Case Study: Long Meal Times and Poor Chewing: A Feeding Team Approach

Case Study: Long Meal Times and Poor Chewing: A feeding Team Approach

Referral:B.T. – a 6 year old female with prolonged meal time (meals can take 45-60 minutes). B.T. also pockets and holds solids in her cheeks and needs verbal cues to chew.

 

Feeding Team Evaluation and Management:

 

Medical history taken during assessment included:

1. 30 week preterm infant

2. Attention deficit disorder (ADD)

3. Constipation

4. Signs of gastroesophageal reflux including bad breath, stomach pain, frequent nasal congestion, and occasional regurgitation

5. Weight loss, (recently lost 1 lb.)

6. Nasal tics (Parents thought this might be from ADD medicine but were unsure)

 

GI: B.T. had reflux and difficulty stooling since infancy. Reflux was not treated because she was growing well. B.T. also had hard stools since infancy, Mother tried prune juice and mirilax but it never really solved the problem. Mother has been talking to pediatrician about constipation “forever”. B.T. complains of stomach pain, regurgitation and is afraid of choking.

 

Feeding History:B.T. bottle fed breast milk and formula well.She transitioned easily to baby food Feeding problems started at 1 year with transition to solids. Mother reported that B.T. had difficulty holding solids right away and seemed to have difficulty swallowing. She did not have vomiting or overt signs of reflux. B.T. transitioned to whole milk and cup drinking without difficulty. At age 3, she tried feeding therapy for chewing with no change in eating.

 

Current Feeding: B.T. is offered the same food the family eats. She eats 3 meals per day and snacks. She eats from all the food groups but meals can take 45-60 minutes with needed verbal cueing from parents. She also holds foods in her cheeks and has slow chewing. Her preferred foods don’t need to be chewed. She drinks 16-24 oz of milk, also juice, flavored water, and lemonade. B.T. drinks shakes or 1 pediasure/day to help with calorie needs. Meal times have been a constant challenge and are affecting the entire family.

 

Observation:

Oral Motor Exam:Within Normal Limits

 

Eating:B.T. was brought to the evaluation hungry and was asking to eat. She self fed a peanut butter sandwich, chips and drank water. B.T. used a rotary chewing pattern without any difficulty forming a bolus and transferring it. There were no clinical symptoms of swallowing difficulty. B.T.’s mother commented that she had never seen her chew this well.

 

Summary:

1. Oral Motor Patterns:Normal for structure and function. Reported pocketing and holding of foods which in B.T’s case is most likely related to underlying discomfort caused by constipation and GER.

2. Swallowing: no s/s of swallowing difficulty

3. Gastrointestinal: long history of constipation. Soft signs of GER ( c/o stomach pain, bad breath, frequent nasal congestion, nasal ticks, poor appetite, pocketing food, regurgitation).

4. Behavior: c/b slow eating, prolonged meals, and pocketing or holding solids most likely related to GI issues.

 

Goals:

1. Pt will eat appropriate size meals in 30 minutes or less.

2. Pt will chew solids without pocketing or need for verbal cues in timely manner in 90% of trials over 3 consecutive sessions.

 

Feeding Team Plan: (GI, Speech and Nutrition)

1. Screening labs for CBC, CMP, TSH, Free T4, Celiac Screening, Vitamin D 25OH.

2. Home clean out (GI provided instructions for a home “clean out”. This means to increase stooling to the point of diarrhea to eliminate any stool that is backed up. After the patient achieves liquid stool, then a regiment of stool softeners is used to maintain daily soft stooling. After clean out: Use Miralax. Goal is to have 1-2 soft BM’s daily.

3. Medication for gastroesophageal reflux (omeprazole).

4. Use high calorie drink during meal time to reduce overall caloric need and shorten meal time length. (B.T. will drink a portion of her caloric need, therefore, reducing need to chew and meal length).

5. Chewy tube: practice biting 30-40x per side several times per day. While B.T. displayed age appropriate chewing during the assessment, due to long history of pocketing and storing food and decreased efficiency of chewing, strengthening exercises were recommended.

1 months later:

• Labs were all normal.

• B.T. completed a clean out at home and is now on maintenance Miralax to and having one soft BM daily.

• B. T. is taking GER medicine. She has decreased c/o stomach pain, resolved regurgitation, and elimination of nasal tics.

• Mother has noticed improvement with eating. Meal time has decreased to 30 minutes with minimal verbal cueing from parents. B.T. has shown improved chewing with GI medical management. Pt is now drinking 1 high calorie shake every few days and weight is stable. Pt is only holding foods in her cheeks at the end of the meal when full. Speech therapy discussed increasing B.T’s awareness of pocketing foods and using behavioral reinforcement strategies for proper chewing.

Final Thoughts

B.T. came to us because of recent weight loss, a concern that meals were taking too long, and that she wasn’t chewing her food but holding it. She had been holding solids since she started table foods at age 1! Her family was exhausted with her feeding issues.

 

It is significant that her first therapist and her pediatrician did not connect her constipation and gastroesophagheal reflux to her feeding behaviors (eating very slowly), fear of choking, and holding or pocketing solid food in her cheeks. All of these behaviors can be signs of underlying GI issues.

 

We know that eating is a learned behavior and for children that experience discomfort with eating, it changes how they eat. They also can not tell us what is wrong. The way they eat tells us a lot about how they feel inside. For B.T., the chewing skills she demonstrated during the evaluation were strong enough that we knew this was not just weak chewing.

 

In one month, we were able to positively impact B.T’s feeding as well as the family meal experience. She will follow up in another month with the feeding team to assess progress.