Step-by-step approach to food
tolerance and diet expansion
The condition of a child's GI
system has a direct effect on feeding. If the GI system is not functioning
efficiently it's going to impact feeding tremendously.
Many of the children with GI
system present with:
- gastroesophageal
reflux disease (GERD),
- constipation due to the limited diets related to food refusal,
- vitamin and mineral deficit, which in consequences affect the GI tract and put things off balance,
- eosinophilic esophagitis, an allergy-based esophageal inflammation
- necrotizing enterocolitis in premature infants - an occurrence when intestines become inflamed or infected. The intestines need to be repaired and reconnected through surgery, causing serious GI complications.
- negative associations with feeding, e.g. If the child is refluxing and it's causing pain, he associates pain with eating so he stops eating.
It is the same with eosinophilic
esophagitis. If the child is constipated and feels bloated and full, he doesn't
want to eat and does not have any hunger cycles. The chiled can learn that
negative association within a month or two and starts refusing the bottle.
Many of the children treated by
speech-language pathologists on the feeding team are tube-dependent. As a result,
they are seen by a team consisting of speech pathology, gastroenterology and
nutrition. The collaboration of these three specialists is necessary.
The speech-language pathologist
requires a constant line of communication with the dietitian because these
nutrition decisions are tied so closely to oral intake. Feeding is the only
activity that involves all your organs and all of your muscles. Everything goes
into feeding, so everything impacts it.
Families of tube-fed children
often struggle with the idea that their children will never be hungry enough to
eat orally if they remain on the tube. It's a double-edged sword. We can not
pull back on the tube just because the child is not eating enough.
Generally, the preference of the
treatment team is to put children who are tube-fed on bolus feeds rather than
continuous feeds. However, if the child cannot tolerate a bolus feed, the
continuous feed will continue.
A fairly normalized mealtime
schedule is arranged for children who can tolerate a bolus feed. In an ideal
situation the feed would be given by a pump over 20 to 30 minutes because that
is a more normalized mealtime that the child would take if they were given
everything PO (orally).
The 20-minute feed time presents
an ideal opportunity for the speech-language pathologist to put the pump behind
the child's chair, where it is out of sight, and begin PO
trials. The children learn that something is going in they mouth and they
stomach is feeling full, but they don't associate feeling full with the sight
of the machine.
Appropriate oral stimulation toys
or devices and textured plastic play food should be used to reinforce oral
associations with feeding. There would be kids who will point to their tube and
say 'hungry' because they know that's how they are fed. Nobody wants that
association. Speech-language pathologist wants the child to point to his mouth
and say “That.”
Even when food finally is
introduced, the child may tolerate puree but reject a "wet" texture
food, such as green beans or mandarin oranges. Food chaining posits that
children are more likely to accept a new food if it is similar in some
way-color, shape or texture-to a food they already like. If a child eats
Goldfish crackers, for example, clinician may use a fish-shaped cookie cutter
to cut slices of cheese to reflect the color scheme. Clinician then introduces
the food to the child by discussing its likeness to the previously accepted
food.
It is not uncommon for these
children to gag or vomit food. With those kids SLP has to work on tolerating
the food on the tray.
The clinicians use the
Sequential, Oral, Sensory (SOS) Approach to Feeding developed by psychologist Kay Toomey, PhD. Dr.
Toomey's approach seeks to lessen the fearfulness of feeding for children by
breaking down the process into much smaller steps. There may be 28 to 32 steps
before a child takes a bite and swallows. These steps include kissing the food,
licking, putting it into the mouth, and spitting it out.
The therapy is pushed as much as
the child can tolerate it and until the kid is finally eating the bite.
The step-by-step approach incorporates
an "all-done bowl" that allows the clinician to maintain control of
the feeding therapy. For example, if a child starts throwing the food, which is
very common, instead of saying: No
throwing, Stop, the clinician would say, The food stays on the table. If you're done with it, you can clean it
up and put it in the bowl. If the child gets distressed about the food does
not just throw it off the table. The child has to follow an instruction to
complete the task. It allows for a much more efficient, less battle-oriented
mealtime, which is something a lot of parents deal with.
Speech-language pathologist on
the team also works with the parents on using appropriate, positive language
during mealtime to allow them to remain in control. The parents should avoid questions,
such as: Will you take a bite? Do you
like it? or Will you eat a bite for Mommy? but use positive statements,
like: You can take a bite. Mommy wants to
see you do it.
Infants don't have trunk support
yet. When we hold them in a cradled position, they're slumped down and putting
a lot of pressure on their abdomen, which causes the reflux to come up a little
easier. As they learn to crawl and walk and sit upright, there's not as much
pressure on the stomach and as the result half of infants outgrow reflux by 9
months of age.
Children who had reflux as
infants need to be monitored for less visible but still present symptoms of GI
disturbance. The reflux instead of coming out of the mouth might be coming up
and down into the esophagus.
Older children with reflux often
present with a chronic cough, hiccups, burping and frequent ear infections.
They may only be able to tolerate small feeds but in frequent intervals.
Dental caries also can serve as
an indicator for a speech-language pathologist. When a toddler has had a lot of
dental work, which can be a red flag because the acid is coming up and eroding
tooth enamel.
Recurrent pneumonia is another
serious concern and GI problem indicator. Reflux is typically worse at night
because we sleep lying down, and by doing so we lose the benefit of gravity. It
comes up, spills over into the larynx, and goes into the lungs. The children
are getting aspiration pneumonia, but they're aspirating reflux.
