When I work with children who don’t eat well, I typically start by teaching them to accept a “dry spoon” which is a spoon with no food . This takes the element of food out of the practice initially and targets the refusal behavior. Once the empty spoon is accepted into the mouth, we work on acceptance of “dips” or tastes, then spoon bites of a simple thin single ingredient purée such as applesauce or sweet potatoes. We progress from tastes to larger bites on the spoon using therapeutic strategies to build comfort , acceptance and success.
We may start with measuring progress by counting the number of tastes or bites accepted during a session. As the child’s acceptance becomes consistent, we can move from counting bites to measuring volume. It’s exciting when a child who has a long history of food refusal or poor intake accepts the first ounce of purée ! From there, we work on increasing the volume. My preference is to stay with the same flavor of thin purée until the child takes 2-4 ounces fairly easily before introducing a second flavor. This way, the child builds comfort and confidence with the flavor before we change it up again. When I introduce the next flavor, we use dip spoons again until the child is comfortable with the flavor and we gradually increase the volume on the spoon. We begin to build a repertoire of accepted foods.
This is where we have a choice. As the child starts accepting small volumes of food- should we add texture to it? Texture can be added by mixing in infant cereals, wheat germ, mashed whole foods, or even cracker crumbs. Adding texture works on tolerance of a thicker more dense food and can be a step toward solids. A step toward something more age appropriate. But for some children, it can also make bolus formation and transfer more difficult. Or should we work on increasing volume or increasing flavor?
Therapists often have to make a clinical decision here- which is right?
- Increase volume
- Increase texture
- Increase taste
I believe this is a case by case decision. For myself, I lean toward volume of easy purée over texture and flavor in the beginning. I like to keep it easy for the child while working on acceptance. I think it’s important that eating not always be hard for the child. I’ve seen many children flourish by starting with easy purée and letting the child have a lot of success initially before working on the harder age appropriate skill.
However, I can think of case examples that are exceptions to this.
Consider increasing the flavor profile or taste with homemade or natural purées for a child who has better response to flavor. Some of our kids have more interest and response when favors are more intense . Children with low tone or reflux history may prefer strong flavors. Try tastes of condiments mixed into puree, guacamole, hummus, soups, or homemade purée.
Consider increasing the texture when it improves oral control. Some of our kids with low oral tone and reduced bolus formation may do better with more dense purée. The denser purée may hold together better orally. I’ve also seen this improve pharyngeal swallowing on a MBSS as well with the theory that the heavier purée may improve sensory response of the swallow. Increasing texture is also a strategy used to work on tolerance of texture while moving toward solids.
Whether you decide to work on volume, flavor or texture will depend on what your ultimate goals are and of course the response of the child. There is no “cook book” approach to feeding therapy. What works with one patient may not necessarily work the same way with another. I believe this is one of the reasons this area of specialty is so interesting and always keep us on our toes as therapists.
Ann Marie Presberg says
Great post! As always, agree whole heartedly. Are these cases inpatient intensive therapy over x weeks, out patient weekly sessions or combo? What are ways you’ve helped families carry these strategies over in the home After discharge and/or between sessions? If it’s intensive in-patient do you follow the kids after discharge? Thanks.
Krisi Brackett says
These cases are seen in an out-patient hospital based clinic- usually with our feeding team and some children are also seen between feeding team visits for therapy sessions. We typically see kids twice per month. Parents are always present for therapy and do a portion of the feeding so they can practice techniques with us. Each child is on a home program that we provide with specific textures, utensils, and feeding techniques.
Nannette Martin, CPNP says
As one who manages gi symptoms and does not do feeding therapy, I am always interested in seeing how you make the decision between increased volume or adding texture. Adding volume can be such a positive move. Not only does it encourage the child because they are successful but it also shows the parent, who is often frustrated, what the child can do and gives hope that mealtimes can be happy and not stressful. When the parent is on board with the feeding therapy and sees what progress can be made in a short time, he or she is often more willing to do the strategies at home.
Nannette Blois-Martin, CPNP
Cary Curtis says
Great article. Thanks for your insight!!