Dysphagia - Swallowing Treatments

Normal Larynx

Behavioral Therapy

Behavioral Therapy are postural maneuvers or compensatory strategies that are implemented to insure a safe swallow.

For example, a HEAD TURN is implemented when it is found that a patient is numb on one side of their throat during a FEESST exam. By having the patient turn their head to the numb side, the area of the throat that is numb becomes narrowed so that incoming food gets directed towards the sensate side of the throat.

Types of Swallowing Behavioral Therapy include:

A. Postural Techniques

• Head Rotation to Weak Side or Strong Side - By rotating the head to the side of either motor or sensory weakness, the patient can eliminate the injured side of the pharynx from the food bolus path.
• Shaker Exercises - Another way to open the upper esophageal sphincter by having the patient lay flat on their back and, in a precise manner, slowly lift their chin to their chest.
• Chin Tuck - By placing the chin downwards toward the chest the patient: 

1. widens the vallecula to prevent bolus from entering airway 
2. puts the epiglottis in a more protective position 
3. narrows the laryngeal entrance

• place bolus in swallow position
• swallow while holding breath 
• cough after swallowing before inhaling (this clears any residue that may have entered the larynx)

Dietary Therapy
Pharmacotherapy
Surgery

A) Zenker's Diverticulectomy Three procedures have been described to treat a Zenker's diverticulum: diverticulectomy, diverticulopexy, and peroral endoscopic division of the party wall between the diverticulum and the esophagus. Diverticulectomy is usually selected for treating large diverticula in otherwise healthy patients. It involves an open-neck operation where the(Zenker's) hernia sac is identified and isolated. The sac is then resected its neck, taking care not to compromise the esophageal lumen by resecting too much mucosa, and closing the pharyngotomy with a watertight closure. A cricopharyngeal myotomy is performed as close to the posterior midline as is possible to minimize risk to the recurrent laryngeal nerves; the myotomy consists of dividing the entire circular cricopharyngeus muscle. Diverticuloplexy, combined with cricopharyngeal myotomy, is preferred by some surgeons for dealing with small diverticula or large diverticula in high-risk patients. The sac is isolated and tacked with permanent suture to the prevertebral fascia, such that the mouth of the sac is in a dependent position. Diverticulopexy avoids a pharyngotomy, reducing the risk of a pharyngocutaneous fistula or injury to the recurrent laryngeal nerves. Endoscopic peroral division of the party wall between the sac and the esophagus was first described by Dohlman in 1960. He used a special double-lipped esophagoscope, inserting one lip into the sac and one lip into the esophagus. Electrocautery was used to divide the party wall, including the cricopharyngeus muscle. Dohlman's procedure fell into disfavor because of an unacceptably high complication rate and mortality from mediastinitis. More recently, with some modifications to Dohlman's original technique such as utilization of an operating microscope and a laser, the endoscopic approach has gained acceptance, especially for very ill patients in whom an open procedure might pose greater risks. B) Cricopharyngeal Myotomy Dysphagia as a result of abnormalities with the cricopharyngeus muscle may be ameliorated by selective use of cricopharyngeal myotomy. Cricopharyngeal myotomy may be either surgical or pharmacologic (botulinum toxin). In general, cricopharyngeal myotomy is primarily useful for true cricopharyngeal achalasia such as after vagus nerve injury at the base of the skull where pharyngeal motor function remains otherwise intact. Cricopharyngeal myotomy is contraindicated in conditions when there is impaired pharyngeal peristalsis or when significant reflux disease exists. Many disease entities where cricopharyngeal myotomy was thought to be useful in improving dysphagia, such as myopathy and brainstem stroke, may actually be of no benefit. C) Salivary Diversion Procedures Dysphagia severe enough to result in the threat or actual circumstance of food and saliva constantly soiling the airway typically requires aggressive management. Surgical procedures that divert or diminish the flow of food and saliva from the airway include vocal fold medialization, tracheostomy, laryngeal stents, reversible laryngeal closure procedures, laryngotracheal separation and total laryngectomy. The application of any one of these treatment modalities depends on several patient factors such as underlying disease process and overall health status of the patient. Patients who are aspirating regularly frequently become malnourished, which only exacerbates their underlying condition. Therefore, as measures are considered to prevent aspiration, alimentation through non-oral means should be implemented as well. Feeding gastrostomy or jejunostomy tubes, placed endoscopically (percutaneous endoscopic gastrostomy (PEG) or percutaneous endoscopic jejunostomy (PEJ), are excellent ways to aliment patients who are at high risk for aspiration as a result of severe dysphagia. Laccourreye O et al. Esophageal diverticulum: diverticulopexy versus diverticulectomy. Laryngoscope 1994.

B. Compensatory Strategies

• Effortfull Swallow - The patient is instructed to bear down, or to squeeze hard with all of their head and neck muscles while swallowing.
• The Supraglottic Swallow - Four step maneuver, inhale and hold breath (this closes the vocal folds)
• The Supra - Supraglottic Swallow - The patient follows the same procedure as with the supraglottic swallow but additionaly he/she  bears down while holding his/her breath. 
• Mendelsohn Maneuver - A technique that opens the upper esophageal sphincter. The patient is instructed to hold the thyroid cartilage up for several seconds. In this way, the larynx is kept tilted forward and elevated, thereby allowing the upper esophageal sphincter to relax.

You can learn more by watching a video with the swallowing strategies presented by a clinician-

http://www.youtube.com/watch?v=UgkRVD-LvjY&feature=endscreen&NR=1

During the FEESST test  it may become evident that certain types of food cause the patient to cough or choke, but other foods do not. During the FEESST exam the various food volumes and consistencies are used until it is determined which combinations allow the patient to swallow easily and safely.

Pharmacotherapy is therapy when certain medications may be prescribed which can help the patient swallow safely.

Depending on the results of the swallowing evaluation, certain medications may be prescribed which can help the patient swallow safely

A)  Mucolytic agents: Medications that thin-out thick secretions. Sometimes patients have very thick phlegm and mucus that makes it difficult for patients to swallow. Mucolytics can thin thick secretions so that they could be more readily expectorated and coughed.

B) Anti-acid medications: Swallowing problems are sometimes due to untreated, or insufficiently treated, acid reflux disease. The acid causes swelling in the throat which can contribute to swallowing difficulties. Under those circumstances, anti-acid medication is prescribed in order to help alleviate the throat swelling that may be contributing to the swallowing problem.

The surgical management of the patient with dysphagia primarily depends on the etiology of the dysphagia. The more common etiologies of dysphagia that lend themselves to surgical correction are described.

References:

1. Dohlman G, Mattsson O. The endoscopic operation for hypopharyngeal diverticulum. A roentgen cinematographic study. Arch Oto Head Neck Surg 1960. 
2. Ian Overbeek JJM. Meditation on the pathogenesis of hypopharyngeal (Zenker's) diverticulum and a report of endoscopic treatment in 545 patients. Ann Otol Rhinol Laryngol 1994.
3. Wisdom G, Blitzer A. Surgical therapy for swallowing disorders. Oto Clin NA 1998.
4. Pou AM. Surgical treatment of swallowing disorders: Cricopharyngeal myotomy in Carrau RL, Murray T (eds.) Comprehensive Management of Swallowing Disorders. Singular Publishing Group, Inc. San Diego, CA 1999.
5. Stevens KM, Newell RC. Cricopharyngeal myotomy in dysphagia. Laryngoscope 1971; 81: 1616-1620.
6. Lebo CP, Sang K, Norris FH. . Cricopharyngeal myotomy in amyotrophic lateral sclerosis. Laryngoscope 1976.
7. Calcaterra TC, Kadell BM, Ward PH. Dysphagia secondary to Cricopharyngeal muscle dysfunction: surgical management. Arch Otolaryngol Head Neck Surg 1975. 
8. Netterville JL, Stone RE, Luken ES, Civantos FJ, Ossoff RH. Silastic medialization and arytenoid adduction, a review of 116 procedures: the Vanderbilt experience. Ann Otol Rhinol Laryngol 1993.
9. Eliachar I, Nguyen D. Laryngotracheal stent for internal support and control of aspiration without loss of phonation. Otolaryngol Head Neck Surg 1990.
10. Castellanos PF. Method and clinical results of a new transthyrotomy closure of the supraglottic larynx for the treatment of intractable aspiration. Ann Otol Rhinol Laryngol 1997. 
11. Biller HF, Lawson W. Total glossectomy. Arch Otolaryngol Head Neck Surg 1983.
12. Lindeman RC, Yarington CT, Sutter D. Clinical experience with the tracheoesophageal anastomosis for intractable aspiration. Ann Otol Rhinol Laryngol 1976.
13. Cannon CR, McClean WC. Laryngectomy for chronic aspiration. Am J Otolaryngol 1982.

Dysphagia - Feeding & Swallowing Disorders in Infants & Children

Children with feeding and swallowing difficulties (also called dysphagia) are at risk for malnutrition, dehydration, and respiratory problems. Infants and children with feeding and swallowing problems are a diverse group, ranging from premature babies to teenagers. Parents are often the first to notice a feeding problem.

Check my other post:

Dysphagia and Swallowing Therapy and Treatment, Diet and Liquid Consistency

http://slpzone.blogspot.com/2012/04/dysphagia-and-swallowing-therapy-and.html

“The best practice for swallowing is swallowing” – Dysphagia in Children and Adults

https://slpzone.blogspot.com/2020/05/the-best-practice-for-swallowing-is.html

Causes of feeding and swallowing problems

• Prematurity
• Cerebral palsy
• Autism
• Head and neck abnormalities
• Muscle weakness in the face and neck
• Gastroesophageal reflux
• Multiple medical problems
• Respiratory difficulties
• Medications that may cause lethargy or decreased appetite
• Problems with parent-child interactions at mealtime

Symptoms

Children with feeding and swallowing problems present with a wide variety of symptoms, depending on the nature and cause of their disorder. Typical symptoms include:

• Poor feeding
• Difficulty chewing
• Difficulty drinking from a bottle or cup
• Difficulty breast feeding
• Refusing food or liquid
• Coughing or choking while eating or drinking
• Excessive drooling and food spilling from the mouth
• Liquid leaking out the nose
• Gagging
• Vomiting during meals
• Increased congestion during meals
• Increased fussiness or crying during meals
• Accepting only certain types of food (only pureed foods or only crunchy foods)
• Poor weight gain
• Frequent respiratory infections or pneumonia (may occur when food or liquid is aspirated into the airway, rather than swallowed effectively)

Evaluation and Diagnosis of Feeding and Swallowing Disorders

If you suspect that your child is having difficulty eating, contact your pediatrician right away. Your physician will examine your child and address any medical reasons for the feeding difficulties, including the presence of reflux or metabolic disorders. The pediatrician may refer you and your child to a feeding team or speech-language pathologist who specializes in treating children with feeding and swallowing disorders. The SLP will discuss your concerns and observe your child while they eat. The SLP may also conduct an instrumental assessment of your child's swallowing ability. This involves having your child eat and drink foods and liquids mixed with barium while watching them on an x-ray. This procedure is typically called a modified barium swallow (MBS) and is conducted in a radiology office. Sometimes a different instrumental assessment will be completed, which involves having a lighted scope inserted through the nose so your child's swallow can be observed.

If a feeding team is involved, which may include the speech language pathologist SLP, an occupational therapist OT, a physical therapist PT, a physician or nurse, and a dietitian, your child's posture, self-feeding abilities, medical status, and nutritional intake will also be examined. The team will then make recommendations on how to improve your child's feeding and swallowing.

You can watch 

normal swallow - animation

https://www.youtube.com/watch?v=4FMnXz6o2vI

X-Ray swallow -

http://www.youtube.com/watch?v=PwVreNrTKBw&feature=related

abnormal swallow

https://www.youtube.com/watch?v=mvAKyuI_nUE

Learn about basic of videofluoroscopy of swallowing

http://www.youtube.com/watch?v=-wmt6HlLduY&feature=related

Treatment

Based on the results of the feeding evaluation, the SLP or feeding team may recommend any of the following:

• Medical intervention, as needed
• Direct feeding therapy designed to meet your child's individual needs
• Nutritional changes
• Postural or positioning changes (different seating, etc.)
• Behavior management techniques
• Desensitization to new foods or textures
• Food temperature and texture changes
• Referral to other disciplines, such as psychology or a dentist

If feeding therapy with an SLP is recommended, the focus of intervention may include:

• Strengthening the muscles of the mouth
• Increasing tongue movement
• Improving chewing patterns
• Increasing tolerance of different foods or liquids
• Improving sucking /drinking ability
• Coordinating the suck-swallow-breathe pattern (for infants)
• Altering food textures and liquid viscosity to ensure safe swallowing
• Other interventions depending on your child's specific needs

Swallowing strategies for dysphagia 

A. Compensatory Strategies
- Supraglottic Swallow
- Effortfull Swallow
- Mendelsohn Maneuver
- The Supra-Supraglottic Swallow

B. Postural Techniques
- Head Rotation To Weak Side
- Head Rotation To Strong Side
- Head Back/ Chin Up
- Chin Tuck

Watch video with the swallowing strategies presented by a clinician - 

http://www.youtube.com/watch?v=UgkRVD-LvjY&feature=endscreen&NR=1

  

Management hints of gastro-oesophageal reflux 

1. Keep your baby upright for at least 30 minutes after a feed. 
2. Use a baby sling; which keeps your child upright, while your hands are free. Avoid baby slumping. 
3. Try elevating the head of the cot/bassinet. 
4.  Consider using a dumm. 
5. Avoid vigorous movements or bouncing a baby. 
6. The best time to lay your baby on the floor is when baby's tummy is empty, i.e. before feeding. 
7. Change nappy before feeding. Take care to elevate baby's head and shoulders. Avoid lifting legs too high. Turn to the side if possible. 
8. Avoid any tight clothing around the waist, such as tight nappies, elastic waistbands. 
9. Avoid overfeeding – if baby vomits, wait until the next feeding rather than feeding your baby again. 
10. If a baby is bottle-fed, it may be worthwhile to try AR (anti-reflux) or hypoallergenic formula.
11.  Offer a spoonful of thickened milk (formula or breastmilk) following the feed. 
12. If breastfeeding, in your diet avoid foods that can aggravate reflux, e.g. citrus, tomato, fatty foods, spicy foods, chocolate and carbonated drinks. 
13. Some reflux children may suffer from food sensitivities, and may need dietary restrictions (or the mother may consider an elimination diet). If you suspect foods may be responsible for your child's condition, it is essential to discuss this with your health care provider. Do not change your or your child's diet before seeking medical advice. 
14. Contact a reflux support organisation for further information and support. The support groups can offer the emotional support you may need.

Oral-Motor Exercises

Rules to follow for a success

Try to apply and look for a triumph. Good Luck!

Make exercises fun as much as possible!

Modify environment by minimizing distractions!

Sit behind a child, the way you both face a mirror!

Make sure your child is in comfortable, supported position!

Explain what you are doing in a simple, narrative way!

Provide exercises for short periods of time!

Don’t do all learned exercises at the same session!

Provide exercises before each meal not during a mealtime!

Pause to allow time to swallow any saliva that may have accumulated!

Don’t attempt swallowing if your child has a cold!

Stop if your child becomes distressed at any time!
Be patient!

 

Exercises to develop and improve oral sensitivity and muscle tone

1. First, before you approach the child’s face verbally explain what are you going to do and what for.
2. Use slow, firm strokes over the hands, arms, shoulders, neck with rough texture (e.g. towel, etc.)
3. Next start at the sides of the face, forehead, chin, gradually working towards the centre of the face.
4. Massage the cheeks using circular movements, particularly around the mouth.
5. Using thumb and index finger press the top and bottom lips firmly together. Hold for a while and release.
6. Stroke firmly downwards on the area between the nose and top lip while using your finger to push the bottom lip upwards.
7. Using 2 fingers pull the top lip down, starting under the nose and working towards the top of the lip (without touching the lip itself).
8. Do the same for the bottom lip, working from the chin to the lip. Support the jaw if necessary.
9. Gradually introduce stronger flavors at mealtimes:

a.       Using seasoning (curry, garlic, etc.)

b.      Introducing organic chips of different flavor (vinegar, pepper, etc.) and dips (mayonnaise, ketchup, etc.)

c.       Offering tangy, bitter flavored fruits or yoghurts (kiwi, lemon, grapefruit, cranberry, etc.)

10.  Introduce food of different temperature (ice-cream, popsicles, etc.)

11.  Gradually introduce sensory toys (textured teethers, etc.)

Exercises to develop and improve lip movements

 

1. Child will drink from a cup making very small sips.
2. Child will drink using straw (tight/round lip seal around the straw; straw has to be held just by lips, not deeply.)
3. Child will blow bubbles in the air, bubbles in the water using a straw, cotton wool balls across the table, whistles/party blowers, etc.
4. Child will make /oo/ sounds (imitating a ghost, owl, monkey, wind) and /ee/ sounds, like E-I-E-I-O in Old McDonald song, using exaggerated lip movements. You might need to gently push the lips from a tight stretched position (smile shape) to the round position (kiss shape).
5. Child will blow kisses. (You might need to gently push the lips from a tight stretched position  -smile shape to the round position - kiss shape. Put on some lip stick or face paint and make kiss marks on a mirror, tissue, paper etc.

Exercises to develop and improve jaw and tongue movements

1. When side-spoon-feeding your child, place spoon on the lower lip. Let the child to clean the spoon.
2. Over time place food at the sides of the mouth, between the teeth. This will encourage munching/sideward tongue movements.
3. To stimulate biting, munching and sideward tongue movements.

a.       Do exercises at times when your child is relaxed.

b.      Exercises should not be done at mealtimes.

c.       Place the item in the mouth, between the teeth, along the line of the jaw and ensure that it is not placed so as to stretch the lips. Do not place too far back in case your child gags.

d.      Place on the best side initially, than move to the other side.

e.       If the child is not munching, pull the item out slightly and gently or press down.

f.       When you feel your child is confident about biting skills, introduce food items. Initially use bite-and-dissolve foods (biscuits, snacks, etc.)

g.      If the child is not biting off the food, break it off for them while they are biting down on it. Do not force your child to take foods that their mouth is not ready.

h.      Over time, gradually introduce chewier foods in the same way.

Picky Eater and New Food

We should provide a toddler with three well-balanced meals each day.

Why? Simply because he or she is growing, needs lots of energy to play and to explore the world. Good nutrition is important to his/her overall health. It can also prevent many medical problems, including becoming overweight, developing weak bones, and developing diabetes.

What if my child has only one or two full meals each day? If your toddler has had a good breakfast and lunch, then it is okay that he doesn't want to eat much at dinner. The only time that you should worry is if your child isn't gaining weight or isn't very active.

You shouldn't worry about a toddler that:

·         Doesn’t seem like he/she eats a lot. Remember that as long as he/she is gaining weight and is active and healthy, then he/she is likely getting enough calories.

·         Only eats a few kinds of food each day, such as peanut butter and jelly sandwiches or chicken nuggets and french fries.

·         Won’t try any new foods. You still should keep trying to introduce new foods offered it 10 or more times.

·         Doesn’t eat a balanced diet each day. Most kids don't. As long as his/her diet seems balanced over a week or two, he/she is likely getting enough variety. If he/she really isn't, talk to your Pediatrician about a vitamin supplement.

·         Doesn’t finish everything on his/her plate. The idea that children should sit at the table until they 'clean' their plate is out of fashion. Instead, children should be taught to recognize when they are full and then stop eating. If your toddler isn't finishing what you offer, learn to offer smaller portions.

·         Doesn’t eat what you prepare for him/her. Try to avoid making elaborate meals for your toddler or offering foods with a lot of spices or sauces. Instead, keep things simple. While you shouldn't have to prepare a separate meal for your toddler every day, don't be surprised if he/she doesn't want to eat 'adult' foods.

·         Is overweight. Okay. Instead of restricting calories provide a healthy diet and encourage regular physical activity. Be sure to watch your serving and portion sizes (offer toddler size portions) and don't offer too much milk, juice, or high calorie snacks.

Feeding youngsters can be challenging. They are often picky eaters, are hesitant to try new foods, and in general, don't seem to eat very much.

You can keep trying to introduce new foods by putting a very small amount (like 1/2-1 tablespoon) on his/her plate and don't force him/her to try or finish it. Many kids won't try a new food until they have been offered it 10 or more times.

The best nutrition advice to keep your child healthy 
includes encouraging him/her to:

·         Eat a variety of foods.

·         Balance the food you eat with physical activity.

·         Choose a diet with plenty of grain products, vegetables and fruits.

·         Choose a diet low in fat, saturated fat, and cholesterol.

·         Choose a diet moderate in sugars and salt.

·         Choose a diet that provides enough calcium and iron to meet their growing body's requirements.

The best way to promote good nutrition is starting from yourself by setting a good example for your child. Healthy eating habits and regular exercise should be a regular part of your family's life. It is much easier if everyone in the house follows these guidelines, than if your child has to do it alone.

Additional tips for caregivers:

• Use lean meats and skim or low fat dairy products.
• Use unsaturated vegetable oils and margarines.
• Read the nutrition label on foods to check for the amount and type of fat it includes.
• Limit foods that contain a large amount of saturated fats.
• Limit foods high in sugar and avoid adding extra sugar to your foods.

To prevent child from being too full you must remember:

• Do not let your child to drink more than 16-24 ounces of milk each day.
• Do not let your child to drink more than 4-6 ounces of juice each day.
• Do not let your child to fill up on sweets and snacks.
• Do not force your child to eat when he/she is not hungry.
• Do not give your child servings that are too big. The average toddler serving is about 1/4 of an adult serving size. Don't go by the serving size listed on nutrition labels, as these are mainly for older children and adults.

To prevent feeding problems we also need to remember:

• Not to use food as a bribe or reward for desired behaviors.
• Avoid punishing your child for not eating well.
• Limit mealtime conversation to positive and pleasant topics.
• Avoid discussing or commenting on your child's poor eating habits while at the table.
• Limit snacks to two nutritious snacks each day.
• Not to prepare more than one meal for your child. If the child doesn't want to eat what was prepared for the rest of the family, then he/she should not be forced to, but you should also not give him/her something else to eat. He/she will not starve after missing a single meal, and providing alternatives to the prepared meal will just cause more problems after.

Food Pyramid

There is not a toddler food pyramid. The Kids' Food Pyramid is for children aged 2-6 years, but you can still use it to guide what your younger toddler eats, including 6 servings of grains, 3 servings of vegetables, 2 servings of fruits, 2 servings from the milk/dairy group, 2 servings from the meat and protein group, and a limited amount of fats and sweets. Just remember that the serving sizes will be smaller for younger toddlers and are equal to about 1/4 an adult's serving size.

The Basics of a Toddler's Diet is about 1300 calories each day. Bigger kids will need a little more and smaller kids a little less. A good hint is - 40 calories each day for each inch of his /her height.

Although you shouldn't usually count calories, knowing how many calories your toddler needs can help when planning his/her diet and can also help reassure you that your child is getting enough to eat.

A common problem is observed in a kid who don't eat much, but drinks 4 cups of milk and 3 cups of juice each day. That can add up to 1350 calories, which is probably more than he/she needs for all day. It is not surprising then that this child wouldn't be hungry for other foods.

If the parent follows the American Academy of Pediatrics (AAP) recommendations as to how much milk and juice he/she drinks, that will take care of:

·         300-455 calories (about 19 calories per ounce) from whole cow's milk (or a similar amount from breastmilk if you are breastfeeding your toddler 2-3 times a day) if he/she is drinking 16-24 ounces a day. Remember to not give low fat milk until your child is 2-3 years old and don't overdo it on milk. If he/she gets up to 48 ounces of milk a day, then he/she is getting over 900 calories a day just from milk, which is almost 70% of the number of calories he/she needs all day.

·         60-90 calories (about 15 calories per ounce) from juice. Don't overdo it on juice either. If your child is drinking 2-3 10 ounce sippie cups of juice that is giving him 300-450 extra calories.

·         So you now have only another 550-950 calories to get in him/her, divided between three meals and two snacks. That is very little if you look bellow at the number of calories in foods kids usually eat.

Product

Calories

american cheese (one slice) apple (1/2 small apple) banana (1/2) beef, ground ( ounces) bologna (1 slice) bread (1/2 - 1 slice) breakfast cereal (1/4-1/2 cup) chicken nuggets (3 - 6 pieces) eggs (1/2 - 1 egg) french fries (7 - 15 steak fries) french fries (8 - 17 Funky Fries) fruit cocktail, canned (1/4 ounce) Grahm Crackers (1 - 2 sheets) grape jelly (1 tablespoon) hot dog (1/2 - 1 hotdog) ice cream (1/2 cup) Macaroni & Cheese (2 1/2 ounces) mozzarella cheese (1 ounce) pancakes (1) peanut butter (1 tbspoon) pizza, cheese (1/2 - 1 slice) Pop Tart (1/2 - 1 pastry) popsicle (1) pudding (1/2 cup) vegetables (1 tbsp per year of age) yogurt (1/3 cup)

45 calories 40 calories 50 calories 85 calories 90 calories 20-40 calories 40-80 calories 105-210 calories 35-70 calories 60 - 120 calories 150-300 calories 50 calories 60-120 calories 50 calories 60-120 calories 135 calories 260 calories 80 calories 60 calories 95 calories 140-290 calories 1-200 calories 70 calories 110 calories 25 calories 50 calories

Sample Diet

Breakfast

·         1/2 cup (4 ounces) of cereal, + 1/4 cup of milk + 4 oz of orange juice = 230 calories.

·         Or a slice of bread with 1 tablespoon of peanut butter and jelly + 4 oz of orange juice = 250 calories.

Lunch

·         1/2 sandwich (one slice of bread - 40 calories) + 1 slice of luncheon meat, e.g. bologna (90 calories) and cheese (45 calories) = 175 calories.

·         Or a tuna fish sandwich (add 1/2 tablespoon of mayo to the tuna to get 50 extra calories).

·         Or a sliced and quartered hot dog + water, juice or milk.

Dinner

·         1-2 ounces of chicken (75-100 calories) or beef (120-165 calories) + 2-3 tablespoons of vegetables (50-75 calories) + some bread (40 calories) + 1/2 cup of milk (76 calories) = 361-456 calories.

Snacks

·         Your child will likely need a couple of small snacks mid-morning and in the early afternoon. These might include 1/2 cup of milk (76 calories) or juice (60 calories) + 2-3 tablespoons of fruit (50-75 calories), or a slice of cheese (45 calories). Alternatives might include some jelly, pudding, or yogurt.

            This sample diet will give your child well over 1000 calories. In reality, he/she may not eat 3 full meals each day though. Many toddlers just eat one good meal a day and it is usually still fine. If he/she eats a good breakfast (250 calories), a small lunch and dinner (100 calories each), has a couple of snacks (150 calories each), 16 ounces of milk (300 calories), and 6 ounces of juice (90 calories), then he/she is still getting almost 1200 calories.

            The Food Guide Pyramid was designed by the US Dept. of Agriculture to promote healthy nutrition in children age of 2 - 6 years. It is just a general guide. The focal emphasis is on the five major food groups, all of which are required for good health. The second emphasizes is that fat, oily and sweet food should be used with a big caution.

            After the age of two or three years, you can begin to use 2%, low fat, or skim milk instead of whole milk. Your child's diet should resemble that of the rest of the families, with 3 meals and 2 nutritious snacks each day. You should limit milk and dairy products to about 16-24 oz each day and juice to about 4-6 oz each day and offer a variety of foods to encourage good eating habits later.

            Feeding practices - avoid giving large amounts of sweet desserts, soft drinks, fruit-flavored drinks, sugarcoated cereals, chips or candy, as they have little nutritional value. Also avoid giving foods that your child can choke on, such as raw carrots, peanuts, whole grapes, tough meats, popcorn, chewing gum or hard candy.

What counts as one serving?

To ensure good nutrition in your child and that they grow up healthy, they will need to eat a large variety of food. The amount of food is much less important. Remember that your child's appetite may decrease and become pickier over the next few years as his growth rate slows. As long as they are gaining weight and have a normal activity level, then you have little to worry about. You can still offer them a variety of foods, but can decrease the serving sizes if they don't eat a lot.

I. Grain group

6 servings a day, e.g.:

1 slice of bread,

1/2 cup of cooked rice or pasta,

1/2 cup of cooked cereal, and

1 ounce of ready to eat cereal

II. Vegetable group

3 servings a day, e.g.:

1/2 cup of chopped or raw vegetables, or

1 cup of raw leafy vegetables

III. Fruit group

2 servings a day, e.g.:

1 piece of fruit or melon wedge,

3/4 cup of 100% fruit juice,

1/2 cup of canned fruit, or

1/4 cup of dried fruit.

IV. Milk group

2 servings a day, e.g.:

1 cup of milk or yogurt or

2 ounces of cheese

V. Meat group

2 servings a day, e.g.

2 to 3 ounces of cooked lean meat, poultry or fish,

1/2 cup of cooked dry beans.

You can substitute

2 tablespoons of peanut butter or 1 egg for 1 ounce of meat.

Fats, Oils and Sweets

No more than 30% of your diet should come from fats. For a 1600 calorie diet, that would equal 53g of fat each day, with most preschool children requiring even less. The type of fat that you eat is also important. Saturated fats in foods such as meats, dairy products, coconut, palm and palm kernal oil, raise cholesterol more than unsaturated fats, which are found in olive, peanut, and canola oils, or polyunsaturated fats in safflower, sunflower, corn, soybean and cottonseed oils. Limit saturated fats to no more than 10% of daily calories.

Sugars supply is a large amount of calories, with little nutritional value. They include white sugar, brown sugar, corn syrup, honey and molasses and foods like candy, soft drinks, jams, and jellies.

References:

http://pediatrics.aappublications.org/content/107/5/1210.full

http://www.pediatricsdigest.mobi/content/117/2/544.full

http://www.keepkidshealthy.com/nutrition/kids_food_guide_pyramid.html