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