Why Is Early Intervention Feeding Therapy So Important for Children?

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Feeding disorders are very common. Though it is hard to quantify, “[a]pproximately 20-50% of normally developing children, and 70-89% of children with developmental disabilities” (1) have a feeding disorder. How does this happen so frequently?!

According to Dr. Kay Toomey’s research and reviews of other studies, of children who have feeding disorders, between 65-95% of cases are caused by both behavioral and natural, organic causes (2017) (2). In other words, more often than not, a feeding disorder is not just behavioral! For example, a child that has undiagnosed reflux or allergies has learned to refuse food, because they have learned that food causes them to have an upset stomach. They may continue to refuse food even after receiving treatment for the initial physiological problem. A child that has choked on some solids because of undiagnosed oral dysphagia will begin to only eat liquid and purees to avoid choking. A child that is refusing crunchy foods could have sensory processing disorder and benefit from desensitization. A child that is having a hard time breathing will refuse food in order to get enough oxygen to survive. The examples could go on and on. Every child is different, and needs to be diagnosed and treated holistically.

Some signs that may indicate your child could have a feeding disorder include:

• If your child eats less than 20 foods
• If mealtimes take more than 30 minutes
• If they refuse all of food of a certain texture or color, or are they having difficulty transitioning to solids
• If they are choking, coughing, or gagging while eating
• If they are demonstrating a lot of negative behaviors during meal times
• If they have difficulty with mealtime routines or have a hard time sitting at the table
• If they have difficulty chewing or swallowing (example: food left in their mouth after they’ve finished eating)

If you think your child could have a feeding disorder, or you feel that you’ve exhausted your options at home and don’t know where else to go, your child could likely benefit from a feeding evaluation and possibly feeding therapy. A pediatric feeding specialist can help you determine the cause, if a cause is present, make appropriate referrals, and plan the best course of treatment. Slowly, your child will become an adventurous and independent eater!

Sources:

1. 2013. June 13. Banchaun Benjasuwantep, Suthida Chaithirayanon, and  Monchutha Eiamudomkan. Feeding Problems in Healthy Young Children: Prevalence, Related Factors and Feeding Practices. Published online 2013 Jun 13. doi: 10.4081/pr.2013.e10
2. Toomey, Kay (2017). Top Ten Myths of Mealtime in America. SOS Approach to Feeding. https://sosapproach-conferences.com/resources/top-ten-myths-of-mealtime-in-america/

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Once a child has been diagnosed with a Pediatric Feeding Disorder due to oral dysphagia or sensory processing disorder or, if diagnosed by a psychologist, ARFID (Avoidant/Restrictive Food Intake Disorder), they will likely be referred for treatment. Eating is a learned behavior. It is only instinctive for the first 6 months of life. Older children must either teach themselves, or be taught (Toomey). Treatment for a feeding disorder can be completed by a Speech-Language Pathologist (SLP), Occupational Therapist (OT), Board-Certified Behavior Analyst (BCBA), Dietician, or Psychologist. All of these disciplines have overlapping and unique approaches to treatment, so a Pediatric Feeding team that involves more than one specialist may be best for your child. As an SLP who is part of a feeding team that involves an OT and BCBA, some approaches to treatment that I utilize alongside the team include the Food Chaining Approach, The Sequential Oral Sensory approach (SOS), and the Escape Extinction approach.

Food Chaining has become recently popular due to a book written by Fraker and Cox called Food Chaining: The Proven 6 Step Plan To Stop Picky Eating, Solve Feeding Problems, and Expand Your Child’s Diet. To summarize this approach, clinicians and parents would “chain” from food that children currently enjoy by changing 1 aspect of the food at a time: either color, texture, flavor, or shape. For example, if a child enjoys cheetos, you might “chain” to orange veggie sticks (changing flavor), then to green veggie sticks (change in color), then to green veggie chips (change in shape), then to zucchini cut in a circle and placed on the chip (change of texture), then remove the chip. The child is now eating zucchini, and it was introduced slowly in a non-threatening manner! In this procedure, food is not forced on children- they are able to touch and explore it themselves, the clinician models eating it, and children are encouraged to take a bite, but they decide if they would like to try it or not. Using food chaining, children will slowly and positively increase their repertoire of acceptable food.

The Sequential Oral Sensory (SOS) approach was developed by Dr. Kay Toomey, a psychologist who specializes in Pediatric Feeding Disorders. This procedure includes another slow process of children having repeat exposures to foods prior to being forced to take a bite. For example, a child would tolerate a new food, let’s say apple slices, on their plate without expectation of eating it. Once that is tolerated, the apple will slowly and systematically move closer to their mouth, again without expectation of eating. They will touch it first with a fork or toy, then their hand, then put it on their arm, then their cheek, then kiss it, then lick it, then take a bite and spit it out, then chew, and finally swallow the apple slice. This could take a couple of days or even weeks. The idea is to allow children to have positive interactions with the food so that eating is enjoyable and they control what is placed in their mouth according to their comfort level. Eventually the child will be able to more quickly and independently follow the above steps with a new food to independently increase their diet. Children will gain confidence and learn that new foods aren’t as scary as they once thought.

The Escape Extinction approach is an effective, evidence based approach used to aid with feeding problems across all ages and is often utilized in ABA therapy by a BCBA or Behavior Technicians under the guidance of a BCBA. Eating novel food items and non-preferred food items is broken down into easier steps to aid your child with succeeding in their feeding journey. Keeping the presentation of bites and the bite sizes predictable decreases anxiety and allows the child to feel more in control during meal times. We never move up in bite size until we are certain your child is able to handle the bite at that size and has the skills needed to properly lateralize the food item, masticate the bite, and take consecutive bites. Furthermore, this approach reinforces appropriate feeding behavior while extinguishing inappropriate or disruptive feeding behaviors by not allowing the child to escape from taking bites by using a non-removal of the spoon. Often times, children will spit out food, swallow food without chewing, pack bites, turn head away from the bite, or engage in aggression. When these behaviors occur, we do not remove the bite from their lips until the bite has been taken, and provide prompts and reinforcement for taking bites and chewing appropriately.

Children enrolled in the feeding program Metro EHS Pediatric Therapy are evaluated and treated as unique individuals, so these approaches, along with others, are often combined to best help your child experience success with eating.

Sources

2019. Tooomey, Kay. SOS Approach To Feeding.
2020. Tarbox, J and Tarbax, C. Training Manual for Behavior Technician Working with Individuals with Autism Spectrum Disorder. Retrieved from Sciencedirect.com.
2021. Fraker, Fishbein, Cox, Walbert. Food Chaining: The Proven 6 Step Plan To Stop Picky Eating, Solve Feeding Problems, and Expand Your Child’s Diet. Da Capo Lifelong Books.