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Case Study: "Z" How Do I as a Parent Get Started Trying Food Chaining Programs?

Posted Oct 13 2009 10:06pm
Hi All
Just had a lovely mom, Taja, write to me for information about Food Chaining, she wanted to know what we do and how we do it. She needed information to understand our approach vs other facilities in the US who work with feeding. I helped with the basics, rule out underlying disorders, questions about swallowing skills, setting up a schedule of three meals and two to three snacks, no grazing on liquid or nibbling on food all day as this dampens appetite, no force feeding, understanding toddler eating and portion sizes before we got started.

This little boy "Z" is coming to our clinic (217-862-0403) so I am getting his mom started in the right direction. We ended up writing back and forth and decided that this might be a great post to help others 'get it' when trying to actually do this and get started with this type of intervention. People make a lot of mistakes with chaining without guidance and that is why we do the blog and courses to try to supplement the book. This wonderful mom gave me permission to post, thank you so much for that. Anyone working in her area (she is from Florida)...I am looking for therapists who have attended a chaining course or are interested in learning and working with us....
Taja and I wrote back and forth for several days to help problem solve our way through expanding food. This is how I deal with my patients and shape their attempts, so they don't have to do this alone.
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Taja: My name is Taja I have a 2 1/2 year old son with a feeding disorder.I hope you don't mind me writing to you,but I saw your blog and I am trying to gather info on different approaches to feeding disorders. My son has severe reflux and sensory integration dysfunction. He basically lives off of pediasure and will only eat french fries, chips, crackers,and a cinnamon roll from cinnabon ( but sometimes only a few bites). Currently, he is receiving occupational therapy using the S.O.S. approach, but we are not seeing any major improvements, we started speech therapy, but she was using the medical approach and we were not happy,so we stopped the sessions. We are looking into the Kennedy Krieger Institute, but I believe that their approach is more behavioral and doesn't really address the sensory issues. Is the multidisplinary team at koke mills any different from KKI? Any advice would be very appreciated?
Thank you for your time,
Taja


Cheri: Hi. We are extremely different from Kennedy Krieger and many other programs. We do not force a child or take away all the foods a child enjoys eating like some other programs recommend. We do not feel that is necessary to do that or that an approach like that respects the sensory system sufficiently. Imagine eating a food you cannot tolerate? Our goal is to build enjoyment of food and eating for life. We feel children eat the way they do for a real, valid reason. We build on what we consider success, in your case, the foods your child eats.
You can ask your library to order our food chaining book and in it, you hear from each of the professionals on our team (our OT is on maternity leave but another OT is with the team).

What I would want to know is:
Does your child have any chewing/biting swallowing issues?
Untreated reflux? It can be silent, any grimacing when swallowing or eating and suddenly stopping?
Constipation? Diarrhea?
Signs of food allergy?
Phobic reactions to new food?
I assume your therapists have checked this all out, but people miss things. Where are you from? We have people come from other countries, so distance is not an issue.

For your son, I would leave the Pediasure alone as my anchor food (unchanged food) to be his source of nutrition and minerals/vitamins. I would offer it with meals and snacks and not let him graze on it or drink it on and off all day. Some children with sensory issues drink to help self regulate their system. I would branch out to other flavors of chips and crackers and other types of fries (baked Ore Ida fast food fries, waffle, crinkles, crispy or foods like Smiles, Tator Tots or Tator crowns, Hash browns) . With chips, crackers and snacks, there are many of these products made from vegetables or have fruit flavor (Terra Chips, Veggie Stix, Pirate's Booty, Seneca apple chips). Just offering different flavors of chips exposes a child to tastes like cheddar, BBQ, sour cream and onion, salt and vinegar and later we can use those tastes to build to new foods. In time, your cinnamon rolls could become cinnamon roll pop tarts and then we could address other flavors of fruit by trying other types of PopTarts. It could be cinnamon bread, cinnamon toast, cinnamon in french toast or waffle pieces, later to pastries with fruit. Some kids like chocolate and you can do a chocolate fondue with little bites of fruit like banana, strawberry. Some kids like to sprinkle cinnamon sugar on fruit, then we fade the chocolate or sugar over a short period of time. Fruit can be fruit smoothies or shakes, Edy's all fruit popsicles, V-8 splash made into little popsicles, yogurt fruit smoothies, frozen GoGurts.....we would keep layering the chains until your son was branching out each of the food items more and more.

The biggest hurdle is not to push when you start. We only offer a bite or two on the plate. Step one is to learn about the food with the senses other than the mouth. If you push him to taste, you know what will happen, a big and resounding no. We let kids crumble a new food, maybe put a bit on the finger (some kids will go ahead and taste it)...just having new foods in front of you is progress. I always tell people to pretend food is not something to eat, pretend that it is a toy or something else to explore and have fun with. When the emphasis is off the mouth, things tend to improve.

If you are interested in a consult, feel free to have your doctor send you a script to us at 217-862-0440 attn: Michelle. Hope this helps a bit, I know how hard this can be. My work email is fraker.cheri@mhsil.com.
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TAJA: The therapist that my son sees told me that she has taken the course in sensory integration therapy for children and she told me that not all therapist have. She tries to get my son to play with the food, break bread and touch liquids. Bbq sauce since he loves bbq chips and maple syrup because she is trying to get him to eat sweet things since m & m's and the cinnamon roll is the only sweet foods that he will eat.So she has him dip his finger in the sauce and she tries to persuade him into just putting his finger in his mouth, if he won't do that then she tells him to kiss it. He will somtimes do this but it takes a lot of persuading and recently she has been using gerber crunchies since he loves them as a reward. Is this a similar approach to what you would do? Interestingly enough he can play with finger paints (loves them), but if it is a food that he has to touch, he cries and has a meltdown. So he has a great fear of food. He is on medicine for reflux, he had an endosopy done and that was normal and he has been tested for food allgeries he has none. He can swallow and chew fine. He is just stuck on the limited foods that he eats. I asked Z's therapist if food chaining was the same as the S.O.S.approach and she said no,but that I could try and use the food chaining technique. Have you seen a high success rate with this approach?
If someone goes to the Koke clinic do they have a day treatment for 6 weeks like Kennedy Krieger? I know that all children are different but on an average using the food chaining technique how long does the process take before a child moves on to a new food? And when to you advance to a new food? Like if my son is willing to take 2 bites of a steak fry, when he usual eats fast food fries then do you move on to sweet potato fries? and what if he tastes, but spits it out and says he doesn't like it, what is the next step?
Oh, and also the pediasure, most days he will eat his fries or chips then say that he is done and ask for pediasure. Some days he won't eat hardly anything and only want pediasure. Is that what you mean by offering it with meals? We have been offering it after we try to get him to eat some solid foods.
Thanks so much for all your information and time.
Thanks again,
Taja

Cheri:Ohhhh...syrup and sauces are so different from what he likes. You are just deepening the aversion when a child turns away from a taste...it is clearly too much. We change taste before texture....I would do an art based activity with pureed fruit as paint and just have fun with exposure. We use sponges and fingers and paint pictures of real fruit. We teach about food rainbows (play fruits and vegetables matched to plastic plates of different colors) and that food of all colors are good for us. keep teaching about food and nutrition, even though he is little. It is so important. The Dole 5 a Day website has fun games on line for kids and teaches about healthy eating.
I don't reward with food. I put out a food or two on the plate that I know a child likes to eat and one tiny amount of something new on a divided plate in the looking place. The expectation is not to eat it yet just to learn about it. I try to get meals back to normal again.
Imagine if you felt challenged and fearful or aversive, every single time you sat down to eat...??? Wouldn't that be awful. Simply taking the pressure off, scheduling meals and snacks, no long meals, shape appetite by keeping meals and snacks under 20 minutes or so....often turns things around a lot. Your son should have one good meal a day as a toddler. Toddlers eat very differently second year of life growth slows way, way down. Portions need to be the right size too. Take the fight out of food, put things out there, don't be afraid to offer a new food in a tiny amount on a small plate beside his plate. Offer foods that are in his chains...the things I suggested that match his sensory needs.
No I don't do lengthy treatments. We do consults and long distance patients come for a three hour assessment and we put a home program together for you. We may have you return in 12 weeks but we do keep up with you via videos and emails and phone calls. You have access to the entire team. We also work with the local therapy team. We send you home with a plan. The vast majority of our families do this themselves in the natural environment. There is no force used and many of our parents are very, very successful. Jase and Stephanie are on the blog and Steph is his mom and she did all of it on her own with us helping guide her. Pull yourself out of paying too much attention to this. Praise him for eating the foods he likes, you may just want to start by cooling down and offering his favorites for a week in a rotation (not the same food every day) and tell him what a good boy he is for eating. Take the stress factor out. I buy cute divided plates (Target has great ones that are inexpensive) and I start by putting a piece of a really visually interesting food on the plate (Bugles for example) and I put them on my fingers and have fun at a meal. Usually the child follows right along and does what I did. Soon we are breaking them apart or filling them up with different foods (look up my fun version of feeding therapy on the blog) and that will show you what I do. Hope this helps!

Taja:Thanks so much Cheri for taking the time to explain the food chaining approach, I am going to try it. It makes sense to me. Today, my daughter, my son, and myself finger painted with pudding. Z__ would only dip one finger in the pudding and put it on the paper and he was done, but at least he tried. I am going to have us finger paint with baby food every day to see if that will help. We also cooked sweet potato fries for him. He tasted it, but spit it out and said that he didn'tlike it. So we gave him his regular fries. I guess maybe next time we will try steak fries. Thanks again for all your time, you have been wonderful!

Cheri: Wow....he went all the way to tasting...so don't stop there. That is fantastic!!! Really praise him for trying! Offer them again next week or something, just like you would cook any other food. Talk about the orange fry...make up a story about the orange fry and see who gets one on their plate next week. Maybe your daughter gets it and make a big deal of it. Just cook one or two and put just one orange fry on the table on someone's plate. Not his yet... Look over on the stove and say, hey there is another one...who gets it? If he doesn't volunteer, you or your husband say "I want it" and eat it. Or cut it in pieces and share if that is what he wants... That is another exposure. Try it again a week later as a game. Whip sweet potatoes or make a sweet potato casserole...He might like it in time, he has to learn to tolerate tastes. The taste is different for him. Expect a rejection on anything new (neophobia-fear of new) is the toddler way.
I would do waffle fries sometimes too. I love to call them baskets or take them apart and make tiny baby fries by pulling little sections off. Smiles are the potatoes that have little smiley faces on them. Don't cook many of them either. That is what is great about fries on a baking stone, you don't have to put too many out and waste food. Or let the kids pick some different fries to put on the baking stone before you cook them. Waffle, crinkle, fast food, sweet, tator tot...just a few of each.....crazy fry night....get it? Food is to be enjoyed.
Loved the paint with pudding, but I would puree real frozen fruit (blueberries for the sky or sea, strawberries or peaches for flowers) in your picture as we want him to eat real fruit and not baby food (which is mainly water). It is fun to get them out, talk about how cold they are, sit them out to warm up, put it in the blender, smell the food and so on....
You can also paint with Cool Whip and add fruit to color parts of the Cool Whip or put some out an a cookie sheet and make all kinds of colors in the Cool Whip snow....
Do you mind if I put some of this on the blog, no names or anything as tips for other parents? C

Taja:Wow, thanks so much for all your time and kindness. Your ideas are great! I am going to try them. We want to help our son so much, but we often get lost or don't know what to do next, like when he ate it then rejected it, your guidance has been a true blessing. Today, Z insisted that he wanted "orange carrots", He has a thing for orange, he likes goldfish crackers, cheetos, gerber crunchies which are really yellow, but you get the idea. So we brought him some cut up carrots, from a can that way it wouldn't be too hard or too soft. We put a piece on a fork and gave it to him. He put the carrots to his lips and then threw the fork down, saying that he didn't like it. So I am assuming that we should try the same method as the sweet potato fry and offer it a later time, maybe to someone else and make a big deal out of it. Yet, we are still happy that he was the one that came up with the idea of trying a carrot. I don't mind at all if you put this up on your blog, you can even use our names we don't mind.

Cheri's comment on this last email:
To Taja and the Readers:
I love the last email about the carrots, she picked canned carrots trying not to go too hard or too soft, he was interested, he was motivated by yellow/orange color and picked this food himself, but at his lip it all fell apart. Why? Now think about all the hard teethers and items children mouth as babies and toddlers. I think he would have had much more success with narrow strips of raw carrot or lightly salted raw carrot. Think of the feel of a raw carrot on your lip vs a cooked one. Think about all the learning opportunities about carrots (Bugs Bunny always has a carrot, Rabbit from Winnie the Pooh or you could go feed horses carrots, my dog Shadow goes crazy when given a baby carrot)...coloring pictures of carrots in coloring books, looking up a video on how they grow on www.cosmeo.com or Dole 5 a Day website. The teaching part is key. A bag of shredded carrots could have also been used for very small pieces. Carrot cake....but the kids have to learn about the food. He is already showing you this with the interest in the food item.

I think our little "Z" has great, great potential...Food Chaining isn't rocket science, but it works because it makes sense.
Thank you Taja! Hopefully other parents and therapists will find this helpful!!!
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