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!