CHILDREN WITH FEEDING PROBLEMS: Considerations for Assessment & Therapeutic Interventions for Sensory Related Feeding Difficulties

03.24.2019

Those of us that parent, care for, and provide therapy services for children are very aware of those youngsters that struggle through meals and have difficulty eating.

The prevalence of feeding disorders in children that are developing typically has been noted to be as high as 25%. For those with developmental disabilities it has been noted to be as high as 80%. The consequences for a child that is struggling with a prolonged feeding problem are serious. It may result in poor nutrition, compromised growth, and interference with social/emotional development.

A child that is considered a picky eater has a limited acceptance of foods and beverages. The parents of a picky eater will usually provide this child with a different snack or meal than the rest of the family. He/she will eat a decreased variety of food but will usually tolerate a new food on their plate. The child may even eat the new food! A picky eater will eat at least one food from each food group.  

In contrast, a child with a feeding problem shows a persistent refusal to eat a certain food group, texture, solid or liquid for a period of at least one month, resulting in no to very little weight gain and body growth. This child may accept less than 20 foods in total and tends to become very upset when new foods are presented.

ASSESSMENT 
of Children with Suspected Feeding Disorders

  >> Mealtime Assessment/Screening

It is important to gather information about a child’s health/medical background, weight & growth, food texture consumption, cognitive and problem-solving skills, posture/large motor control, oral motor skills, fine motor/self-feeding skills, as well as their sensory profile related to meals.

It is very important to get a picture of the child’s mealtime environment. This information is necessary to develop effective treatment strategies and family recommendations that will help a child gain functional and adaptive feeding skills.

To help acquire the aforementioned information, Tools To Grow is pleased to offer our NEW “Mealtime & Feeding Skills: Screening Forms” resource.  This is a 5-page Screening Packet that includes the following categories: Diet, Liquid Intake, Sensory, Biting, Chewing, Swallowing, and Meals/Snack Routine.

Find these NEW Mealtime & Feeding Screening Forms HERE!

>> Food Intake

A food survey of what a child consumes on a daily basis over a span of time can be very valuable to learn what patterns emerge.

Does the child graze all day? Does the child take most of their calories via liquids? Do they fill up on empty calories? Do they have a restricted diet in terms of taste, texture, smells, appearance of food, food groups, etc.?

To help gather the aforementioned information, Tools To Grow is pleased to offer our NEW resource “Mealtime & Feeding: Daily Intake Logs”.

2 Versions are included:

>> 8- Day Meal Log = This is a 4 Page Editable PDF.  TYPE directly into Intake Log!

>> One Day Meal Log = This is a 2 Page Editable PDF.  TYPE directly into Intake Log!

Find these Mealtime & Feeding DAILY INTAKE LOGS HERE!

 To help with the completion of Mealtime Daily Intake Logs we have created a FREE Sample Food List. 

Find this FREE Food List HERE!

TREATMENT PLANNING

for Children with Feeding Problems

Using the assessment information gathered and your clinical skills, the following may be determined to exist:

• Health Concerns- A referral and/or follow up with a physician may be indicated to ensure the child remain safe and healthy. It is extremely important to emphasize to a parent/guardian that your service is just one “piece of the pie”. A child with a very serious feeding disorder requires close contact with a team of providers that includes a medical doctor and nutritionist.

• Delays in Oral Motor Skills – The child may need intervention to develop strength and coordination in facial muscles, lips, jaw, and tongue. Intervention may be indicated to assist with intra-oral awareness to help a child form a food bolus when chewing, minimizing food residue in the mouth, and decreasing food loss through the lips. The scope of interventions that may be indicated and provided is very broad and may require a therapist to seek advanced knowledge/training.

• Delays in Self Feeding Skills- This includes grasp and release of finger foods, bringing finger food to the mouth, use of utensils (scoop/spear, bring to mouth, bring back to plate), and grasping and bringing a cup to the mouth. Specialized and low-tech mealtime tools may be indicated that include a built-up handle, scoop plate, wide based cup, use of a straw, dycem under the plate, etc. The simple addition of a preferred place mat or colorful cup may make a big difference!

• Poor Sitting Posture/Insufficient Seating- The child may not be sitting comfortably or safely at the table. The chair or table height may need revisions to allow for proper foot and forearm support.

INTERVENTION

for Children with Sensory Related Feeding Problems

Helping children with disorders of feeding or eating can be extremely rewarding but can also prove to be extremely challenging. Given the complexity of these concerns, intervention planning in this area often requires advanced training and knowledge.

One thing is for sure, any effective intervention requires a deep commitment to collaborate with the family, and provide highly individualized and safe treatment strategies. To help children with feeding problems with a sensory component, the therapist will not only be working with the child. The intervention must extend to the parents and significant others in the child’s life.

Below are samples of some intervention strategies that may help a child with sensory related feeding disorders:

• Establish routines and a consistent environment- This is the part that takes a dedicated and persuasive therapist! We know that this part is easier said than done! But for real change to occur a regular routine prior to, during, and after meals must exist. As we know a child that has difficulty with transitions needs extra support to break away from a preferred activity and engage in something else. A child with feeding problems needs to know when the meal or snack is occurring and what he/she is expected to do. For example, first wash hands, then come to table, sit in the chair, etc. Aim for no longer than 15-minute snacks and 30-minute meals. The child clears his/plate after the meal (if possible). Meals and snacks need to be scheduled at regular intervals.

• Modifying Foods Offered- This may include thickening liquids, decreasing the quantity of food on the plate, altering the density of food to allow for improved biting, minimizing mixed texture foods (ex: soup), adding flavor via spices, reducing flavor by removing spicy food, being mindful of temperature, etc. You need to match the child’s food to their skills.

• Offer Food Handling & Tolerance Activities- Children with aversions to certain smells, sights, and touch may find it fun to participate in food preparation using simple child friendly recipes. This will provide a perfect opportunity to encourage a child to interact with various foods in a fun and hopefully non-threatening manner. A child may improve his or her tolerance for handling and accepting a greater variety of food through the use of “food art”. Remember…he or she may not need to eat the food, just learn more about it.

To help children engage in food preparation, Tools To Grow is pleased to offer NEW child friendly Visual Recipes!

This NEW resource includes 15 Different Visual Recipes.  Each Recipe Includes:

(1) Tool List (kitchen tools and ingredients needed), and

(2) Visual Recipe and Step-By-Step Sequencing Chart.

NO OVEN OR STOVE NEEDED! You may need a microwave, toaster, and blender.  Find this Visual Recipe Resource HERE!

Recipes Included:

• POLAR BEAR TOAST
• POLAR BEAR RICE CAKE *free printable!
• HEART TOAST
• LEAF TOAST
• STRAWBERRY BANANA SMOOTHIE
• BLUEBERRY SMOOTHIE
• BREAKFAST YOGURT CUP
• PITA POCKET
• APPLESAUCE
• UNDER THE SEA CRACKER SNACK
• SIMPLE SALAD
• TEDDY BEAR RICE CAKE
• MEAT SANDWICH
• CHEESE SANDWICH
• HOT CHOCOLATE

Download a FREE Visual Recipe: Polar Bear Rice Cake!

This FREE Printable includes Step-By-Step Directions & Ingredient/Tool List to make a Rice Cake Polar Bear.

Find it HERE!

Be sure to also download SPRING Visual Recipes! These Printable Recipes includes Step-By-Step Directions & Ingredient/Tool List to make three Spring Themed Snacks.

• Flower Cracker
• Butterfly Cookie
• Celery Caterpillar

 Find these SPRING RECIPE CARDS HERE!

To help children interact with food using “food art”, Tools To Grow is pleased to offer these Food Art Snack Mats!

These Food Art Snack Mats Address the following:

• Accepting and Enjoying a variety of foods.
• Looking, Touching, Tasting, Biting, Chewing, a variety of foods.
• Fine Motor Skills
• Eye-Hand Coordination
• Hand Separation
• Hand Arch Development
• Self-Feeding
• Oral Motor Skills
• Controlled Finger Movements

Simply Print the Food Art Snack Mats and Laminate for durability. Use the suggested food on the legend or try your own!

Find these NEW Food ART Snack Mats HERE!

Tools to Grow also has Color Sorting Meal Time: Snack Mats. This PDF includes 6 Different Snack Mats. Using cereal and/or fish cracker treats, the child places the desired snack on the mat as indicated. These Meal Time Mats are a great activity to address: Color Recognition & Sorting, Number Concepts, Fine Motor Skills, Visual Discrimination Skills, Eye-hand coordination, Controlled finger movements, Self-feeding and Oral Motor Skills.

Find these Meal Time Sorting Snack Mats HERE!

• Offer Reinforcement for Trying New Food- Some children will respond well to positive encouragement and acknowledgment from others that he/she interacted in a positive manner with a new food. This may include looking at the food, touching the food, smelling the food, bringing the food to their lips, taking a bite, chewing the food, and finally swallowing the new food.

To reinforce children for interacting with food in a positive manner, Tools To Grow is pleased to offer the following Resources:

(1) Color (Colour) Your Plate: I Tried It! Food Coloring Sheets

Includes Food Groups: Fruits, Dairy, Vegetables, Proteins, and Grains.  Color each food you have tried! Includes American and Canadian/British Spelling Versions.

Find this Coloring Resource HERE!

(2) Color (Colour), Cut, & Paste: Food Groups

Includes Food Groups: Fruits, Dairy, Vegetables, Proteins, Sugars, and Grains.  Color the food items (36 included), Cut, and Glue in the correct Food Group.  Includes American and Canadian/British Spelling Versions.

Find this Color, Cut, & Paste Resource HERE!

(3) “Give It A Try” Food Game is the perfect tool to introduce and interact with food in a positive and fun way! This PDF includes:

• Detailed Game Instructions
• Printable Die with 6 Colors representing 6 different ways the child can interact with the food
• Snack Mat (Color & Black/White Versions)
• Food Action Chart
• 12 Reward Token Cards (Color & Black/White Versions)

Find this Feeding Game HERE!

(4) “I am Hungry: Let’s Try a New Food!” Mini-Book is another great way to introduce and interact with food in a positive and fun way! This Mini-Book Mealtime Social Story is included in both Girl and Boy Versions.  This PDF includes:

• Detailed Print and Assembly Instructions
• Mini-Book with 22 Story Pages
• 30 Different Food Items

Black/White Ink Friendly Version and Color Versions of each available!

Find these NEW Social Story Mealtime Books here!

• Seating- Help the family set up a mealtime seating arrangement that includes a chair with adequate depth for the child’s legs, a stable pelvis at 90 degrees, and feet that are supported on a stable surface/the floor. The child’s tummy should touch the table. The height of the table should be at the child’s elbows for their forearms to rest properly.

• Encourage Touch Input to Face & Mouth- Try the following:
  • Whistles
  • Blow objects with straws (leaves, cotton balls, feathers, ping pong ball, etc.)
  • Face painting
  • Applying lip gloss/chap stick
  • Stereognosis Game- Child finds and removes a sticker that was placed on their face without the benefit of a mirror
  • Allow bubbles to pop on his/her face

To help children accept touch input to their face and mouth, Tools To Grow is pleased to offer these oral motor blowing games:

• Apple Oral Motor Game: This apple themed table top/floor game is designed to promote development of oral motor, turn taking, following directions, and visual motor skills. Students will enjoy the strategy and chance to have some Fall Fun!

• Go Home Monster! Oral Motor Sorting Game: This monster themed game is designed to promote the development of oral motor, eye-hand coordination, and visual perception skills. Children will be encouraged to identify and/or match colors, take turns, and understand simple rules of the game.

• Igloo Flurry - Oral Motor Game: This winter themed Igloo game is designed to promote development of oral motor, turn taking, following directions, and visual motor skills. Students will enjoy the strategy and chance to have some Winter Fun!

Find these Oral Motor Games HERE!

• Encourage Internal Awareness of the Face and Mouth
  • Imitate facial expressions
  • Imitate lip and tongue movements
  • Move gum around his/her mouth
  • Use a vibrating toothbrush
  • Model how to bite off a firm food, chew and swallow
  • Allow child to watch him/herself eat through use of a mirror

• Increase Tolerance for Varying Food Temperatures & Other Sensory Features
  • Label sensory features of varying objects- warm, cold, hot, soft, hard, bumpy, smooth, etc.
  • Use an ice cube to create art by rubbing in drink powder (ex: Kool Aid) and gently encouraging tastes; may need to start by child wearing thin gloves
  • Use ice cubes dipped in drink powder to apply “lip balm” to lips
  • Change the temperature of the straw (that child is using to blow objects) by dipping the end that will enter their mouth into warm or cold water.
  • Bury small objects in ice- child is to use a tools to dig out of ice
  • Smell different herbs and spices- use to create sensory art
  • Sort foods by how they look- all red apple slices go here, all yellow go there
  • Include a variety of very simple kids cooking activities into therapy (banana slices in chocolate syrup, slicing cucumbers, etc.
  • Label food by taste- salty, sweet, sour, etc.
  • Use snack mats with cheerios, fruit loops, fish crackers
  • Make rainbows- press teeth into carrot, chess, fruit roll ups and make a “rainbow” impression.
  • Proprioception activities before snacks and meal- this can override most other sensory input the child may be over-reacting to during the meal.

• Strategies to Increase Breath Control
  • Practice deep breathing and exhalation- smell the flowers, blow out the candle
  • Blow bubbles
  • Blow feathers

• Strategies to Increase Utensil Use
  • Child performs make-believe feeding of doll, stuffed animal, etc. using a spoon or fork
  • Child cuts dough with safety knife
  • Child carries small objects using a large spoon
  • Stirring with a spoon- can use a dry tactile bin or cup of fluid to stir
  • Scooping with a spoon- can use a tactile bin of dry rice and beans to scoop

• Strategies to Increase Foods Consumed During Family Meals at Home
  •  Focus on volume of food eaten
  • Every person in family aim to eat a serving of each food presented as a good role model
  • Use mealtime for pleasant interactions
  • Each meal should include at least one food child will eat
  • Have meals at scheduled times
  • Provide verbal warning 5 minutes before meals
  • Include a transition activity- washing hands
  • Sit at table in assigned chair that fits child well
  • The child should not be the focus of the meal, but praise should be offered for any good attempts at eating non-preferred foods (looking at, smelling, touching, tasting, swallowing, etc.)
  • Never force child to eat but you may say “you can take a bite of potatoes”.
  • Everyone should empty their own plate.

• At Other Times
  • Discourage grazing
  • Discourage excessive drinking
  • Aim for 15 minute snacks and 30 minute meals

References

1. Feeding Strategies for Picky Eaters. Shawn Manvell
2. When Children Won’t Eat: Picky Eaters Versus Problem Feeders, Assessment and Treatment Using the S.O.S. Approach to Feeding. Kay Toomey, PhD, Lindsey Beckerman MOT, OTR/L, and Deborah Lagerborg, CCC-SLP

Related Topics: Feeding

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