "We need to know the signs of those disorders and when to refer," Fraker said.
The next issue is nutrition. Are children growing? Are they getting enough micronutrients? Clinicians need to consider the sensory side of feeding.
Lucy was a 27-week preemie with severe allergies, adenoiditis, dysphagia and severe aversion. At 11 months, she is now eating a wide range of foods and working to transition off her g-tube for liquids.
Take special note of a child's behaviors. Only 3 percent to 12 percent of children have a purely behavioral feeding disorder, yet over 90 percent of what people do to treat it is behavioral, she said. "You've got to build oral-motor and sensory skills, and you've got to get the body feeling well, or the child is going to say 'no.' It's not a behavioral 'no,' it's a 'No, my body can't handle this.'"
After reviewing a child's swallowing, it's time to focus on food. "We break down food for therapists so they can offer a food matching a child's oral-motor skills, swallowing skills and taste texture preferences," she said.
Clinicians can scare children when they change food. For children with autism, a change in food can be like a bug or a hair in our food. "They go into panic mode, and that can interfere with appetite," Fraker said. "You want to teach the child to handle the changes and let the child be in control of their food."
It's important to customize food chaining to each child. In fact, it's the only way.
"I tell people all my kids are snowflakes-their eating issues are different," she said. "We tell therapists to trust their skill and develop eyes that see. They shouldn't feel like they have to do a cookie-cutter approach because they won't be successful. They have to zoom in on what's going on."
There are three techniques involved in food chaining that put children on the path to success:
flavor mapping,
transitional foods and
flavor masking.
In flavor mapping, speech-language pathologists map out a child's favorite flavors. Are they all sweet? All salty? Then they need to figure out ways to expand the child's flavor menu. A child who only likes salty crackers, for example, might want to try to eat a Club or Ritz cracker that is slightly sweeter.
"We start a progression by trying to introduce them to a range of flavors. We might put a tiny amount of food on their tasting straws or their finger and see what they like," she said. "Then we rate the child's response to the new food from one to 10. How did it taste? Is it a one, a five, a 10? We keep track of that and offer more foods like the higher-rated items."
In the second phase, which involves transitional foods, clinicians can ask children to take a bite of a familiar food, such as bread, followed by a bite of a new food. "You taste a food you really like and then try a bite of a new food, and we go back and forth. I've done that with drinks, too, to kill the aftertaste for kids," she said. Some children with autism have reported tasting a new food for days because the aftertaste is so strong.
Flavor masking is when the clinician dips a new food in a flavor the child likes, such as ranch dressing or barbecue sauce. "I will dip foods and say, 'You're going to taste your ranch dressing first, and then tell me what you think about the rest of the food.' We work progressively to decrease the amount of the dip," Fraker said. For children who don't like dip, clinicians can use "dry dips," such as garlic salt or cinnamon sugar. "I have one little boy with autism who will eat anything now if I put Mrs. Dash on it."
The rating scales in food chaining can help speech-language pathologists find the right direction for therapy. "When the kids rate food, I tell them, 'This helps me continue to make a map for you.' They may surprise me. Kiwi might be a 10 when I didn't expect that. I'm going to go in that direction with them," she said.
It's important to let children know they are in control. Not only does it lead to more success, but it increases the trust level.
"It's not healthy to take control of someone's eating because it can spiral into an eating disorder of another kind," Fraker said. "Once I put food in front of them, it belongs to them. I don't try to force them, and I never say, 'Take a bite.' I model, and I let them feel that control and trust because that is absolutely key. I have expectations for them, and they know that, but I don't let it become a battle. I always try to leave on a success."
Planning themes is a big part of food chaining. One day might be Baseball Day, with a focus on the foods found at a ballpark, while the next day could be all about Hawaii. Other themes could focus on crunchy or spicy foods or the colors of foods and drinks.
"When I wrap it up in a theme of language and learning, they calm down. Food is so dynamic," she said. "Food can be melted, and it can be sliced. There's so much language involved in it, and it's so social. I have a little boy who puts peas on a toothpick. He loves Star Wars, and we talk about Star Wars the whole time. I combine feeding and language therapy."
She tells parents eating should be enjoyable. "In so many of these kids, there's no joy in eating because it is too hard," she said. "We try to build confidence and enjoyment to help children become healthy eaters for life."
Reference
Lumeng, J. (2005). Is the picky eater a cause for concern? Contemporary Pediatrics, March 1.
Resources
Fishbein, M.,, Fraker, C., Cox, S., et al. (2004). Food chaining: A systematic approach for the treatment of children with eating aversion. Journal of Pediatric Gastroenterology & Nutrition, 39 (S51).
Food Chaining with Cheri Fraker and Laura Walbert, http://cheriandlaura.blogspot.com
Fraker, C., Walbert, L., Cox, S., et al. (2007). Food Chaining: The Proven 6-Step Plan to Stop Picky Eating, Solve Feeding Problems, and Expand Your Child's Diet. New York: Da Capo Press.
For More Information
Cheri Fraker, fraker.cheri@mhsil.com
Jason Mosheim is Senior Associate Editor at ADVANCE. He can be contacted at jmosheim@advanceweb.com.
By Jason Mosheim
Posted on: April 5, 2011
View Comments (0)Print ArticleEmail ArticleShare
Vol. 21 • Issue 6 • Page 6
Cover Story
When the ultimate goal of a program is to find joy in eating, who could argue? Food chaining is an approach to help children expand their diets by using their favorite foods or drinks as a launching pad to gradually beef up their eating repertoire. Developed by Cheri Fraker, MS, CCC-SLP, with Laura Walbert, MS, CCC-SLP, of the Koke Mill Medical Center, in Springfield, IL, and Sibyl Cox, RD, LD, of the Southen Illinois University School of Medicine, food chaining complies with best practices for treatment of feeding disorders.1
About 25 percent to 35 percent of children, including those developing typically, have a feeding disorder of some kind, according to Fraker. However, more than 70 percent of premature or medically fragile children have a feeding disorder, and up to 90 percent of children with cerebral palsy have a significant feeding or nutritional problem. All of these children are candidates for food chaining.
"The main goal of food chaining is to expand the diet and have children eat food from all food groups. Not necessarily all foods, but food they enjoy," Fraker told ADVANCE. "Enjoyment is one of our biggest goals."
Best practice guidelines recommend a low-pressure approach to feeding. Clinicians need to provide children with multiple exposures to food, become familiar with the swallowing aspect of feeding, and understand some children lack certain skills to eat some foods. They may appear picky, but in many cases they are probably avoiding particular foods because they don't know how to eat them successfully.
Speech-language pathologists should study carefully what the child eats-including tastes, textures and aftertastes-as well as the child's chewing patterns and expand on all of them. "My belief is children eat the crunchy crackers and chips not just because they like them, but because they only have the skills to eat those foods. They eat those foods because they can breathe around them or they are successful. I don't necessarily think they love those crackers," she said.
In food chaining the clinician put foods in an order and builds the child's oral motor skills. "We have to develop flexible oral-motor skills," Fraker said. "These kids literally do not know how to sequence the motor patterns to eat food of different textures. For example, with a challenging food like meat, you need to stabilize the bolus of food inside of the cheek, chew a piece off, and then swallow a portion of it and repeat. We teach the mechanics of eating different foods. I tell them, 'You drink soup differently than you eat a pretzel, mashed potatoes or a steak. If you use the same pattern over and over with those foods, you'll gag, choke, and be unsuccessful.'
To put food in order, speech-language pathologists first must look at a child's core diet. What do they eat? What are they good at eating? A food is considered part of the core diet if a child can comfortably eat at least a portion of it and not just one or two bites.
Clinicians also should study the child's upper airway system, too. Are the adenoids enlarged? Is the child swallowing well? Is the child handling everything well? Could the child begin to head down the right path if the clinician expanded the intake of breads and grains? For example, children can be given a banana or apple bread to expand fruit flavor in a texture they can handle. The clinician then can start working to progress the chewing process.
Ewan, who has autism, dysphagia and eosinophilic esophagitis, was eating just 10 foods when he started food chaining. He now eats all foods, including a wide variety of meat, fruit and vegetables.
"I might go after dried fruits at first. I tell them they are a little gummy or a little chewier, and I show them where to put it in their mouth, what their tongue does, and where it moves the food," she said. Fraker sometimes uses puppets to model the process.
She also may put children on a therapy ball and bounce them up and down as though they were a piece of food in their mouth. "I say, 'We push it to the side,' and I take them to the side of the ball. Then I say, 'We push it to the middle.' I teach them the big motor plan."
Food chaining also utilizes the "Get Permission" approach developed by Marsha Dunn Klein, MEd, OTR/L, as well as her ideas of "mouse bites" and "elephant bites." "I expand the flavor of food before I expand the texture of food," Fraker said. "I just want to get kids tasting something new in a way they can handle. I don't want them gagging on the texture or not being able to chew it. I want them to experience it and see what they like."
For children with feeding disorders, the introduction of new foods can be a very frightening experience, she said. "They are very scared. When you bite into an orange, you bite through skin. You have this white stuff on the outside, and all this juice comes out. They are dealing with two food consistencies, liquid and fruit, and they never stay the same. The food is complexly textured. It becomes mushy, and they don't know what to do with it."
She instructs children to bite into the fruit and drink the juice first. "I've had kids standing up, tipping their head down, trying to let the juice run forward in their mouth," she said. "I tell the parents they want the fruit; they just don't know how to do it. Once we teach them and they have the confidence, the food chaining takes off because they feel, 'I can do this, and I can be safe.' They can really explore flavor and then more textures."
At the beginning of food chaining, clinicians need to be aware of any gastrointestinal issues or food allergies children have. Can they digest certain foods, or do they experience severe constipation? Do they have reflux esophagitis or an eosinophilic disorder? "We need to know the signs of those disorders and when to refer," Fraker said.
The next issue is nutrition. Are children growing? Are they getting enough micronutrients? Clinicians need to consider the sensory side of feeding.
Lucy was a 27-week preemie with severe allergies, adenoiditis, dysphagia and severe aversion. At 11 months, she is now eating a wide range of foods and working to transition off her g-tube for liquids.
Take special note of a child's behaviors. Only 3 percent to 12 percent of children have a purely behavioral feeding disorder, yet over 90 percent of what people do to treat it is behavioral, she said. "You've got to build oral-motor and sensory skills, and you've got to get the body feeling well, or the child is going to say 'no.' It's not a behavioral 'no,' it's a 'No, my body can't handle this.'"
After reviewing a child's swallowing, it's time to focus on food. "We break down food for therapists so they can offer a food matching a child's oral-motor skills, swallowing skills and taste texture preferences," she said.
Clinicians can scare children when they change food. For children with autism, a change in food can be like a bug or a hair in our food. "They go into panic mode, and that can interfere with appetite," Fraker said. "You want to teach the child to handle the changes and let the child be in control of their food."
It's important to customize food chaining to each child. In fact, it's the only way.
"I tell people all my kids are snowflakes-their eating issues are different," she said. "We tell therapists to trust their skill and develop eyes that see. They shouldn't feel like they have to do a cookie-cutter approach because they won't be successful. They have to zoom in on what's going on."
There are three techniques involved in food chaining that put children on the path to success:
flavor mapping,
transitional foods and
flavor masking.
In flavor mapping, speech-language pathologists map out a child's favorite flavors. Are they all sweet? All salty? Then they need to figure out ways to expand the child's flavor menu. A child who only likes salty crackers, for example, might want to try to eat a Club or Ritz cracker that is slightly sweeter.
"We start a progression by trying to introduce them to a range of flavors. We might put a tiny amount of food on their tasting straws or their finger and see what they like," she said. "Then we rate the child's response to the new food from one to 10. How did it taste? Is it a one, a five, a 10? We keep track of that and offer more foods like the higher-rated items."
In the second phase, which involves transitional foods, clinicians can ask children to take a bite of a familiar food, such as bread, followed by a bite of a new food. "You taste a food you really like and then try a bite of a new food, and we go back and forth. I've done that with drinks, too, to kill the aftertaste for kids," she said. Some children with autism have reported tasting a new food for days because the aftertaste is so strong.
Flavor masking is when the clinician dips a new food in a flavor the child likes, such as ranch dressing or barbecue sauce. "I will dip foods and say, 'You're going to taste your ranch dressing first, and then tell me what you think about the rest of the food.' We work progressively to decrease the amount of the dip," Fraker said. For children who don't like dip, clinicians can use "dry dips," such as garlic salt or cinnamon sugar. "I have one little boy with autism who will eat anything now if I put Mrs. Dash on it."
The rating scales in food chaining can help speech-language pathologists find the right direction for therapy. "When the kids rate food, I tell them, 'This helps me continue to make a map for you.' They may surprise me. Kiwi might be a 10 when I didn't expect that. I'm going to go in that direction with them," she said.
It's important to let children know they are in control. Not only does it lead to more success, but it increases the trust level.
"It's not healthy to take control of someone's eating because it can spiral into an eating disorder of another kind," Fraker said. "Once I put food in front of them, it belongs to them. I don't try to force them, and I never say, 'Take a bite.' I model, and I let them feel that control and trust because that is absolutely key. I have expectations for them, and they know that, but I don't let it become a battle. I always try to leave on a success."
Planning themes is a big part of food chaining. One day might be Baseball Day, with a focus on the foods found at a ballpark, while the next day could be all about Hawaii. Other themes could focus on crunchy or spicy foods or the colors of foods and drinks.
"When I wrap it up in a theme of language and learning, they calm down. Food is so dynamic," she said. "Food can be melted, and it can be sliced. There's so much language involved in it, and it's so social. I have a little boy who puts peas on a toothpick. He loves Star Wars, and we talk about Star Wars the whole time. I combine feeding and language therapy."
She tells parents eating should be enjoyable. "In so many of these kids, there's no joy in eating because it is too hard," she said. "We try to build confidence and enjoyment to help children become healthy eaters for life."
Reference
Lumeng, J. (2005). Is the picky eater a cause for concern? Contemporary Pediatrics, March 1.
Resources
Fishbein, M.,, Fraker, C., Cox, S., et al. (2004). Food chaining: A systematic approach for the treatment of children with eating aversion. Journal of Pediatric Gastroenterology & Nutrition, 39 (S51).
Food Chaining with Cheri Fraker and Laura Walbert, http://cheriandlaura.blogspot.com
Fraker, C., Walbert, L., Cox, S., et al. (2007). Food Chaining: The Proven 6-Step Plan to Stop Picky Eating, Solve Feeding Problems, and Expand Your Child's Diet. New York: Da Capo Press.
For More Information
Cheri Fraker, fraker.cheri@mhsil.com
Jason Mosheim is Senior Associate Editor at ADVANCE. He can be contacted at jmosheim@advanceweb.com.
My Battle with Food
I love food, yet food and I have been enemies literally all of my life. I fit no mold, I am negative for food allergies, celiac disease, eosinophilic esophagitis and a variety of other GI disorders, yet the result of eating for me =pain and a general feeling of ick. My diagnosis in my own mind as a feeding specialist, is inflammation. I have a general inflammation, auto-immune complex. I have polycystic liver disease and thankfully I am negative for polycystic kidney disease. I have cysts in my liver, pancreas and lung. I am allergic to most of Illinois (off the charts environmentally) and react to medications in small ways and big, life threatening ways (v-tach). I just had a big ol' renal work up because I am becoming puffy. Retaining fluid and it is inching my blood pressure up and making me feel, well...ick. My doctor thinks I am becoming increasingly reactive to the world around me.
At times, I am tempted to run an NG and live on Elecare for a month and start all over again. I need to do something. What I don't know. I do know that the things my allergist suggested have been the closest to working and actually kept me alive this spring. No big respiratory illness this year and that has only happened probably 5 out of my 48 years.
What should I do? Become a vegan? Try an elimination diet? Talk to my good friend Dr. Fishbein and the amazing Sibyl Cox, RD to see what one does for inflammation. Inflammation friends can lead to many many whole body complications.
How many other "ick" people are there like me? How many kids? This impacts my mood, my sleep, my focus, my joint pain, my energy level...the gut and the brain are linked, completely linked and in ways we cannot imagine. I need a neurogastroenterologist and a new treatment plan. I am much more than an IBS patient, I need to ponder this more and come up with a treatment plan for myself. I have had inflammation of my heart twice, inflammation of my lungs which left me with scary dyspnea and multiple scans due to fear of a pulmonary embolism, now renal system inflammation and all the GI stuff too. It is tough for an Irish redhead to live the in this world. http://my.clevelandclinic.org/symptoms/inflammation/hic_inflammation_what_you_need_to_know.aspx
From The Second Brain...
Down the road, the blossoming field of neurogastroenterology will likely offer some new insight into the workings of the second brain—and its impact on the body and mind. "We have never systematically looked at [the enteric nervous system] in relating lesions in it to diseases like they have for the" central nervous system, Gershon says. One day, perhaps there will be well-known connections between diseases and lesions in the gut's nervous system as some in the brain and spinal cord today indicate multiple sclerosis.
Cutting-edge research is currently investigating how the second brain mediates the body's immune response; after all, at least 70 percent of our immune system is aimed at the gut to expel and kill foreign invaders.
U.C.L.A.'s Mayer is doing work on how the trillions of bacteria in the gut "communicate" with enteric nervous system cells (which they greatly outnumber). His work with the gut's nervous system has led him to think that in coming years psychiatry will need to expand to treat the second brain in addition to the one atop the shoulders.
At times, I am tempted to run an NG and live on Elecare for a month and start all over again. I need to do something. What I don't know. I do know that the things my allergist suggested have been the closest to working and actually kept me alive this spring. No big respiratory illness this year and that has only happened probably 5 out of my 48 years.
What should I do? Become a vegan? Try an elimination diet? Talk to my good friend Dr. Fishbein and the amazing Sibyl Cox, RD to see what one does for inflammation. Inflammation friends can lead to many many whole body complications.
How many other "ick" people are there like me? How many kids? This impacts my mood, my sleep, my focus, my joint pain, my energy level...the gut and the brain are linked, completely linked and in ways we cannot imagine. I need a neurogastroenterologist and a new treatment plan. I am much more than an IBS patient, I need to ponder this more and come up with a treatment plan for myself. I have had inflammation of my heart twice, inflammation of my lungs which left me with scary dyspnea and multiple scans due to fear of a pulmonary embolism, now renal system inflammation and all the GI stuff too. It is tough for an Irish redhead to live the in this world. http://my.clevelandclinic.org/symptoms/inflammation/hic_inflammation_what_you_need_to_know.aspx
From The Second Brain...
Down the road, the blossoming field of neurogastroenterology will likely offer some new insight into the workings of the second brain—and its impact on the body and mind. "We have never systematically looked at [the enteric nervous system] in relating lesions in it to diseases like they have for the" central nervous system, Gershon says. One day, perhaps there will be well-known connections between diseases and lesions in the gut's nervous system as some in the brain and spinal cord today indicate multiple sclerosis.
Cutting-edge research is currently investigating how the second brain mediates the body's immune response; after all, at least 70 percent of our immune system is aimed at the gut to expel and kill foreign invaders.
U.C.L.A.'s Mayer is doing work on how the trillions of bacteria in the gut "communicate" with enteric nervous system cells (which they greatly outnumber). His work with the gut's nervous system has led him to think that in coming years psychiatry will need to expand to treat the second brain in addition to the one atop the shoulders.
Tuesday, March 8, 2011
Hey Chicago, Here We Come! Food Chaining and Get Permission Approach
We would love to see you at our conference in Chicago on May 13 and 14, 2011. Laura and I will be joined not only by the wonderful Marsha Dunn Klein, OT extraordinaire, but we are also going to have a special evening with Mark Fishbein, MD, pediatric gastroenterologist at Children's Memorial Hospital in Chicago, IL. Dr Fishbein will present a lecture on GI disorders and feeding. He will also have a question-answer session with the audience. The course will focus on using Food Chaining and Get Permission approaches together in treatment. PreChaining and treatment for premature infants throughout the first year of life will also be discussed. Great course, great information, wonderful location with great shopping. Hope to see you there!
To register, contact www.cepauniversity.com or email cepa@mtco.com for more information.
This advanced course will combine the best of two treatment approaches that focus on dealing with feeding aversion, food refusal, and understanding aversive behaviors. The “Get Permission” approach builds a foundation of trust in the feeding relationship and supports children who have sensory mealtime challenges to eat with enjoyment and confidence. Food Chaining© programs emphasize multidisciplinary evaluation and non-threatening, child- centered intervention based on analysis of the child’s food preferences. The work- shop is filled with practical mealtime and treatment suggestions. DVD cases will be used throughout the course to maximize the learning outcomes. Mark Fishbein, MD, will present “Feeding Disorders in Infants and Children: A Peds GI Approach”.
WHERE: Oak Brook, Illinois Feeding Course - Doubletree Hotel
WHEN: May 13 & 14 Doubletree Hotel 1909 Spring Road, Oak Brook, IL
PARKING – complimentary
LOCATION – just across the street from Oak Brook Mall shopping/dining extra- ordinaire! (www.oakbrookcenter.com) for directory of stores and restaurants); Near Container Store, I-294, I-88, and I-55.
ACCOMMODATIONS
Doubletree Hotel
1909 Spring Road, Oak Brook, IL 630-472-6000 HOTEL DIRECT$ OR 800-222-TREE Rates: $105$ single or double includes breakfast buffet
$ When reserving a hotel room, identify $ yourself with CEPA to obtain this rate.
Cutoff on rooms: TBI: April 14, 2011 Feeding/Voice: April 29, 2011
HOTEL AMENITIES – lovely suburban hotel with indoor pool, fitness center, and the Oak Brook Mall within walking distance.
ARRIVING BY AIR?
Fly into O’Hare or Midway Airports American Taxi from O’Hare = $35 (est.) 847-255-9600 City Suburban Taxi from Midway = $40 (est.) 630-689-6299
CONTINUING EDUCATION RECOGNITION
Each participant will receive a certificate documenting attendance and CEU’s and/ or
contact hours/clock hours/PDU’s. (see specific courses for exact amount of CE credit).
For SLPs ASHA CEU's
Additional Continuing Education Approval by:
• Commission on Dietetic Registration CPEULevel3=14hours
• CaliforniaBoardofRegisteredNursing–#CEP12564
• Illinois Department of Professional Regulation for Occupational Therapists
Occupational Therapists– CEPA is approved by numerous state Occupational Therapy licensing boards and therefore these courses meet all CE requirements of NBCOT. (Note: NBCOT does not accredit or preapprove CE courses.)
Illinois Early Intervention Program
approved for 14.5 hours (11.5 = Intervention, 1.5 - Atypical, 1.5 = Assessment)
To register, contact www.cepauniversity.com or email cepa@mtco.com for more information.
This advanced course will combine the best of two treatment approaches that focus on dealing with feeding aversion, food refusal, and understanding aversive behaviors. The “Get Permission” approach builds a foundation of trust in the feeding relationship and supports children who have sensory mealtime challenges to eat with enjoyment and confidence. Food Chaining© programs emphasize multidisciplinary evaluation and non-threatening, child- centered intervention based on analysis of the child’s food preferences. The work- shop is filled with practical mealtime and treatment suggestions. DVD cases will be used throughout the course to maximize the learning outcomes. Mark Fishbein, MD, will present “Feeding Disorders in Infants and Children: A Peds GI Approach”.
WHERE: Oak Brook, Illinois Feeding Course - Doubletree Hotel
WHEN: May 13 & 14 Doubletree Hotel 1909 Spring Road, Oak Brook, IL
PARKING – complimentary
LOCATION – just across the street from Oak Brook Mall shopping/dining extra- ordinaire! (www.oakbrookcenter.com) for directory of stores and restaurants); Near Container Store, I-294, I-88, and I-55.
ACCOMMODATIONS
Doubletree Hotel
1909 Spring Road, Oak Brook, IL 630-472-6000 HOTEL DIRECT$ OR 800-222-TREE Rates: $105$ single or double includes breakfast buffet
$ When reserving a hotel room, identify $ yourself with CEPA to obtain this rate.
Cutoff on rooms: TBI: April 14, 2011 Feeding/Voice: April 29, 2011
HOTEL AMENITIES – lovely suburban hotel with indoor pool, fitness center, and the Oak Brook Mall within walking distance.
ARRIVING BY AIR?
Fly into O’Hare or Midway Airports American Taxi from O’Hare = $35 (est.) 847-255-9600 City Suburban Taxi from Midway = $40 (est.) 630-689-6299
CONTINUING EDUCATION RECOGNITION
Each participant will receive a certificate documenting attendance and CEU’s and/ or
contact hours/clock hours/PDU’s. (see specific courses for exact amount of CE credit).
For SLPs ASHA CEU's
Additional Continuing Education Approval by:
• Commission on Dietetic Registration CPEULevel3=14hours
• CaliforniaBoardofRegisteredNursing–#CEP12564
• Illinois Department of Professional Regulation for Occupational Therapists
Occupational Therapists– CEPA is approved by numerous state Occupational Therapy licensing boards and therefore these courses meet all CE requirements of NBCOT. (Note: NBCOT does not accredit or preapprove CE courses.)
Illinois Early Intervention Program
approved for 14.5 hours (11.5 = Intervention, 1.5 - Atypical, 1.5 = Assessment)
Friday, December 17, 2010
Effective Treatment for Feeding Aversion and Dysphagia
Treating Children with Feeding Aversion and Swallowing Disorders-Copyright 2010 Fraker and Walbert. This is an excerpt from our upcoming book #3.
Remember, Food Chaining is a six-step program. Oral motor swallowing skills must be adequate for your child to make progress!
How do you help children with oral motor or swallowing problems become skilled and confident eaters?
For day-to-day therapeutic meals and snacks at home, my goal is to work on the motor sequences of eating. I suggest that parents read my Food Chaining blog and Food Chaining Facebook page for additional tips and then try this out at home. What does “treatment at home” look like? This is not nearly as daunting as it sounds. The swallowing part is customized to each child and I do a complete assessment, including swallow study and assessment with our otolaryngologist. A g-tube may be needed and may be our lifeline as it gives us time to work safely on skills. For swallowing therapy, I will select products to help the child overcome their challenges with dysphagia. I teach them how to be safe. I may start with single drops of liquid for some children and work up from there. It also does not matter what cognitive level the child is at, feeling safe is a great teaching tool. Don’t underestimate kids; they will rise to the challenge. Just because a child is non-verbal don’t assume they don’t learn and learn well. WE just have to be more creative in how we facilitate their communication and learning.
How often, how many times per week? Generally speaking, I usually have parents try to do a food fun activity at a snack time once a day to at least 4 times a week. This should not be work, everyone should have fun AND it is not about how often but how pleasant the experience is for the child that really matters. Put the pressure behind you, amount does not matter. Kids will eat and drink more as they become more skilled. Remember just using the right feeding products is treatment every time your child eats or drinks.
Why do you say a child has to develop a repertoire of FLEXIBLE oral motor skills? Each food has a different set of challenges in regard to how to chew and swallow safely. Each product you drink through requires a shift in your skills; can you purse your lips like you do for straw drinking when you drink from a coffee mug? No. What if you approached eating chicken noodle soup the same way you approach eating a Big Mac? You would not be successful and you would have a wet shirt. Do you drink water the same way you drink a thick milkshake? No! You have to be FLEXIBLE with your oral motor skills. Think of a skilled gymnast, they have to be able to shift from floor routine to high bars to balance beam. If they tried to do all things the same way, it would not work. Foods vary widely in texture and we chew foods in different ways, so oral motor/feeding skills are very much like gymnastics. A skilled therapist helps TEACH kids to eat and drink safely and with confidence.
OK Cheri, how do you have fun with food, food has always been terribly stressful for us?
Well, start down the right road starting today. You must understand the scope of the problem to treat it. Stress and pressure do not help. Would someone pressuring you while you are trying to walk on a balance beam help or hurt you? Kids have to chew/drink and swallow and clear the pharynx in one second. Pretty challenging stuff! Think how your child feels at the table. We need to understand what is happening to help in an effective manner. Many children eat simple crunchy foods because they don’t have the skills to eat the other foods well. Maybe the child can’t breathe through his nose. Put a clip on your nose and try to eat a pork chop. It isn’t easy is it? The child may be picking foods he can breathe around as he munches his food or he takes very small amounts of liquid so he can get air again. He doesn’t know how to chew or drink in a sophisticated manner. For this child, “picky” may not be the issue. Kids who munch look a lot like Pac Man when they eat, they use only an up and down pattern that likely started from bottle-feeding by munching instead of truly sucking. If you approach steak like Pac Man, you will choke to death. Kids eat what they have skills to eat. Texture and taste matter too, but this is a key issue. So, we need to figure out what came first Picky or Pac Man? This is MUCH more complex than it seems.
Tell me more about Picky Eating
By the way, I HATE the label picky eater. It sounds like a bad kid with an indulgent parent and it does not describe the problem(s). I prefer to use the term SELECTIVE eating. Kids select the foods they can eat and feel safe eating. Your child may not eat goldfish and chicken nuggets just for the flavor or texture; he may do it because he has no other choice. So go back to that idea of being a gymnast, your child can only do “floor routine” (munching) and he may lack the skills for eating more advanced textures. This is also why force-feeding does not work. My job is to help your child develop the higher level, flexible oral motor skills. Food Chaining allows me to put foods in a sequence based on your child’s skills. It is much more than color, taste and crunch….it is much more complex. These are the reasons why each child’s Food Chaining program is customized to their individual needs.
Examples of Food Fun Activities
Here are some sample ideas of food activities for home. With food, go to the cabinet or to the store, pick something out and figure out HOW to eat it. Use a mirror or camera, take digital pictures for feedback. Remember, treatment is daily with my programs, just by letting me select the right products to match your child’s oral motor/swallowing skills=daily treatment. Do what I ask of you and don’t push beyond. Pushing does not equal success. You have to trust that I have your child at a place where he is safe and I will determine when it is ok to do more. So remember, much of the work of this program is going to be done for you as every time your child eats or drinks. With the right flow rate, a child is treating himself when drinking, with chewing on the DuoSpoon your child may soon be able to tolerate textures and he will learn more about the mouth. The DuoSpoon improves chewing skills, reduces gagging and helps a child develop the ability to make sense of what is going on in the mouth. Food cut in narrow strips helps kids learn to put it under the teeth. Teaching the skills of eating helps us show kids to “sweep” food over to the teeth with the tongue. We teach them HOW to chew this way. We make the bite sizes very small and work up in size as the child becomes more confident and skilled. With the regulated flow of the cups, straws I issue to the family and cold sensory loaded liquids in single swallows, therapeutic feeds or amounts that I feel are safe, liquid intake should improve quickly. We are working the muscles of the mouth, improving awareness of the sensations inside the mouth, giving a flow rate that does not flood the mouth or throat and making it cold, sour and/or carbonated so the swallow triggers faster. This IS treatment. My friend and colleague Alicia Hart does a Favorite Food Night with her family. That night there are no rules and each family member designs their own meal. I think that is a great idea. Joy is the key to the success of eating; help kids find the joy at the table. Put down this burden once in a while. Daily success and feeling safe at the table will successfully treat the child more than anything else.
I have fun with the kids showing them how to start looking at a bite of food and trying to figure out if they have to kiss it goodbye (purse the lips, activate the cheeks), chew it like a little puppy dog or really chew it like a T-Rex and crush it with the teeth. This helps them get the motor plans down. Cut fruit in little pieces from mouse bite to bunny bite (mandarin oranges are great for this and put colored toothpicks in the cut fruit), see if your child can squeeze the juice out of the bite and swallow it first. Work up in bite size as tolerated. This is fun and easy, but works really well.
I get little fruit cups and we go “fishing” with our toothpicks in therapy. Then the kids use plastic knives to cut the piece of fruit in sections and they use the toothpicks as their utensil (great for fine motor too). They learn where to put the food in the mouth, how to bite and swallow the juice, then they learn to bite a few times more and swallow the juice again and then swallow the rest of the bite of food. This is good to practice with orange, pear, pineapple, watermelon or any watery fruit! I also get Jell-O cups and we turn them upside-down and make a Jell-O mountain. If we have the ones with fruit inside, we figure out how to eat both as Jell-O melts into liquid and fruit usually remains pretty solid. We figure out if our mouth can figure out how to do two things at once! Cool Whip on top is fun too (put snow on your mountain!)
Don’t forget to think about sprinkles to add texture to your fruit. Wilson’s cake sprinkles are fun to add to bites of fruit. You feel the crunch but don’t have to swallow a hard solid texture. Dips may also help the child deal with taste and texture too (watch the video on my Facebook food chaining page from Alicia Hart about dips, I had her son use them and she did a talk about them for her class at Eastern Illinois University). Dips can be wet or dry (powdered sugar, garlic salt, cinnamon sugar). Have fun with the your food and liquid activities. Shaved ice or using an ice chip to dip in juice is a lot of fun too. Make your own popsicles or flavored ice cubes with juice. There are straws that connect to make a very long straw and that is great fun for oral motor and liquid activities.
See how much I use the word “fun”…this does not and should not be torture.
Happy Chaining! Cheri
Remember, Food Chaining is a six-step program. Oral motor swallowing skills must be adequate for your child to make progress!
How do you help children with oral motor or swallowing problems become skilled and confident eaters?
For day-to-day therapeutic meals and snacks at home, my goal is to work on the motor sequences of eating. I suggest that parents read my Food Chaining blog and Food Chaining Facebook page for additional tips and then try this out at home. What does “treatment at home” look like? This is not nearly as daunting as it sounds. The swallowing part is customized to each child and I do a complete assessment, including swallow study and assessment with our otolaryngologist. A g-tube may be needed and may be our lifeline as it gives us time to work safely on skills. For swallowing therapy, I will select products to help the child overcome their challenges with dysphagia. I teach them how to be safe. I may start with single drops of liquid for some children and work up from there. It also does not matter what cognitive level the child is at, feeling safe is a great teaching tool. Don’t underestimate kids; they will rise to the challenge. Just because a child is non-verbal don’t assume they don’t learn and learn well. WE just have to be more creative in how we facilitate their communication and learning.
How often, how many times per week? Generally speaking, I usually have parents try to do a food fun activity at a snack time once a day to at least 4 times a week. This should not be work, everyone should have fun AND it is not about how often but how pleasant the experience is for the child that really matters. Put the pressure behind you, amount does not matter. Kids will eat and drink more as they become more skilled. Remember just using the right feeding products is treatment every time your child eats or drinks.
Why do you say a child has to develop a repertoire of FLEXIBLE oral motor skills? Each food has a different set of challenges in regard to how to chew and swallow safely. Each product you drink through requires a shift in your skills; can you purse your lips like you do for straw drinking when you drink from a coffee mug? No. What if you approached eating chicken noodle soup the same way you approach eating a Big Mac? You would not be successful and you would have a wet shirt. Do you drink water the same way you drink a thick milkshake? No! You have to be FLEXIBLE with your oral motor skills. Think of a skilled gymnast, they have to be able to shift from floor routine to high bars to balance beam. If they tried to do all things the same way, it would not work. Foods vary widely in texture and we chew foods in different ways, so oral motor/feeding skills are very much like gymnastics. A skilled therapist helps TEACH kids to eat and drink safely and with confidence.
OK Cheri, how do you have fun with food, food has always been terribly stressful for us?
Well, start down the right road starting today. You must understand the scope of the problem to treat it. Stress and pressure do not help. Would someone pressuring you while you are trying to walk on a balance beam help or hurt you? Kids have to chew/drink and swallow and clear the pharynx in one second. Pretty challenging stuff! Think how your child feels at the table. We need to understand what is happening to help in an effective manner. Many children eat simple crunchy foods because they don’t have the skills to eat the other foods well. Maybe the child can’t breathe through his nose. Put a clip on your nose and try to eat a pork chop. It isn’t easy is it? The child may be picking foods he can breathe around as he munches his food or he takes very small amounts of liquid so he can get air again. He doesn’t know how to chew or drink in a sophisticated manner. For this child, “picky” may not be the issue. Kids who munch look a lot like Pac Man when they eat, they use only an up and down pattern that likely started from bottle-feeding by munching instead of truly sucking. If you approach steak like Pac Man, you will choke to death. Kids eat what they have skills to eat. Texture and taste matter too, but this is a key issue. So, we need to figure out what came first Picky or Pac Man? This is MUCH more complex than it seems.
Tell me more about Picky Eating
By the way, I HATE the label picky eater. It sounds like a bad kid with an indulgent parent and it does not describe the problem(s). I prefer to use the term SELECTIVE eating. Kids select the foods they can eat and feel safe eating. Your child may not eat goldfish and chicken nuggets just for the flavor or texture; he may do it because he has no other choice. So go back to that idea of being a gymnast, your child can only do “floor routine” (munching) and he may lack the skills for eating more advanced textures. This is also why force-feeding does not work. My job is to help your child develop the higher level, flexible oral motor skills. Food Chaining allows me to put foods in a sequence based on your child’s skills. It is much more than color, taste and crunch….it is much more complex. These are the reasons why each child’s Food Chaining program is customized to their individual needs.
Examples of Food Fun Activities
Here are some sample ideas of food activities for home. With food, go to the cabinet or to the store, pick something out and figure out HOW to eat it. Use a mirror or camera, take digital pictures for feedback. Remember, treatment is daily with my programs, just by letting me select the right products to match your child’s oral motor/swallowing skills=daily treatment. Do what I ask of you and don’t push beyond. Pushing does not equal success. You have to trust that I have your child at a place where he is safe and I will determine when it is ok to do more. So remember, much of the work of this program is going to be done for you as every time your child eats or drinks. With the right flow rate, a child is treating himself when drinking, with chewing on the DuoSpoon your child may soon be able to tolerate textures and he will learn more about the mouth. The DuoSpoon improves chewing skills, reduces gagging and helps a child develop the ability to make sense of what is going on in the mouth. Food cut in narrow strips helps kids learn to put it under the teeth. Teaching the skills of eating helps us show kids to “sweep” food over to the teeth with the tongue. We teach them HOW to chew this way. We make the bite sizes very small and work up in size as the child becomes more confident and skilled. With the regulated flow of the cups, straws I issue to the family and cold sensory loaded liquids in single swallows, therapeutic feeds or amounts that I feel are safe, liquid intake should improve quickly. We are working the muscles of the mouth, improving awareness of the sensations inside the mouth, giving a flow rate that does not flood the mouth or throat and making it cold, sour and/or carbonated so the swallow triggers faster. This IS treatment. My friend and colleague Alicia Hart does a Favorite Food Night with her family. That night there are no rules and each family member designs their own meal. I think that is a great idea. Joy is the key to the success of eating; help kids find the joy at the table. Put down this burden once in a while. Daily success and feeling safe at the table will successfully treat the child more than anything else.
I have fun with the kids showing them how to start looking at a bite of food and trying to figure out if they have to kiss it goodbye (purse the lips, activate the cheeks), chew it like a little puppy dog or really chew it like a T-Rex and crush it with the teeth. This helps them get the motor plans down. Cut fruit in little pieces from mouse bite to bunny bite (mandarin oranges are great for this and put colored toothpicks in the cut fruit), see if your child can squeeze the juice out of the bite and swallow it first. Work up in bite size as tolerated. This is fun and easy, but works really well.
I get little fruit cups and we go “fishing” with our toothpicks in therapy. Then the kids use plastic knives to cut the piece of fruit in sections and they use the toothpicks as their utensil (great for fine motor too). They learn where to put the food in the mouth, how to bite and swallow the juice, then they learn to bite a few times more and swallow the juice again and then swallow the rest of the bite of food. This is good to practice with orange, pear, pineapple, watermelon or any watery fruit! I also get Jell-O cups and we turn them upside-down and make a Jell-O mountain. If we have the ones with fruit inside, we figure out how to eat both as Jell-O melts into liquid and fruit usually remains pretty solid. We figure out if our mouth can figure out how to do two things at once! Cool Whip on top is fun too (put snow on your mountain!)
Don’t forget to think about sprinkles to add texture to your fruit. Wilson’s cake sprinkles are fun to add to bites of fruit. You feel the crunch but don’t have to swallow a hard solid texture. Dips may also help the child deal with taste and texture too (watch the video on my Facebook food chaining page from Alicia Hart about dips, I had her son use them and she did a talk about them for her class at Eastern Illinois University). Dips can be wet or dry (powdered sugar, garlic salt, cinnamon sugar). Have fun with the your food and liquid activities. Shaved ice or using an ice chip to dip in juice is a lot of fun too. Make your own popsicles or flavored ice cubes with juice. There are straws that connect to make a very long straw and that is great fun for oral motor and liquid activities.
See how much I use the word “fun”…this does not and should not be torture.
Happy Chaining! Cheri
Sunday, November 21, 2010
Now for something completely different...teaching a new course in a whole new way!
Hi All
I am just finishing up the presentation for our new Food Chaining II course with Dr. Fishbein. Studies show that participants only remember 20% of what they hear, so this course will be taught in a whole new way. It will be extremely visual. That is right, lots of pictures, videos and you will be participating with us, analyzing cases, filling out worksheets and in other words, passive learning will go out the door. There will be a food lab. I am VERY EXCITED and more than a little nervous about doing things a new way but I think this is going to be one of the strongest, most dynamic courses we have ever put on. You do not have to be a 'graduate' of a past chaining course either, we will hit treatment so hard, in so many ways you will not be confused if you are new and if you are a past participant, this one will give you a wide range of ways to use all 6 steps of a chaining program. Some brave souls will also be part of our food lab!
So put on your thinking caps and get ready for a fun, fast and functional two day lecture. Oh yeah, that GI we like so much will be there to talk to you about a whole range of GI disorders from simple ones to the very complex.
Want to come to beautiful San Antonio, enjoy the Christmas lights and get away from it all? Call CEPA university at 309-472-1292. Come to the Riverwalk and have some fun with Dr. Fishbein, Laura and I. Hope to see you there!!
Course Details: December 3 & 4, 2010
San Antonio, Texas at the Hyatt Regency Riverwalk at 123 Losoya Street right in the heart of San Antonio, Tx
Parking is $15 a day (reduced from $23 but there are other cheaper parking areas close by)and guest room rate for course participants in $109. Check with hotel for cut off dates for registration at this rate. Identify yourself as a CEPA participant.
Dining and entertainment and we are just across the street from the Alamo.
Go to www.cepauniversity.com for more information!
I am just finishing up the presentation for our new Food Chaining II course with Dr. Fishbein. Studies show that participants only remember 20% of what they hear, so this course will be taught in a whole new way. It will be extremely visual. That is right, lots of pictures, videos and you will be participating with us, analyzing cases, filling out worksheets and in other words, passive learning will go out the door. There will be a food lab. I am VERY EXCITED and more than a little nervous about doing things a new way but I think this is going to be one of the strongest, most dynamic courses we have ever put on. You do not have to be a 'graduate' of a past chaining course either, we will hit treatment so hard, in so many ways you will not be confused if you are new and if you are a past participant, this one will give you a wide range of ways to use all 6 steps of a chaining program. Some brave souls will also be part of our food lab!
So put on your thinking caps and get ready for a fun, fast and functional two day lecture. Oh yeah, that GI we like so much will be there to talk to you about a whole range of GI disorders from simple ones to the very complex.
Want to come to beautiful San Antonio, enjoy the Christmas lights and get away from it all? Call CEPA university at 309-472-1292. Come to the Riverwalk and have some fun with Dr. Fishbein, Laura and I. Hope to see you there!!
Course Details: December 3 & 4, 2010
San Antonio, Texas at the Hyatt Regency Riverwalk at 123 Losoya Street right in the heart of San Antonio, Tx
Parking is $15 a day (reduced from $23 but there are other cheaper parking areas close by)and guest room rate for course participants in $109. Check with hotel for cut off dates for registration at this rate. Identify yourself as a CEPA participant.
Dining and entertainment and we are just across the street from the Alamo.
Go to www.cepauniversity.com for more information!
Friday, November 12, 2010
Food Chaining II Course-Questions
Food Chaining II: The Digestive Tract Disorders
Q. Cheri and Laura, can you give us more information about your new feeding course?
A. Hi Friends! If you want to know more about how to help children with feeding aversion, nutrition problems and digestive tract disorders, then this is the course for you. We are debuting this course in beautiful San Antonio right on The Riverwalk. (Can’t wait to see it decorated for Christmas!) Mark Fishbein, MD, pediatric gastroenterologist from Children’s Memorial Hospital in Chicago, Illinois will join us. We have greatly expanded Dr. Fishbein’s role in teaching this course. This course is therapy-packed and you asked for it, we are going to teach and show you how to use Food Chaining through cases, cases and more cases. We will work with the audience as a group to demonstrate Food Chaining in new fun ways. Get ready to have some fun with food!
This course is a follow-up to the introductory Food Chaining course, however, it is open to everyone. We get so many questions about infants who do not tolerate formula, treating children with food allergies and understanding how a digestive tract disorder can derail your treatment program. So special focus will be spent on the impact of digestive tract disorders on the child and how to tailor your feeding therapy plan to meet those needs. Dr Fishbein will also have a question-answer session with the audience.
We will discuss how to help infants and children with:
• Prematurity, poor weight gain/growth and Failure to Thrive
• Dysphagia and tube feeding regimens
• NEC/Short gut
• Food allergies, FPIES
• Malabsorption
• Mitochondrial disorders
• Esophagitis
• Vomiting, Cyclic vomiting syndrome, Behavioral vomiting
• Rumination
• Motility disorders, bowel problems, abdominal pain
• Constipation and diarrhea
• Reflux, medications, Nissen fundoplication (when is this procedure needed?)
• Retching
• Eosinophilic Esophagitis.
• Tube feeding will also be discussed
• Aspiration and reactive airway disease
• Autism (The Great Debates: Gluten Casein, Chelation, Leaky Gut)
Therapy will hit the complex challenges of sensory processing disorder and what to do in each of your treatment sessions. How can you successfully introduce new foods? How do you get started and know when to move forward? What do you offer, when and how? How do you adjust your approach when it is not working?
Food Chaining will be demonstrated in new, fun ways with a food lab. Therapy plans will focus on establishing trust first, educating the family and implementing effective, enjoyable Food Chaining programs at home, school or daycare. This course will be very interactive with the audience and we will help participants work with us through evaluation, development of treatment plans and making the right referrals for infants and children. Hope to see you there!!
Thanks again!
Cheri and Laura
Q. Cheri and Laura, can you give us more information about your new feeding course?
A. Hi Friends! If you want to know more about how to help children with feeding aversion, nutrition problems and digestive tract disorders, then this is the course for you. We are debuting this course in beautiful San Antonio right on The Riverwalk. (Can’t wait to see it decorated for Christmas!) Mark Fishbein, MD, pediatric gastroenterologist from Children’s Memorial Hospital in Chicago, Illinois will join us. We have greatly expanded Dr. Fishbein’s role in teaching this course. This course is therapy-packed and you asked for it, we are going to teach and show you how to use Food Chaining through cases, cases and more cases. We will work with the audience as a group to demonstrate Food Chaining in new fun ways. Get ready to have some fun with food!
This course is a follow-up to the introductory Food Chaining course, however, it is open to everyone. We get so many questions about infants who do not tolerate formula, treating children with food allergies and understanding how a digestive tract disorder can derail your treatment program. So special focus will be spent on the impact of digestive tract disorders on the child and how to tailor your feeding therapy plan to meet those needs. Dr Fishbein will also have a question-answer session with the audience.
We will discuss how to help infants and children with:
• Prematurity, poor weight gain/growth and Failure to Thrive
• Dysphagia and tube feeding regimens
• NEC/Short gut
• Food allergies, FPIES
• Malabsorption
• Mitochondrial disorders
• Esophagitis
• Vomiting, Cyclic vomiting syndrome, Behavioral vomiting
• Rumination
• Motility disorders, bowel problems, abdominal pain
• Constipation and diarrhea
• Reflux, medications, Nissen fundoplication (when is this procedure needed?)
• Retching
• Eosinophilic Esophagitis.
• Tube feeding will also be discussed
• Aspiration and reactive airway disease
• Autism (The Great Debates: Gluten Casein, Chelation, Leaky Gut)
Therapy will hit the complex challenges of sensory processing disorder and what to do in each of your treatment sessions. How can you successfully introduce new foods? How do you get started and know when to move forward? What do you offer, when and how? How do you adjust your approach when it is not working?
Food Chaining will be demonstrated in new, fun ways with a food lab. Therapy plans will focus on establishing trust first, educating the family and implementing effective, enjoyable Food Chaining programs at home, school or daycare. This course will be very interactive with the audience and we will help participants work with us through evaluation, development of treatment plans and making the right referrals for infants and children. Hope to see you there!!
Thanks again!
Cheri and Laura
Sunday, October 24, 2010
Here it comes...The Food Chaining II course!!
Well, I am in the middle of writing two new courses. Laura and I will be joined by an old friend for this course in San Antonio on the Riverwalk December 3 and 4, 2010. Mark Fishbein, MD, pediatric gastroenterologist from Children's Memorial Hospital in Chicago, IL will present with us. This is the debut of Food Chaining II courses. This one addresses the Digestive Tract Disorders. This course will explore treatment using a Food Chaining program for children with all types of digestive tract disorders. Food Chaining will be demonstrated through cases, but come ready to work, this will not be a passive learning course. (You may attend this one even if you have not attended a chaining course before, but the approach will not be taught the same detailed way, it will be demonstrated through the case studies).
In Spring of 2011, we will debut the other half of this lecture addressing the upper airway, dysphagia, treatment of infants and children with swallowing disorders with Sandra Ettema, MD, otolaryngologist from the SIU School of Medicine in Springfield, IL. Dr. Ettema is also a doctoral speech pathologist.
Much to do!!!
In Spring of 2011, we will debut the other half of this lecture addressing the upper airway, dysphagia, treatment of infants and children with swallowing disorders with Sandra Ettema, MD, otolaryngologist from the SIU School of Medicine in Springfield, IL. Dr. Ettema is also a doctoral speech pathologist.
Much to do!!!
Bronchiectasis and Aspiration
http://www.nhlbi.nih.gov/health/dci/Diseases/brn/brn_whatis.html
This is information from the National Heart Lung and Blood Institute. I just returned from the pediatric Feeding course in Cincinnati. The pulmonologist, Dr. Boesch, talked about aspiration. His lecture was amazing and he takes aspiration of food as seriously as we therapists do. We talked about abducting him and bringing him to our team in Springfield, but he was young and wiry and got away. :) Aspiration can lead to bronchiectasis. A chest x-ray will not tell you if a child is having damage from aspiration. Chest CT is how you evaluate for damage from aspiration. Here is some very basic beginning information for you on this subject. I have also posted information/links from other sources on my Facebook Food Chaining page.
"Bronchiectasis (brong-ke-EK-ta-sis) is a condition in which damage to the airways causes them to widen and become flabby and scarred. The airways are tubes that carry air in and out of your lungs.Bronchiectasis usually is the result of an infection or other condition that injures the walls of your airways or prevents the airways from clearing mucus. Mucus is a slimy substance that the airways produce to help remove inhaled dust, bacteria, and other small particles.
In bronchiectasis, your airways slowly lose their ability to clear out mucus. When mucus can't be cleared, it builds up and creates an environment in which bacteria can grow. This leads to repeated, serious lung infections.Each infection causes more damage to your airways. Over time, the airways lose their ability to move air in and out. This can prevent enough oxygen from reaching your vital organs.
Bronchiectasis can lead to serious health problems, such as respiratory failure, atelectasis (at-eh-LEK-tah-sis), and heart failure.
Bronchiectasis can affect just one section of one of your lungs or many sections of both lungs.The initial lung damage that leads to bronchiectasis often begins in childhood. However, symptoms may not appear until months or even years after you start having repeated lung infections.In the United States, common childhood infections, such as whooping cough and measles, used to cause many cases of bronchiectasis. However, these causes are now less common due to the use of vaccines and antibiotics.
Now, in the United States, bronchiectasis usually is due to an underlying medical condition that injures the airway walls or prevents the airways from clearing mucus. Examples of such conditions include cystic fibrosis and primary ciliary dyskinesia (SIL-e-ar-e dis-ki-NE-ze-ah).
Bronchiectasis that occurs in only one part of the lung may be due to a blockage rather than an underlying condition.Bronchiectasis can be congenital or acquired. Congenital bronchiectasis usually affects infants and children. It's the result of a problem with how the lungs form in a fetus.Acquired bronchiectasis occurs as a result of another medical condition. It can affect adults and older children. This type of bronchiectasis is more common than the congenital type.
Outlook
Bronchiectasis can't be cured. However, with proper care, most people who have it can enjoy a good quality of life. Early diagnosis and treatment of bronchiectasis are important. The sooner your doctor can start treating your bronchiectasis and any underlying conditions, the better the chances of preventing further damage to your lungs."
Revised May 2009
This is information from the National Heart Lung and Blood Institute. I just returned from the pediatric Feeding course in Cincinnati. The pulmonologist, Dr. Boesch, talked about aspiration. His lecture was amazing and he takes aspiration of food as seriously as we therapists do. We talked about abducting him and bringing him to our team in Springfield, but he was young and wiry and got away. :) Aspiration can lead to bronchiectasis. A chest x-ray will not tell you if a child is having damage from aspiration. Chest CT is how you evaluate for damage from aspiration. Here is some very basic beginning information for you on this subject. I have also posted information/links from other sources on my Facebook Food Chaining page.
"Bronchiectasis (brong-ke-EK-ta-sis) is a condition in which damage to the airways causes them to widen and become flabby and scarred. The airways are tubes that carry air in and out of your lungs.Bronchiectasis usually is the result of an infection or other condition that injures the walls of your airways or prevents the airways from clearing mucus. Mucus is a slimy substance that the airways produce to help remove inhaled dust, bacteria, and other small particles.
In bronchiectasis, your airways slowly lose their ability to clear out mucus. When mucus can't be cleared, it builds up and creates an environment in which bacteria can grow. This leads to repeated, serious lung infections.Each infection causes more damage to your airways. Over time, the airways lose their ability to move air in and out. This can prevent enough oxygen from reaching your vital organs.
Bronchiectasis can lead to serious health problems, such as respiratory failure, atelectasis (at-eh-LEK-tah-sis), and heart failure.
Bronchiectasis can affect just one section of one of your lungs or many sections of both lungs.The initial lung damage that leads to bronchiectasis often begins in childhood. However, symptoms may not appear until months or even years after you start having repeated lung infections.In the United States, common childhood infections, such as whooping cough and measles, used to cause many cases of bronchiectasis. However, these causes are now less common due to the use of vaccines and antibiotics.
Now, in the United States, bronchiectasis usually is due to an underlying medical condition that injures the airway walls or prevents the airways from clearing mucus. Examples of such conditions include cystic fibrosis and primary ciliary dyskinesia (SIL-e-ar-e dis-ki-NE-ze-ah).
Bronchiectasis that occurs in only one part of the lung may be due to a blockage rather than an underlying condition.Bronchiectasis can be congenital or acquired. Congenital bronchiectasis usually affects infants and children. It's the result of a problem with how the lungs form in a fetus.Acquired bronchiectasis occurs as a result of another medical condition. It can affect adults and older children. This type of bronchiectasis is more common than the congenital type.
Outlook
Bronchiectasis can't be cured. However, with proper care, most people who have it can enjoy a good quality of life. Early diagnosis and treatment of bronchiectasis are important. The sooner your doctor can start treating your bronchiectasis and any underlying conditions, the better the chances of preventing further damage to your lungs."
Revised May 2009
Visit us at Facebook Food Chaining page too...New Product Ideas
Hi Bloggers. I have some new products I really like and wanted to share. First of the all, the Beabacook Baby Food Steamer is a great product to make your own baby food (you cook and puree in the same product) or to just steam vegetables, meat, etc. I want one for our clinic to cook food for feeding sessions. Beabacook website also has some great spoons and ways to transport food (so parents can take their baby or older child's food to restaurants, school, etc). http://www.williams-sonoma.com/products/beaba-babycook-baby-food-maker/. It is pricey, so check around, Ebay, etc.
I also love the Magic Bullet at http://www.buythebullet.com/ (or Ebay, etc) and the convenience of this product is off the charts. Puree food for infants or make chicken salad for your family. It also chops nuts to a fine coffee ground consistency and you can stir them in to other foods. A good coffee bean grinder can also be helpful to a therapist for this reason.
I also love all things Special Tomato. http://www.specialtomato.com/index.html Special Tomato has chairs, seating options and products that are so wonderful. Positioning is a key part of successful eating. Marsha Dunn Klein says the shoulders are the floor the head rests upon and the hips/pelvis are the floor the trunk sits on, stability is a key part of eating well and chewing. Kids can't be dangling in space, so check out Special Tomato.
One of my favorite finds of the year (Thanks to one of my dearest patients) is the Beyond Play Little Spill cup. I love this cup and it creates a safe way to introduce open cup drinking. It can also be used up to adulthood and great for those who have occasional tremors of the hand, etc which might lead to spills. I usually start out with slightly thicker liquids for kids. Great product. http://www.beyondplay.com/CATALOG/ORA1.HTM
I also love the Magic Bullet at http://www.buythebullet.com/ (or Ebay, etc) and the convenience of this product is off the charts. Puree food for infants or make chicken salad for your family. It also chops nuts to a fine coffee ground consistency and you can stir them in to other foods. A good coffee bean grinder can also be helpful to a therapist for this reason.
I also love all things Special Tomato. http://www.specialtomato.com/index.html Special Tomato has chairs, seating options and products that are so wonderful. Positioning is a key part of successful eating. Marsha Dunn Klein says the shoulders are the floor the head rests upon and the hips/pelvis are the floor the trunk sits on, stability is a key part of eating well and chewing. Kids can't be dangling in space, so check out Special Tomato.
One of my favorite finds of the year (Thanks to one of my dearest patients) is the Beyond Play Little Spill cup. I love this cup and it creates a safe way to introduce open cup drinking. It can also be used up to adulthood and great for those who have occasional tremors of the hand, etc which might lead to spills. I usually start out with slightly thicker liquids for kids. Great product. http://www.beyondplay.com/CATALOG/ORA1.HTM
Monday, August 30, 2010
A Tale of a Boy and a Sandwich by Alicia Hart
Alicia sent this to me via Facebook. What a gift this story was to motivate me to keep fighting the good fight and trying to help children learn to eat. I must tell you that this is an amazing story that did NOT include force, z-vibes, pointless oral motor for no reason or direction, timers or the words "just take a bite."
What this WAS about was consistency, resolve, timing, offering food in a natural low pressure way, taking time to teach Ewan about what was on the plate, where it came from, how it grows and to allow the sensory system to adjust to new foods. It was about learning and life and food. What foods do you eat at a baseball game? Alicia and Stacy found ways to make this a whole learning-language activity and they did the same things over and over again. Food Ewan liked was also allowed to be part of his day to day and not taken away. He enjoyed Ewan food while learning about new food during treatment. Who wants to come to the table if it is torture? So we recommended that they change things slowly and let Ewan set the pace of what food, when based on his reactions to what we offered. The wonderful amazing Stacy Vitale worked with him every week in Mattoon, Illinois at Sarah Bush Lincoln Hospital. We were the feeding team and yes, I did see that he had EE, but the true heroes of this story are Alicia, Anthony, Stacy and most especially, our dear Ewan.
A Tale of a Boy and a Sandwich
Right now I’m crying over a sandwich. I know, this sounds utterly ridiculous and most of you are wondering if “Miss Lisha has left the building,” but I can assure you there is a sound and rational reason for my tears of joy.
Yes, joy.
It’s not that I have discovered the best kept sandwich secret in the greater Charleston / Mattoon region. It’s not that I have discovered some secret ingredient to the Crabby Patty recipe. It’s because my son asked for a sandwich and ate it. It’s that simple. He asked, I made it, and he ate it—with excitement and eagerness.
Now before too many of you think Miss Lisha is easily entertained let me tell you a story about a boy….
Over 8 years ago, there was a little boy born in a small hospital amidst laughter and joyful anticipation. Within seconds of this child’s birth, his parents knew without a doubt that he was different. He wasn’t your average everyday newborn baby. They didn’t know what it was about him that was different—they simply knew he was.
Over the following weeks and months the things that made him special became more and more obvious. Things like not sleeping, staring at the blinds and shadows on the wall, and always fighting against human contact. There were also things like nursing round the clock every 45 minutes and then throwing it all up—a constant vicious cycle of need and refuse. No one really knew what was wrong—it was as if everyone was dancing around the edge of some greater mystery.
And so they waited for the kinks to work themselves out and simply hoped and prayed that it would. The boy grew and grew but he didn’t talk and he didn’t eat much—people and food and places and things were sometimes just plain frightening to him. Eventually his parents found a word for the why—autism—and from that day forward life became a series of therapy visits and doctor visits and tests, tests, tests.
The boy learned to communicate, he learned about himself, and he learned how to learn—but he still didn’t eat. Then one day his mother drew a line in the sand and said, “You’re going to eat this young man and I don’t care if you throw it up.” And throw it up he did. Finally, the boy and his parents ended up in a feeding clinic amidst a plethora of white coats, khaki pants, and big hair—all telling them the same thing—it’s not that he won’t, it’s that he can’t. It took many days and weeks and months before this mother and this father finally understood what all those fancy therapists were saying—it’s not that he won’t, it’s that he can’t.
And so this mother and this father learned how to help this boy and they worked day in and day out on making food an enjoyable part of life—three times a day, every single day, year after year. They erased the line in the sand and started from scratch. Learning to learn and teaching to teach they saw this boy willingly reach out for food. But still, he could only reach so far before he drew back again and it’s not that he wouldn’t, it’s that he couldn’t.
One day this mother ended up in a therapy clinic with a video camera in hand to show everyone else that again it wasn’t that he wouldn’t, it was that he couldn’t. And finally, finally, the Redhead with eyes that saw what everyone else missed whispered the name for all the tears and struggles—Eosinophilic Esophagitis. His parents had to take food away in order to give it back again—and for the first time in four years of his life, this boy could eat food without pain. Yet each bite came with fear and trepidation—each bite brought back the ‘what ifs’ and it took all his courage and strength to reach out and just take a bite. Despite his fear, despite his pain, despite everything—he continued to reach and to trust and to learn.
And despite all of that, today MY son asked me for a salami, lettuce, cheese and tomato wrap. I made it and he ate it. He gleefully ate every last bite of it. He ate it, and I cried. And when Ewan asked me, “Mom, why do you cry?” I replied simply, “I cry because I am so proud of you and I cry because I’m happy and I cry because it’s been a long, long road to get here.” To which the literal young man said, “Mom, we went from the kitchen to the living room—it wasn’t THAT far.”
What this WAS about was consistency, resolve, timing, offering food in a natural low pressure way, taking time to teach Ewan about what was on the plate, where it came from, how it grows and to allow the sensory system to adjust to new foods. It was about learning and life and food. What foods do you eat at a baseball game? Alicia and Stacy found ways to make this a whole learning-language activity and they did the same things over and over again. Food Ewan liked was also allowed to be part of his day to day and not taken away. He enjoyed Ewan food while learning about new food during treatment. Who wants to come to the table if it is torture? So we recommended that they change things slowly and let Ewan set the pace of what food, when based on his reactions to what we offered. The wonderful amazing Stacy Vitale worked with him every week in Mattoon, Illinois at Sarah Bush Lincoln Hospital. We were the feeding team and yes, I did see that he had EE, but the true heroes of this story are Alicia, Anthony, Stacy and most especially, our dear Ewan.
A Tale of a Boy and a Sandwich
Right now I’m crying over a sandwich. I know, this sounds utterly ridiculous and most of you are wondering if “Miss Lisha has left the building,” but I can assure you there is a sound and rational reason for my tears of joy.
Yes, joy.
It’s not that I have discovered the best kept sandwich secret in the greater Charleston / Mattoon region. It’s not that I have discovered some secret ingredient to the Crabby Patty recipe. It’s because my son asked for a sandwich and ate it. It’s that simple. He asked, I made it, and he ate it—with excitement and eagerness.
Now before too many of you think Miss Lisha is easily entertained let me tell you a story about a boy….
Over 8 years ago, there was a little boy born in a small hospital amidst laughter and joyful anticipation. Within seconds of this child’s birth, his parents knew without a doubt that he was different. He wasn’t your average everyday newborn baby. They didn’t know what it was about him that was different—they simply knew he was.
Over the following weeks and months the things that made him special became more and more obvious. Things like not sleeping, staring at the blinds and shadows on the wall, and always fighting against human contact. There were also things like nursing round the clock every 45 minutes and then throwing it all up—a constant vicious cycle of need and refuse. No one really knew what was wrong—it was as if everyone was dancing around the edge of some greater mystery.
And so they waited for the kinks to work themselves out and simply hoped and prayed that it would. The boy grew and grew but he didn’t talk and he didn’t eat much—people and food and places and things were sometimes just plain frightening to him. Eventually his parents found a word for the why—autism—and from that day forward life became a series of therapy visits and doctor visits and tests, tests, tests.
The boy learned to communicate, he learned about himself, and he learned how to learn—but he still didn’t eat. Then one day his mother drew a line in the sand and said, “You’re going to eat this young man and I don’t care if you throw it up.” And throw it up he did. Finally, the boy and his parents ended up in a feeding clinic amidst a plethora of white coats, khaki pants, and big hair—all telling them the same thing—it’s not that he won’t, it’s that he can’t. It took many days and weeks and months before this mother and this father finally understood what all those fancy therapists were saying—it’s not that he won’t, it’s that he can’t.
And so this mother and this father learned how to help this boy and they worked day in and day out on making food an enjoyable part of life—three times a day, every single day, year after year. They erased the line in the sand and started from scratch. Learning to learn and teaching to teach they saw this boy willingly reach out for food. But still, he could only reach so far before he drew back again and it’s not that he wouldn’t, it’s that he couldn’t.
One day this mother ended up in a therapy clinic with a video camera in hand to show everyone else that again it wasn’t that he wouldn’t, it was that he couldn’t. And finally, finally, the Redhead with eyes that saw what everyone else missed whispered the name for all the tears and struggles—Eosinophilic Esophagitis. His parents had to take food away in order to give it back again—and for the first time in four years of his life, this boy could eat food without pain. Yet each bite came with fear and trepidation—each bite brought back the ‘what ifs’ and it took all his courage and strength to reach out and just take a bite. Despite his fear, despite his pain, despite everything—he continued to reach and to trust and to learn.
And despite all of that, today MY son asked me for a salami, lettuce, cheese and tomato wrap. I made it and he ate it. He gleefully ate every last bite of it. He ate it, and I cried. And when Ewan asked me, “Mom, why do you cry?” I replied simply, “I cry because I am so proud of you and I cry because I’m happy and I cry because it’s been a long, long road to get here.” To which the literal young man said, “Mom, we went from the kitchen to the living room—it wasn’t THAT far.”
Friday, July 30, 2010
Fall-Winter Courses 2010
Hi All
Looking for a fun get away and great course on treatment of pediatric feeding disorders? This fall-winter, Laura and I are going to San Diego, San Francisco, San Antonio and St Louis. We will be joined by Marsha Dunn Klein for our feeding aversion course combining treatment using Food Chaining and Get Permission approach. We will then do our first follow up course to the Food Chaining course. This one focuses on treatment of children with feeding aversion and GI disorders. We will be joined by pediatric gastroenterologist, Mark Fishbein, MD. Hope to see you there!
To register contact www.cepauniversity.com
Course: Feeding Therapy for Infants & Children: What To Do & How, When & Why To Do It" (Two dates for this course)
Faculty: Cheri Fraker, MS, CCC, CLP-L, CLC and Laura Walbert, MS, CCC, SLP-L, CLC
September 24 & 25, 2010 - San Francisco, CA
November 5 & 6, 2010 - San Diego, CA
"Treatment of Severe Feeding Aversion: Dealing with "No!" The Best of Both Worlds-Food Chaining & The Get Permission Approach"
Faculty: Cheri Fraker, MS, CCC/SLP-L, CLC, Laura Walbert, MS, CCC/SLP-L, CLC and Special Guest Marsha Dunn Klein, MEd, OTR/L
October 22 & 23, 2010 - St. Louis, Missouri
Food Chaining II: Feeding Aversion and Dealing with Digestive Tract Disorders
Faculty: Mark Fishbein, MD (Pediatric Gastroenterologist), Cheri Fraker, MS, CCC/SLP-L and Laura Walbert, MS, CCC/SLP-L December 3 & 4, 2010 - San Antonio, Texas
Looking for a fun get away and great course on treatment of pediatric feeding disorders? This fall-winter, Laura and I are going to San Diego, San Francisco, San Antonio and St Louis. We will be joined by Marsha Dunn Klein for our feeding aversion course combining treatment using Food Chaining and Get Permission approach. We will then do our first follow up course to the Food Chaining course. This one focuses on treatment of children with feeding aversion and GI disorders. We will be joined by pediatric gastroenterologist, Mark Fishbein, MD. Hope to see you there!
To register contact www.cepauniversity.com
Course: Feeding Therapy for Infants & Children: What To Do & How, When & Why To Do It" (Two dates for this course)
Faculty: Cheri Fraker, MS, CCC, CLP-L, CLC and Laura Walbert, MS, CCC, SLP-L, CLC
September 24 & 25, 2010 - San Francisco, CA
November 5 & 6, 2010 - San Diego, CA
"Treatment of Severe Feeding Aversion: Dealing with "No!" The Best of Both Worlds-Food Chaining & The Get Permission Approach"
Faculty: Cheri Fraker, MS, CCC/SLP-L, CLC, Laura Walbert, MS, CCC/SLP-L, CLC and Special Guest Marsha Dunn Klein, MEd, OTR/L
October 22 & 23, 2010 - St. Louis, Missouri
Food Chaining II: Feeding Aversion and Dealing with Digestive Tract Disorders
Faculty: Mark Fishbein, MD (Pediatric Gastroenterologist), Cheri Fraker, MS, CCC/SLP-L and Laura Walbert, MS, CCC/SLP-L December 3 & 4, 2010 - San Antonio, Texas
Friday, July 23, 2010
Picky Eating in Adults/Teens
The plight of picky eating adults
Researchers are finally exploring distress at the dinner table
by Julia Belluz
Rhonda West’s picky eating began during breastfeeding. “I couldn’t have my mother’s milk, so they put me on cow’s milk, but I was allergic, so then they put me on soy,” she says. “When it came time for solid foods, I didn’t want any part of that.” In fact, most foods made her want to gag.
Now, 41 years later, West is a picky eating adult. She survives on toast, waffles, pancakes, simply cooked meats, and French fries. (Oddly, almost all adult “selective eaters” include French fries in their limited food repertoire). “I don’t like foods that are mixed-up together,” says West, who lives in the Washington, D.C.-area and is currently looking for work. No vegetables, few fruits, and absolutely nothing that’s too soft or squishy. “I equate eating pasta with eating a plate of worms.”
For picky eaters, most meals are unbearable, and nearly all foods make them nauseous. Failed relationships, lost work opportunities, and anxiety caused by the very thing others derive great pleasure from.
While childhood picky eating is commonly recognized, little has been done to understand people like West—until now. In July, Duke University and the University of Pittsburgh launched the first national public registry of picky eaters, known as the Finicky Eating in Adults study (eatingdisorders.mc.duke.edu). People can log in and complete a survey about their relationship with food and eating habits. It’s still early stages, but this study is designed to help researchers better understand “avoidant, restrictive food intake disorder”—which is currently under consideration as an officially recognized eating disorder, like bulimia or anorexia.
Marsha D. Marcus, chief of the Behavioral Medicine Program at the University of Pittsburgh Medical Center and one of the lead investigators on the study says, picky eaters tend to fall into one of three groups: those with taste issues, those who have never had a real interest in food, and a third group who have had traumatic or aversive experiences with food.
Marcus says it’s too early to tell how many suffer from this disorder, but she’s heard of cases where one’s eating restrictions are so acute they survive by a feeding tube. Others avoid vacations, business meetings, dinner parties, and weddings—any event that brings them into contact with unknown food. Indeed, one American sufferer said that Thanksgiving is known among picky eaters as “Black Thursday”.
However, Marcus is careful to distinguish adult picky eaters from people with the food quirks most everybody lives with. “We’re not trying to pathologize people’s preferences,” she says. “We’re looking for people whose food restrictions are a source of impairment or distress or have led to a health problem.”
One interesting theory the researchers will explore is whether picky eating is genetic. “There might be a group of people who have different ways of tasting, so the food that tastes good to you or me tastes awful to them,” says Marcus.
According to picky eater West, this is a distinct possibility. “Picky eating is nature not nurture,” West says. “People are light, sound, smell, touch, skin sensitive—why not taste?” In fact, West insists that if she could change her palate, she would. “It’s high anxiety when you’re going to meet new people, especially for a job, and you have to explain why you’re not eating anything on the menu,” she says. When she summons the courage to go to a restaurant, she usually requests plain grilled chicken.
T.J. Haselden, a computer salesman living in Montreal, refers to himself as “the pickiest eater in Canada.” Of the disorder, the part-time comedian says, “I have learned to laugh about it, but the truth is that I’m really getting fed-up.”
Haselden eats only six foods: hot dogs, hamburgers, chicken, turkey, bacon, and French fries. He gags at the thought of tasting anything new, and also claims that this disorder began in childhood. “Everybody tries to say it’s my mom’s fault for not treating it the right way. I always say the only thing I can blame my mom for is that she was too accommodating.”
When he was a teenager living with roommates, Haselden would stay away from the kitchen. When friends ordered pizza, he’d tell them he was allergic to tomatoes to avoid confrontation. Now 30, he lives with his wife, Chantal, and has realized that his picky eating infringes on her life, too. “She can’t explore her taste buds the way she would want to.” For example, when she eats something as simple as pasta—a dish he abhors—the two have to sit at opposite ends of the dinner table. “I can smell the pasta so much I feel like I could taste it and it makes me want to gag.”
Haselden is undertaking a film project in the hopes that he can broaden his palate. He’ll document a 30-day journey of new tastes, attempting to try every food he’s been afraid of. “I want to use the power of the camera to overcome my fear and make people laugh.”
But can he and other picky eaters change their ways? Nancy Zucker, the director of the Duke Center for Eating Disorders who is leading the study with Marcus, says she hopes so. Her goal is to come up with effective coping strategies and treatment, and to distinguish selective eating from other eating disorders.
“People have a tough time having empathy for those who taste things differently,” she observes. “Even more profoundly, imagine you had an experience and you tasted something and thought, ‘this tastes like cardboard’ and people were mad at you for that, saying that you’re not experiencing what you’re experiencing. That’s what these people go through everyday. It’s time we explore and recognize what’s going on here.”
Researchers are finally exploring distress at the dinner table
by Julia Belluz
Rhonda West’s picky eating began during breastfeeding. “I couldn’t have my mother’s milk, so they put me on cow’s milk, but I was allergic, so then they put me on soy,” she says. “When it came time for solid foods, I didn’t want any part of that.” In fact, most foods made her want to gag.
Now, 41 years later, West is a picky eating adult. She survives on toast, waffles, pancakes, simply cooked meats, and French fries. (Oddly, almost all adult “selective eaters” include French fries in their limited food repertoire). “I don’t like foods that are mixed-up together,” says West, who lives in the Washington, D.C.-area and is currently looking for work. No vegetables, few fruits, and absolutely nothing that’s too soft or squishy. “I equate eating pasta with eating a plate of worms.”
For picky eaters, most meals are unbearable, and nearly all foods make them nauseous. Failed relationships, lost work opportunities, and anxiety caused by the very thing others derive great pleasure from.
While childhood picky eating is commonly recognized, little has been done to understand people like West—until now. In July, Duke University and the University of Pittsburgh launched the first national public registry of picky eaters, known as the Finicky Eating in Adults study (eatingdisorders.mc.duke.edu). People can log in and complete a survey about their relationship with food and eating habits. It’s still early stages, but this study is designed to help researchers better understand “avoidant, restrictive food intake disorder”—which is currently under consideration as an officially recognized eating disorder, like bulimia or anorexia.
Marsha D. Marcus, chief of the Behavioral Medicine Program at the University of Pittsburgh Medical Center and one of the lead investigators on the study says, picky eaters tend to fall into one of three groups: those with taste issues, those who have never had a real interest in food, and a third group who have had traumatic or aversive experiences with food.
Marcus says it’s too early to tell how many suffer from this disorder, but she’s heard of cases where one’s eating restrictions are so acute they survive by a feeding tube. Others avoid vacations, business meetings, dinner parties, and weddings—any event that brings them into contact with unknown food. Indeed, one American sufferer said that Thanksgiving is known among picky eaters as “Black Thursday”.
However, Marcus is careful to distinguish adult picky eaters from people with the food quirks most everybody lives with. “We’re not trying to pathologize people’s preferences,” she says. “We’re looking for people whose food restrictions are a source of impairment or distress or have led to a health problem.”
One interesting theory the researchers will explore is whether picky eating is genetic. “There might be a group of people who have different ways of tasting, so the food that tastes good to you or me tastes awful to them,” says Marcus.
According to picky eater West, this is a distinct possibility. “Picky eating is nature not nurture,” West says. “People are light, sound, smell, touch, skin sensitive—why not taste?” In fact, West insists that if she could change her palate, she would. “It’s high anxiety when you’re going to meet new people, especially for a job, and you have to explain why you’re not eating anything on the menu,” she says. When she summons the courage to go to a restaurant, she usually requests plain grilled chicken.
T.J. Haselden, a computer salesman living in Montreal, refers to himself as “the pickiest eater in Canada.” Of the disorder, the part-time comedian says, “I have learned to laugh about it, but the truth is that I’m really getting fed-up.”
Haselden eats only six foods: hot dogs, hamburgers, chicken, turkey, bacon, and French fries. He gags at the thought of tasting anything new, and also claims that this disorder began in childhood. “Everybody tries to say it’s my mom’s fault for not treating it the right way. I always say the only thing I can blame my mom for is that she was too accommodating.”
When he was a teenager living with roommates, Haselden would stay away from the kitchen. When friends ordered pizza, he’d tell them he was allergic to tomatoes to avoid confrontation. Now 30, he lives with his wife, Chantal, and has realized that his picky eating infringes on her life, too. “She can’t explore her taste buds the way she would want to.” For example, when she eats something as simple as pasta—a dish he abhors—the two have to sit at opposite ends of the dinner table. “I can smell the pasta so much I feel like I could taste it and it makes me want to gag.”
Haselden is undertaking a film project in the hopes that he can broaden his palate. He’ll document a 30-day journey of new tastes, attempting to try every food he’s been afraid of. “I want to use the power of the camera to overcome my fear and make people laugh.”
But can he and other picky eaters change their ways? Nancy Zucker, the director of the Duke Center for Eating Disorders who is leading the study with Marcus, says she hopes so. Her goal is to come up with effective coping strategies and treatment, and to distinguish selective eating from other eating disorders.
“People have a tough time having empathy for those who taste things differently,” she observes. “Even more profoundly, imagine you had an experience and you tasted something and thought, ‘this tastes like cardboard’ and people were mad at you for that, saying that you’re not experiencing what you’re experiencing. That’s what these people go through everyday. It’s time we explore and recognize what’s going on here.”
Thursday, June 3, 2010
Question of the Week...Treatment for Older Children
QUESTION: Hi Cheri, I recently saw a 14 year old boy for a feeding evaluation and I was wondering if you could provide suggestions regarding feeding therapy. Here is some background.
D did not have any difficulty breast/bottle feeding, but he did not take to finger foods as a baby. He was diagnosed with sensory integration disorder at age 2. No one else in the family has been diagnosed with sensory integration disorder.
He saw a feeding therapist at age 3 for a few months before he started resisting feeding therapy. D was seen at a _____Hospital for a day treatment admission of 2.5 weeks at age 5. During his time there, he was transitioned from baby food to soft solid foods. He would spit out hard solids. He was discharged after 2.5 weeks and his parents were told to work on the feeding skills at home. He saw an occupational therapist from age 4 to approximately age 6-9 at school with a sensory gym. He discontinued occupational therapy as the occupational therapist was let go from the school.
His current (very limited) diet includes the following purees and solids: mashed potatoes, bologna, cinnamon apple sauce, peas, spaghetti, ham, bologna sandwich, chicken nuggets, french fries and liquids: apple juice, soda, water, whole milk. He does not like eating chunky, hard foods (pizza, meat, chicken, dry crusty bread, chicken fingers, cookies). There are some foods such as cherry Italian ice that he used to eat, but no longer eats. D does not have any difficulty gaining weight. He's never been diagnosed with reflux. His mother was doubtful that D would even try a nutritional supplement such as Ensure.
D's mother reported that all of D's sensory integration disorder tendencies have resolved/improved with the exception of feeding. During the evaluation, D began to cry in the room because this was the first time that he was told about his history of sensory integration disorder. I tried to explain that his condition is not a disease and that he just has difficulty processing sensations. He was also upset because he felt that this was a problem that should have been addressed earlier by his parents and he felt like they did not try hard and early enough to help him. D will begin high school this fall and his mother would like to see if he can increase the number of foods he can eat. D does meet with a therapist weekly, but it seems that the topics of discussion are more about fighting with his sister.
Initially he was reluctant to try any foods during the evaluation. He only eats cinnamon apple sauce and he finally agreed to try a bite of non-cinnamon apple sauce. He ate that then refused to take a bite of a graham cracker. He had difficulty labeling tastes (salty, sour).
D's mother did not recall if her son has had a modified barium swallow study previously. I didn't think that an MBS was warranted because there were no signs and symptoms of penetration/aspiration/difficulty swallowing, but I can certainly recommend the test if you think it is necessary.
It took a lot of encouragement to get D to agree to start feeding therapy. I suggested that perhaps we could start with foods he once ate but no longer eats. At the evaluation, he agreed to try feeding therapy.
Yesterday I had my first feeding therapy session with him. My expectations were not high for the session, but I think it went even worse than expected. I gave D a choice whether he wanted his mother in the room or not. She came with us into my room since he seemed to grunt that he wanted her there. In the room, D was very quiet and at times angry because he didn't want to be there. He did not respond to most questions and his responses were typically limited to yes/no. He was very disinterested and pretended to sleep. After about 40 minutes of me talking and very little interaction from D, I stopped the session. I feel like there are a lot of the control issues that you mentionedin the Food Chaining book. I scheduled another session with D in a few weeks as I will be away and his baseball practice couldn't accomodate a closer date. At the end of the session, mom told me that D expressed to his therapist the day before that he was angry that his parents were forcing to attend therapy. Just prior to the session, he told his mom that she was wasting her money on feeding therapy.
Do you think that I should continue these feeding therapy attempts or should I discontinue because he is 14 and capable of making his own decisions? Do you have any suggestions for approaches you would take? Should I ask mom to stay out of the room?
Thank you so much for being such great resources. I look forward to hearing your insight so that I can help D improve his feeding issues.
ANSWER: He is so loaded with emotions and a has a lack of information about this problem, that he isn’t ready to work on the food right away. The Picky Eating Adults website might help and it might also help for him to learn that it isn’t just his parents...physicians and professionals from all over miss this, don’t understand it and do the wrong thing over and over and over. Treatment has to address all sides of the disorder or the disorder will re-establish itself, like weeds, they just keep popping up and the complexity of the disorder grows. You can't just pull ONE weed.
He had years of OT so I don’t think anything was missed as far as effort to help him, it was just that no one knew how to treat feeding. The fact that he was on baby food until that age means a lot. It could be he lacked the motor plan to be able to advance his skills. He could have dysphagia and huge sensory challenges. This will require a complete feeding history and referral to RD to see where he is from a nutrition/growth standpoint. More on that later...
He feels different and the thing he wants more than anything in the world is to fit in and NOT be different. His mom should not be there yet, I would see him and then have her join you for the last 5 minutes or so to go over what happened. He is not going to initiate a lot. Establish rapport, see what he wants out of this. There are two kinds of kids, kids who feel they can't overcome it so are afraid to try and kids who are scared to death of us and what we will make them do. Kids that do not want to grow or eat, may also have components of an eating disorder. The complexity of these issues can be daunting, therefore, team care is needed. The counseling/therapy needs to go way beyond issues with his sister.
Kids this age need a plan that fits their lives. He needs a plan that thinks ahead to being able to eat with friends, school trips, on a date, in a dorm. He has a decent variety of foods in his diet. For example, if he could learn to eat a ham sandwich at Arby’s and fries he would have a place to go eat with friends or Subway ham sandwich, if you chained fries to McDonald’s hash browns or Hardees hash browns, he has another place he can go socially. Pasta-can be expanded so Olive Garden and other restaurants are within his reach. He has a small food repertoire and it doesn’t translate well to real life, but at least all the foods aren’t the same texture. I crumb/crush solid foods like crackers, chips, etc and let the kids taste the crumbs and see if they like the flavor of any of these foods first. Then I work up to helping them eat larger crumbs and build the skills. Some kids tell me that chips feel like eating pieces of glass. So does it feel uncomfortable or does he not know how to eat it?
Are there foods he wants to learn to eat? What does he want to do in life? Does he have the ability to tell you if he wants to go to college, etc? Tailor the plan to HIS life.
We need a Sibyl here to address nutrition, but Carnation Instant Breakfast added to milk could take him a long, long way toward the micronutrients and calories he needs. He is standing on the edge of a huge growth spurt and this is the time he needs more. You can start by adding a very small amount of the (usually vanilla) powder to milk and letting him taste it. Give him a 1/4 tsp up to T spoon and let him pick which one and mix it into a glass of milk. Have a glass of regular milk and CIB milk. Let him dip a straw in it at first and taste and compare. If he can learn to use CIB that is a "meal". Adult supplements are not great in taste and texture for some of our sensory kids. So, this may be a much better choice. It can also be mixed in to milkshakes for extra calories. Even if he doesn’t make huge changes, that will be something normal looking, tasting that he can work toward.
Now, I have also had kids take on chains to work toward lattes and coffee drinks, big time calories and makes them feel very normal as they grow up at college or later in HS. They can also get a drink like this in many places if they can’t stand the food. It makes an adult feel normal to say, “Oh I am just going to have a coffee, I am not that hungry.” Strategies, here, these are strategies that can work and help.
This is painful, it hurts, it never goes away. Meals are endured. Does he enjoy anything at the table? Could he learn to drink V-8 Splash or fruit smoothies, fruit flavored shakes, etc? He isn’t going to like treatment unless it makes sense to him. Fruit breads, muffins, softer breads....also could be good for him.
Success can be one session at a time, one meal where he feels safe and in control, one thing he tries and it isn't that bad...it does not matter WHAT food it is right now, so don't target brussel sprouts, there are no good or bad foods...just get him to where he can eat something. We can expand the diet in time to more nutritious foods.
D did not have any difficulty breast/bottle feeding, but he did not take to finger foods as a baby. He was diagnosed with sensory integration disorder at age 2. No one else in the family has been diagnosed with sensory integration disorder.
He saw a feeding therapist at age 3 for a few months before he started resisting feeding therapy. D was seen at a _____Hospital for a day treatment admission of 2.5 weeks at age 5. During his time there, he was transitioned from baby food to soft solid foods. He would spit out hard solids. He was discharged after 2.5 weeks and his parents were told to work on the feeding skills at home. He saw an occupational therapist from age 4 to approximately age 6-9 at school with a sensory gym. He discontinued occupational therapy as the occupational therapist was let go from the school.
His current (very limited) diet includes the following purees and solids: mashed potatoes, bologna, cinnamon apple sauce, peas, spaghetti, ham, bologna sandwich, chicken nuggets, french fries and liquids: apple juice, soda, water, whole milk. He does not like eating chunky, hard foods (pizza, meat, chicken, dry crusty bread, chicken fingers, cookies). There are some foods such as cherry Italian ice that he used to eat, but no longer eats. D does not have any difficulty gaining weight. He's never been diagnosed with reflux. His mother was doubtful that D would even try a nutritional supplement such as Ensure.
D's mother reported that all of D's sensory integration disorder tendencies have resolved/improved with the exception of feeding. During the evaluation, D began to cry in the room because this was the first time that he was told about his history of sensory integration disorder. I tried to explain that his condition is not a disease and that he just has difficulty processing sensations. He was also upset because he felt that this was a problem that should have been addressed earlier by his parents and he felt like they did not try hard and early enough to help him. D will begin high school this fall and his mother would like to see if he can increase the number of foods he can eat. D does meet with a therapist weekly, but it seems that the topics of discussion are more about fighting with his sister.
Initially he was reluctant to try any foods during the evaluation. He only eats cinnamon apple sauce and he finally agreed to try a bite of non-cinnamon apple sauce. He ate that then refused to take a bite of a graham cracker. He had difficulty labeling tastes (salty, sour).
D's mother did not recall if her son has had a modified barium swallow study previously. I didn't think that an MBS was warranted because there were no signs and symptoms of penetration/aspiration/difficulty swallowing, but I can certainly recommend the test if you think it is necessary.
It took a lot of encouragement to get D to agree to start feeding therapy. I suggested that perhaps we could start with foods he once ate but no longer eats. At the evaluation, he agreed to try feeding therapy.
Yesterday I had my first feeding therapy session with him. My expectations were not high for the session, but I think it went even worse than expected. I gave D a choice whether he wanted his mother in the room or not. She came with us into my room since he seemed to grunt that he wanted her there. In the room, D was very quiet and at times angry because he didn't want to be there. He did not respond to most questions and his responses were typically limited to yes/no. He was very disinterested and pretended to sleep. After about 40 minutes of me talking and very little interaction from D, I stopped the session. I feel like there are a lot of the control issues that you mentionedin the Food Chaining book. I scheduled another session with D in a few weeks as I will be away and his baseball practice couldn't accomodate a closer date. At the end of the session, mom told me that D expressed to his therapist the day before that he was angry that his parents were forcing to attend therapy. Just prior to the session, he told his mom that she was wasting her money on feeding therapy.
Do you think that I should continue these feeding therapy attempts or should I discontinue because he is 14 and capable of making his own decisions? Do you have any suggestions for approaches you would take? Should I ask mom to stay out of the room?
Thank you so much for being such great resources. I look forward to hearing your insight so that I can help D improve his feeding issues.
ANSWER: He is so loaded with emotions and a has a lack of information about this problem, that he isn’t ready to work on the food right away. The Picky Eating Adults website might help and it might also help for him to learn that it isn’t just his parents...physicians and professionals from all over miss this, don’t understand it and do the wrong thing over and over and over. Treatment has to address all sides of the disorder or the disorder will re-establish itself, like weeds, they just keep popping up and the complexity of the disorder grows. You can't just pull ONE weed.
He had years of OT so I don’t think anything was missed as far as effort to help him, it was just that no one knew how to treat feeding. The fact that he was on baby food until that age means a lot. It could be he lacked the motor plan to be able to advance his skills. He could have dysphagia and huge sensory challenges. This will require a complete feeding history and referral to RD to see where he is from a nutrition/growth standpoint. More on that later...
He feels different and the thing he wants more than anything in the world is to fit in and NOT be different. His mom should not be there yet, I would see him and then have her join you for the last 5 minutes or so to go over what happened. He is not going to initiate a lot. Establish rapport, see what he wants out of this. There are two kinds of kids, kids who feel they can't overcome it so are afraid to try and kids who are scared to death of us and what we will make them do. Kids that do not want to grow or eat, may also have components of an eating disorder. The complexity of these issues can be daunting, therefore, team care is needed. The counseling/therapy needs to go way beyond issues with his sister.
Kids this age need a plan that fits their lives. He needs a plan that thinks ahead to being able to eat with friends, school trips, on a date, in a dorm. He has a decent variety of foods in his diet. For example, if he could learn to eat a ham sandwich at Arby’s and fries he would have a place to go eat with friends or Subway ham sandwich, if you chained fries to McDonald’s hash browns or Hardees hash browns, he has another place he can go socially. Pasta-can be expanded so Olive Garden and other restaurants are within his reach. He has a small food repertoire and it doesn’t translate well to real life, but at least all the foods aren’t the same texture. I crumb/crush solid foods like crackers, chips, etc and let the kids taste the crumbs and see if they like the flavor of any of these foods first. Then I work up to helping them eat larger crumbs and build the skills. Some kids tell me that chips feel like eating pieces of glass. So does it feel uncomfortable or does he not know how to eat it?
Are there foods he wants to learn to eat? What does he want to do in life? Does he have the ability to tell you if he wants to go to college, etc? Tailor the plan to HIS life.
We need a Sibyl here to address nutrition, but Carnation Instant Breakfast added to milk could take him a long, long way toward the micronutrients and calories he needs. He is standing on the edge of a huge growth spurt and this is the time he needs more. You can start by adding a very small amount of the (usually vanilla) powder to milk and letting him taste it. Give him a 1/4 tsp up to T spoon and let him pick which one and mix it into a glass of milk. Have a glass of regular milk and CIB milk. Let him dip a straw in it at first and taste and compare. If he can learn to use CIB that is a "meal". Adult supplements are not great in taste and texture for some of our sensory kids. So, this may be a much better choice. It can also be mixed in to milkshakes for extra calories. Even if he doesn’t make huge changes, that will be something normal looking, tasting that he can work toward.
Now, I have also had kids take on chains to work toward lattes and coffee drinks, big time calories and makes them feel very normal as they grow up at college or later in HS. They can also get a drink like this in many places if they can’t stand the food. It makes an adult feel normal to say, “Oh I am just going to have a coffee, I am not that hungry.” Strategies, here, these are strategies that can work and help.
This is painful, it hurts, it never goes away. Meals are endured. Does he enjoy anything at the table? Could he learn to drink V-8 Splash or fruit smoothies, fruit flavored shakes, etc? He isn’t going to like treatment unless it makes sense to him. Fruit breads, muffins, softer breads....also could be good for him.
Success can be one session at a time, one meal where he feels safe and in control, one thing he tries and it isn't that bad...it does not matter WHAT food it is right now, so don't target brussel sprouts, there are no good or bad foods...just get him to where he can eat something. We can expand the diet in time to more nutritious foods.
Sunday, May 16, 2010
Fiberoptic Endoscopic Evaluation of Swallowing-Pediatrics
Pediatric FEESST: Fiberoptic endoscopic evaluation of swallowing with sensory testing
Journal Current Gastroenterology Reports
Publisher Current Medicine Group LLC
ISSN 1522-8037 (Print) 1534-312X (Online)
Issue Volume 7, Number 3 / May, 2005
DOI 10.1007/s11894-005-0041-x
Pages 240-243
J. Paul Willging, MD and Dana M. Thompson
Division of Pediatric Otolaryngology, Cincinnati Children’s Hospital Medical Center, 3333 Burnet Avenue, 45229 Cincinnati, OH, USA
Abstract Fiberoptic endoscopic evaluation of swallowing (FEES) was developed as an adjunct to the videofluoroscopic swallowing study and clinical examination of swallowing function in the adult. The sensory testing aspect of fiberoptic endoscopic evaluation of swallowing with sensory testing (FEESST) utilizes an air pulse stimulus of mechanoreceptors within the larynx. The study can be performed safely in children as young as premature infants and in adults. Adequate levels of cooperation can be obtained in nearly all children requiring FEESST. No cases of laryngospasm or respiratory compromise have been encountered. FEESST was initially applied to patients with dysphagia. It is now used in the study of the effects of gastroesophageal reflux on the larynx and swallowing function. The extent of pooled secretions in the hypopharynx can be used as a surrogate measure of laryngopharyngeal sensory testing. When patients managed by FEESST were compared with patients managed by video-fluoroscopic swallow studies, there were no statistical differences in the rates of pneumonia or pneumonia-free interval. A learning curve is present for the operator, but with basic endoscopic skills, FEESST is a skill within the scope of practice of most pediatric endoscopists.
Journal Current Gastroenterology Reports
Publisher Current Medicine Group LLC
ISSN 1522-8037 (Print) 1534-312X (Online)
Issue Volume 7, Number 3 / May, 2005
DOI 10.1007/s11894-005-0041-x
Pages 240-243
J. Paul Willging, MD and Dana M. Thompson
Division of Pediatric Otolaryngology, Cincinnati Children’s Hospital Medical Center, 3333 Burnet Avenue, 45229 Cincinnati, OH, USA
Abstract Fiberoptic endoscopic evaluation of swallowing (FEES) was developed as an adjunct to the videofluoroscopic swallowing study and clinical examination of swallowing function in the adult. The sensory testing aspect of fiberoptic endoscopic evaluation of swallowing with sensory testing (FEESST) utilizes an air pulse stimulus of mechanoreceptors within the larynx. The study can be performed safely in children as young as premature infants and in adults. Adequate levels of cooperation can be obtained in nearly all children requiring FEESST. No cases of laryngospasm or respiratory compromise have been encountered. FEESST was initially applied to patients with dysphagia. It is now used in the study of the effects of gastroesophageal reflux on the larynx and swallowing function. The extent of pooled secretions in the hypopharynx can be used as a surrogate measure of laryngopharyngeal sensory testing. When patients managed by FEESST were compared with patients managed by video-fluoroscopic swallow studies, there were no statistical differences in the rates of pneumonia or pneumonia-free interval. A learning curve is present for the operator, but with basic endoscopic skills, FEESST is a skill within the scope of practice of most pediatric endoscopists.
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