Feeding Therapy: What to Do When You are Stuck

I get emails all the time asking for advice on how to get kids to eat. Many of these children are in therapy but are having difficulty progressing toward the acceptance of food and liquid. I have said this before but will say it again, these kids are hard, feeding intervention can be challenging and what works for one child may not work for another. As a feeding therapist, I am a believer in working on the goal of “improved acceptance of volume and variety of foods” from the standpoint of health and nutrition (kids need to eat from all food groups) and also because if a child is orally feeding then they are using and developing their oral-pharyngeal muscles which helps with oral motor skill development. I cannot stress enough that these children are all unique and need to be assessed individually but I thought I would try to come up with a top ten (really twelve) list of ideas to break the plateau. I hope these ideas help to generate some progress!

 

1. Look more closely at medical reasons for refusing food. This might include gastroesophageal reflux, constipation, food intolerance, eoscinophillic esophagitis, increased work of breathing, respiratory problems, dysphagia, or poor appetite. Consider working closely with a primary care physician, developmental pediatrician or gastroenterologist to obtain further assessment and trial some medical management strategies.
2. Refer to a multidisciplinary Feeding Team. Sometimes two or more heads are better than one meaning a feeding team may be able to assess a child who is not progressing and come up with some new ideas to jump start things. Typically you can find a multidisciplinary feeding team in a children’s hospital. We do this all the time for our kids in NC!
3. Increase the child’s appetite. Some of the children we work with have a history of poor appetite, volume limiting, or have been tube fed and do not have a reference for hunger/fullness. An appetite stimulant may help in getting a child eating (this tends to be more effective after medical management strategies have been implemented or when you are certain the child is not in pain).
4. Manipulate tube feedings. Many clinicians have the goal of getting a child to bolus feeds to simulate normal eating but for some children, especially those with underlying abnormal motility this will not necessarily encourage intake. Manipulating tube feeding schedules to allow a significant amount off time off the tube to develop hunger or an opportunity to orally feed or changing the type of formula to something predigested which may have a faster gastric emptying time can be effective strategies to encourage intake.
5. Alter supplement intake. Sometimes when a child is drinking a supplement either for meals or extra calories they develop a preference for the sweet taste of the formula and may refuse food to get the formula or because they are full. Try altering how the supplement is given by offering smaller amounts during meals (example, 4 oz instead of 8 oz), giving it after meals or at snacks only.
6. Consider an intensive feeding program. I am always surprised to hear that feeding therapists do not know these programs exist. There are intensive feeding programs around the country (in the U.S.), typically housed in a childrens hospital, ( I admit I am not sure what is available in other countries) that will provide intensive feeding intervention daily for 4-8 weeks depending on the program. Intensive feeding program are not all the same. These feeding programs have different philosophies on intervention and vary on length of treatment and follow-up. I always give advice to caregivers who are interested to pick a program based on their child’s needs and not just based on geographical location. Many insurance companies will cover these or a portion of the cost if a child has “failed” out patient treatment.
7. Try a different therapeutic technique. There are many different therapeutic techniques and strategies some more formal than others to encourage intake. If you are using an oral-sensory based feeding approach and are stuck consider trying some behavioral strategies.
8. Reach out to your colleagues. There are many professional involved in feeding each with a unique skill set to bring to the table. Try reaching out to a feeding therapist from another discipline, a different profession or an expert for ideas. Many clinicians will be open to discuss a client over the phone or via email to generate some ideas.
9. Take a break from therapy. Sometimes a child or a parent may need a break especially if they have complicated medical needs, may be in and out of the hospital with illness or surgical needs, or have other extenuating circumstances. There are children where oral feeding may not be the priority. For these children we want to make sure they are receiving proper nutrition for weight gain and growth until they are ready to work on oral feeding.
10. Work closely with caregivers and give homework. Include caregivers in therapy and have them participate in actively using the feeding techniques. Provide homework so that caregivers can practice therapy strategies daily at home with their children. This builds confidence in the caregiver that they can successfully feed their child and provides the child with positive daily practice! Additionally, if you watch caregivers feed their children you can coach them through difficult meal time behaviors. I often think of myself as a feeding coach.
11. Match the child’s diet texture to their oral motor skills. Many (actually most) of our clients have some oral motor delay. The child’s diet (food textures) should be consistent with their oral skills. If a child is being given foods that are above their skills level, the result will often be poor intake, refusal, long meal times, food pocketing or holding, and expelling. I have seen children make immediate improvement in mealtime just by taking them back to purees or mashed foods, or making a portion of their meal purees with limited solids (determined by their stamina for chewables).
12. Work on cup drinking. This if often a good way to move a child off of a feeding tube because it is a direct correlation in terms of calories and nutrients. If the child can drink what is going into the tube (and the child’s weight is good), then it can be deducted from the tube feeding. There are often many options for formulas or supplements to choose from. If the child will not drink the tube feeding formula (or it may be an enteral only formula or one with little to no taste), talk with a dietician and obtain samples of alternative supplements with comparable calories and nutrients or about having the caregivers make their own high cal supplement. It can be motivating for caregivers to see the tube feedings decrease.