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Loving Food Isn't Always Easy

Posted Jan 02 2010 11:48am
From the second my 'lil miracle was welcomed in to the world, food consumption has been a topic of great interest. Of course, as if having a baby with a terminal condition wasn't quite enough, knowing the hows, when, and whats of feeding time just makes it that much more of an adventure!


The beginning was a little shaky, only because I was told that since Brayden had hydranencephaly, he would not survive long enough to need food. On the contrary, I'm pretty positive that he was instead born hungry...or at least born with a love for all things consumable. I elected to bottle feed rather than struggle with the turmoil that often accompanies breast feeding. Since hospitals generally supply only one brand of formula, choosing one was easy and that happened to be Enfamil Lipil. Since this formula has all the brain-boosting nutrients that make it as close to breast milk as mechanically possible, like DHA and ARA (I think), I was actually told that we could switch to a "cheaper" brand when we started buying our own. I thought that was strange, since generally you're advised to not switch formulas except under the advice of a physician to conquer any problems that may arise. I guess the nurse thought he didn't need the brain-boosting nutrients, since most of his brain was non-existent. Instead, that just told me that he needed that brain-boosting goodness even more, we had to boost what he did have!


A month later, Brayden had his shunt placement surgery and overcame some minor feeding issues with the help of the occupational therapist in the hospital. We also avoided having a feeding tube placed, beyond the ng-tube through his nose for a day or so. From this occupational therapist, and against the dr's idea that he had lost his suck reflex and would no longer be capable of eating orally, we learned to stimulate his sucking action and help him to latch on to his bottle. We tried every shape of nipple and bottle available, while discovering that he likes to eat and get done using a fast-flowing latex nipple...he was not about to have any part of using a silicone nipple. We learned to position our hand underneath his chin, kind of as a reminder for him to move his jaw to suck. We also, at the same time, offered up a little cheek support, helping squeeze his mouth around his bottle to suck effectively. It was hard, but once we mastered this baby bottle balancing act...it was well worth the effort! Brayden was now one happily and orally feeding little man...


At around 5 months old, Brayden had started to eat fruits and cereal which was a wonderfully positive step, and he loved bananas. At the same time, however, he also began to not want to take his bottle again. After talking to his pediatrician, she recommended having him seen for a feeding tube so that he was getting the nourishment that he needed through supplementing through tube feeds. I avoided this, he wasn't losing weight or showing any signs of dehydration. Fortunately, we moved to South Carolina at about 6 months and shortly thereafter met Brayden's new occupational therapist.


Since OTs deal with all things, from feeding to mobility, Brayden's new defiance against his bottle was one of the first issues we addressed. She felt around in his mouth to see what was going on, and advised that we try switching to a sippy cup. I, that very afternoon, rushed out and bought 4 or 5 different kinds. After trying the first one, a soft-spout Nuby cup with handles, Brayden found his match and since that moment we have never had another issue with drinking. Again, avoided the feeding tube...


Now Brayden is 18 months old, and still orally fed. He does not have the hand and arm control to feed himself quite yet, so that is one feeding issue being tackled at a regular pace. However, the biggest issue is what to feed, how much to feed, and how to be sure he is eating and chewing properly. Although Brayden had been successfully eating pureed foods and even the second stage baby foods, most larger soft pieces and various textures really choked him up. Brayden was making the chewing action, so I assumed he was chewing but was not sure how to pass it from his mouth, down his throat, and into his stomach where it belongs. I knew that I wanted to avoid any aspiration issues, when the food is essentially inhaled in to the lungs causing sickness and great damage. So I did a little research to find out how to help.


The first wonderful place I found in my online search, was a website for Novita Children's Services which probably deals with all things child related but I was interested in feeding a developmentally delayed child so that is where my focus was.


I first learned the importance of Brayden's caloric and nutritional intake to avoid malnutrition. We met with a nutritionist who we obtained through our local health department, who specialized in children with disabilities. I wrote down Brayden's meals for the three days prior to our meeting, and we discussed what changes I should make to his daily menus. I was happy to hear, that Brayden was eating the perfect variations of foods to complete his daily recommendations, however was advised to cut back a bit since he is not yet physically mobile. The needs of a child that isn't burning off the excess calories through walking, running, playing, etc., is much lower than that of a "typical" child. Brayden was healthy, but could obtain more mobility and better ease of movement if we backed off of the calories a bit and allowed him to thin out some.


The most important feeding time topic I learned was in regards to oromotor stimulation, or sensory stimulation to the face and mouth area. Brayden now sees a speech and language pathologist, which has helped immensely with the minor feeding time troubles we were still having. By increasing his awareness of his tongue and different areas of his mouth in and out, he has learned to move his tongue to move food around in his mouth and chew effectively. He also has learned to bite down all of the way, when he previously was only chewing half of the way and not mincing his food with his teeth. I already knew that Brayden was a bit hypersensitive to cold foods, but by introducing him to more temperatures and textures varied the menu of items he could eat and enjoy. We now use a Z-Vibe to help raise awareness of his mouth, and since it also has a spoon tip available I am hoping that will help he achieve self-feeding as well. He can feed himself a few bites, occasionally, however it is not a regular habit. If you have a child with oral-motor or feeding issues, I would advise a z-vibe :) Also, it has helped Brayden achieve greater use of his arms because he loves the vibrating sensation and purposefully touches it to his highchair tray table to make noise, so it serves many purposes!


Another wonderful website I discovered was New Visions. There you can find out valuable information about  feeding, swallowing, gastrointestinal, dysphagia, oral motor, sensorimotor, and sign up for workshops on all things feeding related. I especially liked this site since they take a more holistic approach to issues, rather than a pharmacological approach. Since this post is about feeding issues, I want to share the informative article posted in regards to this topic: 



FOOD PROGRESSIONS FOR BITING AND CHEWING

Learning to bite and chew foods efficiently is influenced by the sensory properties of the food and it's placement in the mouth. As with any new skill, progress is determined by the specific challenges presented by the food and the degree of success achieved by the learner. The challenge for the parent or therapist is to select foods that offer a "just right" challenge and a high degree of success for the child who is developing these skills. When the challenge is too great, the child will revert to familiar movement patterns that may be inappropriate for handling the food, or be at risk of gagging, choking, or aspirating unchewed pieces. Fear and low levels of success will convince the child that learning to chew is dangerous or not worth the effort involved. Limits in food choices and textures result, creating overall limits in the child's ability to function freely in society.

Biting and chewing food is a multisensory task that requires a high level of coordination of all parts of the mouth. The degree of skill is determined by sensory awareness and discrimination and integrated coordination of the jaw, lips, cheeks, and tongue. Different foods offer different challenges and require different sensorimotor strategies. The goal in therapy is for the child to be able to perceive and interpret the sensory information from the food and activate the appropriate oral movements to transform the solid piece of food into a masticated bolus that can be efficiently swallowed. The child must be able to fine tune sensory awareness and select the most efficient movements for each specific food. This requires a high level of oral sensorimotor skill and processing and opportunities to explore many different foods in an order or progression that assures success in learning.

Selecting food can be a challenging task for the parent or therapist because each food has multiple sensory features. Although there is a general progression or rationale for the food being easier or more difficult, the specific challenges offered by the food interact with the specific skills, limitations, and needs of the individual child. Each food has at least 8 sensory features that simultaneously determine the degree of ease or difficulty for biting and chewing. These include resistance, sensory input, size, shape, texture scatter, consistency, placement, and need for transfer during chewing. The combination of these features determine the overall sensorimotor skills required in biting and chewing. These, in turn, interact with the specific skills and needs of the individual child.

This set of chart progressions looks at a variety of foods, and rates them on a 3-point scale of difficulty. These progressions can be used to select foods for a specific child in the development of a long-term program to develop appropriate biting and chewing skills. The more expanded 3-point system allows for subtle gradations of difficulty in each point area. This allows an adult to select foods within the same difficulty category that are on a continuum of subtle challenge for the child.

Learning to bite and chew foods efficiently is influenced by the sensory properties of the food and it's placement in the mouth. As with any new skill, progress is determined by the specific challenges presented by the food and the degree of success achieved by the learner. The challenge for the parent or therapist is to select foods that offer a "just right" challenge and a high degree of success for the child who is developing these skills. When the challenge is too great, the child will revert to familiar movement patterns that may be inappropriate for handling the food, or be at risk of gagging, choking, or aspirating unchewed pieces. Fear and low levels of success will convince the child that learning to chew is dangerous or not worth the effort involved. Limits in food choices and textures result, creating overall limits in the child's ability to function freely in society.

Biting and chewing food is a multisensory task that requires a high level of coordination of all parts of the mouth. The degree of skill is determined by sensory awareness and discrimination and integrated coordination of the jaw, lips, cheeks, and tongue. Different foods offer different challenges and require different sensorimotor strategies. The goal in therapy is for the child to be able to perceive and interpret the sensory information from the food and activate the appropriate oral movements to transform the solid piece of food into a masticated bolus that can be efficiently swallowed. The child must be able to fine tune sensory awareness and select the most efficient movements for each specific food. This requires a high level of oral sensorimotor skill and processing and opportunities to explore many different foods in an order or progression that assures success in learning.

Selecting food can be a challenging task for the parent or therapist because each food has multiple sensory features. Although there is a general progression or rationale for the food being easier or more difficult, the specific challenges offered by the food interact with the specific skills, limitations, and needs of the individual child. Each food has at least 8 sensory features that simultaneously determine the degree of ease or difficulty for biting and chewing. These include resistance, sensory input, size, shape, texture scatter, consistency, placement, and need for transfer during chewing. The combination of these features determines the overall sensorimotor skills required in biting and chewing. These, in turn, interact with the specific skills and needs of the individual child.

This set of chart progressions looks at a variety of foods, and rates them on a 3-point scale of difficulty. These progressions can be used to select foods for a specific child in the development of a long-term program to develop appropriate biting and chewing skills. The more expanded 3-point system allows for subtle gradations of difficulty in each point area. This allows an adult to select foods within the same difficulty category that are on a continuum of subtle challenge for the child.

Sensory Features of Food and Their Challenges for Biting and Chewing

A series of multisensory features of food has been selected for analysis and comparison for biting and chewing. Examples are provided of typical foods for each level of challenge or difficulty. The easiest level is represented by a #1, and the most challenging level by a #3.

Resistance
Resistance is a measure of the amount of pressure or force required to bite through a piece of food, and chew it into small pieces that can be swallowed easily. Foods with low resistance require very little chewing because they tend to dissolve easily in the mouth. Those with medium resistance are still relatively soft but require some chewing. Foods that create the most resistance require strong, sustained chewing. Many require a grinding motion of the teeth and chewing on both sides of the mouth.

1 – Less
Veggie Stix, graham crackers, French fries, well-cooked vegetable dices, peaches, kiwi
2 – More
Hard cookies, pretzels, bread crusts, firm toast, oranges, pineapple, fish, chicken
3 – Most
Raw vegetables, bagels, beef, pork, dried fruit, raisins

Sensory Input
Sensory input is a subjective measure of the amount and type of taste and proprioceptive input received by the mouth during biting and chewing. Sensory inputs of crunchy, spicy, sour, bitter, and cold provide the strongest inputs to the oral sensory system. Foods that provide a strong sensory input are often easier to bite and chew because they provide more sensory information for the jaw, tongue, lips, and cheeks.

1 – High
Veggie Stixs, pretzels, chips, raw carrots, ice chips, pickles, tart apple
2 – Medium
Sharp cheddar cheese, saltine crackers, goldfish crackers, hard cookies
3 – Low
Mild cheddar cheese, graham cracker, sweet apple

Size (Diameter or Thickness)
The size or diameter of the food determines the amount of mouth opening required for biting and the amount of sustained pressure required to bite through a piece of food. Thinner foods are usually easier to bite through than thicker foods. Size also refers to the size of the piece of food that must be chewed. Smaller pieces require less chewing than large pieces. Although smaller pieces require less overall chewing, they may demand greater precision of movement and a stronger movement to place them between the teeth.

Small
Veggie Stix, graham crackers, soft cookies, small pretzels
Medium
Bread sandwich, large pretzels, Gerber toddler meat sticks
Large
Hamburger on a bun, bacon lettuce and tomato sandwich

Shape (Ease of Lateral Placement)
The shape of the food strongly affects the ease with which a piece of food can be placed between the side teeth for biting. This is a very important feature for a child who is learning to bite and chew. A wider shape may require biting with the central incisors. If the child is unable to use the tongue to transfer food from the center of the mouth to the side, chewing may be impossible or too challenging. The side teeth are stronger and require less precise holding and bite-through than the central incisors. Thus, foods that are narrower can be placed more precisely on the side for biting and chewing. The shape of many foods can be alternated by cutting them narrower or wider.

Easy
Veggie Stixs, goldfish crackers, animal crackers, long thin pretzels, raw carrot strips
Medium
Rectangular graham cracker pieces, thin rectangular cookies, 1 inch toast strips
Difficult
Square graham cracker pieces, large round cookie, 1/2 piece of toast or sandwich

Texture Scatter
Texture scatter refers to the amount of dispersion of pieces, or "scatter" that typically occurs when an individual bites into a piece of food and prepares to chew it. Foods with less scatter retain their basic form as a piece is bitten off. As the food is chewed, pieces stick together, and bolus formation is relatively easy. These are often foods that absorb saliva well and are of a single consistency. Foods with a high degree of scatter break into many small pieces that don't bind together easily. A child with poor coordination of tongue and cheek movement may find individual pieces scattered randomly on the surface of the tongue. Gagging, choking, and food refusal may result from this type of scatter.

Less
Veggie Stixs, animal crackers, graham crackers, saltine crackers, cooked fruit and vegetables
More
Goldfish crackers, Ritz crackers, bread, toast, sandwiches, hamburger on bread, popcorn
Most
Meatballs, hamburger, raw carrot, nuts

Consistency
Food consistency is related to food texture. In this context it refers to the number of individual textures that are contained within the food that is offered for biting and chewing. The easiest foods have a single consistency. More difficult foods require the integration of more sensory information during biting, and differential handling of several different consistencies. A multiple consistency food such as an unpeeled apple requires the differential swallowing of the juice, chewing of the pulp, and greater chewing of the peel.

Single
Veggie Stix, sugar cookies, chips, meat, fish
Dual
Cookies with nuts, peeled apple, orange slices, watermelon, cooked peas and carrots
Multiple
Unpeeled apple, grapes

Placement
Food placement is a feature of the size and shape of the food and the placement choices of the child or feeder. Most foods can be place in any of the three locations. Some foods are easier with either a side or central placement. For example, corn-on-the-cob is torn off with the central incisors. A caramel or firm piece of meat requiring grinding and chewing is usually placed on the side where the teeth are stronger. Food that is placed on the side requires a simple 1-step chewing process. Food is chewed and then moved from the side to the center for swallowing. Food that is placed in the center of the tongue or between the center and side requires a 2-step chewing process. Food is initially transferred from the center to the side for chewing, and then moved back to the center for swallowing.

Side
Any food whose shape and resistance allows placement for biting and chewing in the area of the molar teeth or between the gums in this region of the mouth.
Mid-Side
Any food whose shape and resistance allows placement for biting and chewing in the area of the canine teeth or between the gums in this region of the mouth.
Center
Any food whose shape and resistance allows placement for biting and chewing in the area of the central incisor teeth or between the gums in this region of the mouth.

Transfer
Transfer refers to the amount of chewing needed by a specific food and the choice to transfer the food to the opposite side of the mouth for more chewing. Some foods dissolve or fall apart and are chewed on only one side of the mouth. Other foods retain enough shape that they can be transferred to the other side if desired. Still other foods require extended chewing and a grinding motion that is accomplished most easily when the food is transferred from one side of the mouth to the other.

No
Veggie Stixs, cookies, crackers, soft cheese, soft cooked vegetables and fruits,
Possible
Raisins, raw fruit, sandwich, fish
Yes
Meat, raw vegetables, caramel candy

Overall Difficulty Level
The overall level of difficulty for biting and chewing is a logical and intuitive blending of all of the separate characteristics of the food. This is a very general rating since different features will make biting and chewing easier or more difficult for a specific child. For example, some children will find foods that have a high resistance and sensory input much easier than foods with a low input. Low input foods that have a high texture scatter may be very difficult. Other children find cookies and soft crackers at the easy level, and foods that have more resistance extremely difficult. This is an attempt to look at the overall characteristics of the food itself. Many foods are listed with a range of difficulty (i.e. easy–medium) because of specific variants of the type or brand of food.

Easy
Veggie Stixs, soft cookies, cheese, cooked vegetable dices,
Medium
Raw fruits
Difficult
Raisins, beef, raw vegetables

Individual Variables

Individual variables within the food, the child, and the feeder influence the degree of ease or difficulty experienced when biting and chewing a food. These variables may play a major role for some children, and have very little influence on others.

Food Variables
A wide range of variation can occur within a specific food category. For example, a very ripe fruit will be very soft and offer less resistance than an incompletely ripened piece of the same fruit. The degree of sourness or sweetness also varies with the amount of ripening and the variant of the fruit. A Granny Smith apple and a Red Delicious apple are both apples, but differ in their sensory input and resistance. A shortbread cookie by one company will hold its shape when bitten. A different brand of the same cookie may crumble and have extensive texture scatter when bitten and chewed. In general charts of this type, it is impossible to specify every single food variable.

Child Variables
The child's specific sensorimotor strengths and needs will influence the relative ease or difficulty of specific foods. A child with low tone in the jaw, tongue, and cheeks will find foods with a high level of resistance (such as meat or raw carrots) much more challenging than a child with more normal tone or strength in the mouth. Some children with sensory-based feeding difficulties will find any food that gives a strong clear input easier. They may be more comfortable learning to bite and chew a tart apple, a pickle, or a raw carrot than a more typical beginning food such as a graham cracker. Other children with sensory feeding issues are extremely uncomfortable when food must be moved around in the mouth. They may find meats or other foods requiring more extended oral contact and transfer extremely challenging.

Feeder and Environmental Variables
The way in which the feeder creates the mealtime environment, and offers the food will influence the child's sensorimotor skills for biting and chewing. When food is cut in a shape and size that fits the child's mouth and emerging skills, biting and chewing movements are learned with greater ease. When the feeder takes time to position the child so that the body is well supported by the lap or chair, the child's mouth moves more skillfully. A child who has difficulty with the sensory properties of food, will learn to handle new foods more easily during or after activities that improve overall sensory processing.

Self-Exploration for Success
The must successful way to develop an individualized food progression for biting and chewing is through eating potential foods with a high level of awareness and analysis. Begin by selecting foods from these charts that you thing will meet the learning needs of the child. Take several bites of the food and consider each of the sensory features listed for the food. Find out what you experience as you bite and chew the food. What type of sensory awareness and perception do you have as you eat this food? How do you move your jaw, tongue, cheeks, and lips? How easy is it to prepare the food for swallowing?

Observe the child, and notice the general movements that the child uses in handling smooth food, lumpy food, and food requiring biting and chewing. Take several bites of the food as you imitate the typical movements used by the child. If the child has low tone in the jaw, pretend that you have a very weak bite. If the child moves the tongue back and forth with a suckle movement, find out what happens when you place the food in the middle and on the side of the mouth for biting and chewing. Use your own body to explore and discover foods that will be easier or at the right level of challenge for a child with these abilities and limitations. Explore different brands of the same food. If you decide to work with a pretzel, try a number of different brands or shapes. Some will be saltier than others. Some will hold their shape when bitten while others will crumble. Find the best one for the child at this point by selecting from your own experience and observing the child with different pretzels. Expand the child's ability to eat many different types of pretzels by gradually introducing pretzels with slightly different features.

This information has helped me to help Brayden be able to now eat with us at mealtimes, so I hope that it helps you too. Although he already did share the table with our family, he can now share our food as well. With help from us and the discoveries I have made, he eats what we eat, which helps on food costs while not having to buy special meals for him, and preparation time in pureeing or processing foods for him to find manageable enough to eat safely. Not to mention, the new flavors and textures makes mealtime much more enjoyable...unless it is green beans, I think he got that taste deterrent from his mommy!!

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