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Pediatric Feeding Case Study: Zachary – age 3:11 - featured July 26, 2011

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Pediatric Feeding Case Study: Zachary – age 3:11.

By: Melanie Potock, MA, CCC-SLP

History
Zachary (Zach) was referred to this therapist for home based feeding therapy by his pediatric gastroenterologist at the age of 3 years, 11 months. At that time, no oral motor or gastrointestinal issues were found to be impacting Zach’s difficulty eating a variety of tastes, temperatures or textures. Zachary was diagnosed with sensory processing disorder at 20 months of age and began feeding therapy at that time in a clinic based environment for 12 months. Currently, Zach’s preferred foods consist of smooth vegetable, meat and/or fruit purees, typically served directly from the “baby food” rectangular container and a limited number of finger foods. Zach readily used his own spoon to eat the purees. Favorite foods eaten with his fingers were peanut butter and honey on cinnamon bread, Cheetos, Doritos, Fritos, Pringles, plain M & M’s, club crackers, graham crackers, one flavor of a Gerber cereal bar, dry Cheerios, dry marshmallows from Lucky Charms cereal, and Pop Tarts. Zach will drink water or whole milk through a straw with ease. Zach was able to use utensils, but did not need them other than for purees, due to the dry nature of his preferred “finger foods”. His family would like Zachary to eat whole fruits, vegetables and proteins with ease and enjoy trying new foods.

Environment
Zachary was observed during a typical family dinner with his parents, grandmother and younger brother present at the table. The therapist ate with the family while observing family dynamics, Zach’s oral motor skills and his behavior during mealtimes. Prior to the meal, his parents were asked to include both preferred and non-preferred foods on Zach’s plate so that the therapist could observe his reaction.

Observations
Zach was presented with a fruit puree and a vegetable puree, one half of a peanut butter and honey sandwich on cinnamon bread, and canned, whole green beans that were slightly warm. Zach became upset and anxious when he saw the green beans on his plate and repeatedly asked for the offending food to be removed. After discussing possible treatment modalities with his parents, the therapist suggested the following approach as it appeared to match Zach’s need to be challenged in order to make consistent progress while keeping his anxiety level low.

Strategies prior to starting therapy
Zach’s parents were offered the following strategies for increasing his tolerance to new foods being placed on his plate. These strategies were implemented immediately at home until therapy could begin 2 months later, when the therapist had a weekly opening on her schedule.
  1. Family style serving vs. parent dishing up the plate and presenting it to the child.
    1. Family style servings allow the child to experience the food by passing bowls or plates using a large spoon or fork to put his own serving on his plate. This method is ideal for some families and adds to the social atmosphere of sharing at meals. Repeated exposure to the same foods, especially if the child is responsible for serving everyone and dishes up everyone’s plates, may be helpful if a child is at the stage where they need to experience food at the most basic level. Other family members can cue the child “Oh, more green beans for me, please” while he dishes up the plates, thus providing the opportunity to interact with the new foods over and over.
    2. Parent dishing up plate and bringing it to the child’s place setting: Zach’s parents chose this option. For Zach, it eliminated his tendency to engage in long discussions about the food whenever he saw it, which served to slow down the process of food getting on his plate. Zach’s parents simply presented approximately 2 tablespoons of the new food beside the preferred foods and when he fussed, they stated “Yes, it’s on your plate” and moved on to another topic. Parents were instructed not to say “You don’t have to eat it” because a child knows that eating is the ultimate goal. Simply state the fact – “Yes, It’s on your plate” or “Everyone has broccoli on their plates tonight”, which reassures the child that they can tolerate it. State the fact and move on. Give the presence of the food very little attention and more importantly, give the child’s fussing over the food minimal to no attention. The undesired behavior – the protest over the presence of the food – will fade away.
  2. Exploring new foods without eating: Green beans quickly became the dinner time science experiment. Zach learned to separate the two halves, take out the seeds and talk about the properties of each one. He became comfortable with picking up green beans, licking green beans and smelling green beans. Other new foods followed suit, as every food that the family was eating was always presented on his plate.


Therapy plan
The following plan was followed over the course of 6 months and therapy was conducted in the home on a weekly basis for one hour sessions. Zach’s parents were consistent in implementing a home program with specific goals to be completed each week in preparation for the next session. His parents had desensitized Zach to the presence of new foods on his plate at home prior to starting therapy.

Each step in progress was facilitated by using basic principles of rewarding the desired behavior via a toy tied to social reinforcement and ignoring undesired behaviors, such as engaging in Zach’s discussions that stalled desired behaviors from occurring. Zach’s mother practiced specific oral motor skills with him one time per day during “mouth games” and used highly motivating toys allowed only during this time. Mouth games lasted approximately 20 minutes.

Month 1: Zach understood the concept of swallowing, but was anxious to do so. He tended to gag if any new food touched the central groove of his tongue after chewing. Thus, he habitually chewed small pieces of even familiar foods very quickly and then “sucked back” the food immediately by pursing his lips and sucking in the sides of his cheeks. His other solution was to chew quickly and then quite forcefully spit out the food onto his plate. Mouth games included practicing holding mandarin oranges with his incisors and carefully dropping (rather than spitting) them onto a Floating Plate held by the therapist or parent. The adult gradually increased the amount of time that Zach held the orange piece and controlled the drop onto the plate by moving the plate in the air while counting silently. Zach learned in a fun atmosphere how to tolerate the mandarin orange in his mouth for longer periods. Next steps were to instruct Zach to place the mandarin orange piece onto his molars. Zach learned to chew a bean sized piece of mandarin orange a specific number of times before “dropping” it onto a plate. Essentially, the fun of eventually dropping the food onto the plate became the reward. But, the behavior being rewarded was holding the food in his teeth for longer periods of time. This behavior was shaped by the adult’s movement of the plate through space while keeping the atmosphere light and silly during the plate game. As the plate was raised higher in the air (perhaps eye level) Zach would raise his chin to watch the plate and swallow the chewed pieces automatically, being rewarded by the therapist response “Hey, you fooled me! You swallowed it!” Zach was highly motivated by fooling the therapist! Once Zach learned to tolerate bean sized foods on his molars for chewing and allowed them to move across his tongue before dropping them onto a plate, his anxiety decreased and he began to swallow spontaneously. After the 4th session, Zach was able to chew and swallow pea-sized mandarin oranges, bean-sized apple chunks and bean-sized hot dogs with ease. Zach preferred to reach for his milk or water to wash down the chewed bolus, but was allowed just one or two sips to do so. The therapist simply took the drink away with a gentle “that’s enough” after the first swallow and then rewarded the behavior.

Month 2: The same technique was utilized to help Zach learn to eat macaroni and cheese elbows and other shapes of pasta either in cheese sauce or in marinara sauce. Zach no longer needed to drop food from his teeth and was now able to pick up wet foods with his fingers, place them on his molars and chew. Skipping the step of biting with his incisors and placing food directly on the molars allowed Zach more control of the food and kept the new food closer to the pharyngeal area to eventually be swallowed. Over time, Zach began to bite off portions on his own and transfer the food to the lateral margins of the oral cavity with ease. He still required a sip of milk or water to wash the first few bites down, but over the course of each session he would reach less for the liquid and swallow in anticipation of the reward. This was accomplished by consistently rewarding the reflexive swallow with a toy placed in his hands and tied to social interaction, which lasted about 10 seconds. While Zach was chewing, minimal attention was given and instead, the adult simply waited with the toy in her hands, ready transfer the toy to Zach and thus reward the swallow. If Zach spit the food out, the adult calmly and reassuringly said “Try again” and waited up to 20 seconds before cueing him again or rewarding immediately if he was successful. Mouth games were limited to 30 minutes during a session and the remainder of the session was devoted to discussing strategies and developing the home program with his mother.

Month 3: Zach was able to chew 1 TB. of 6 different pea-sized foods during mouth games with minimal use of liquids to propel the bolus of food posteriorly to be swallowed. Month 3 incorporated the use of a Happy Spot on his dinner plate for independent eating of these same foods during mealtimes. The Happy Spot (also referred to as The Magic Spot) is a section of the plate, marked by a sticker, any sectioned area or any character already imprinted on the plate. For example, if the plate has a flower printed in the plastic, that is the Happy Spot. A specific Disney princess can be designated as the Happy Spot. The Happy Spot is the spot where the adult places 3 pea sized pieces of one food that the child has already learned to eat during mouth games and the child is cued to eat those 3 small pieces at each meal. Parents may incorporate a sticker chart and a reward system for this task. Once the child can easily eat 3 pea sized pieces, the bites become bean sized (twice the size of a pea) but are still limited to three. This makes the task comfortable and easy for children, building confidence for independent eating, phasing out the cues to eat except for an occasional reminder to “eat the food on tonight’s Happy Spot” and exposing the child to the same food repeatedly in small amounts to help his develop a desire for that food. If the child chooses not to eat the food, there is no discussion about it. The child is rewarded for eating the food on the Happy Spot and no attention is given to not eating it. Simply finish dinner and go on about the evening’s business. Children always have the choice to eat, but may require some social or tangible reward as they develop the courage to try new foods. Once the food on the Happy Spot has become familiar (typically eaten with ease 3 times) the food moves onto the other portions of the plate, just like any other food. The child understands that the Happy Spot is for learning about new foods and is reserved just for that purpose.

Month 4 through 6: Mouth games were faded out of the home program and only used during weekly therapy sessions to reinforce new foods. Zach was now able to eat whole cashews, whole peanuts and bean sized bites of mandarin orange, hot dog, apple, pizza, chicken nuggets, peanut butter and jelly on oat nut bread, baked chicken breast, bananas, strawberries, canned green beans, macaroni and cheese, pasta in marinara and scrambled eggs. Smoothies were also introduced and he typically will drink 2 oz. of a cold smoothie the texture of applesauce with a meal at this time. Therapy sessions often are structured around eating a snack together and then playing outside afterward and mouth games are incorporated into the session only when exceptionally challenging foods are introduced.

Conclusion
Zachary’s sessions over the next 3 months will focus on increasing his ability to eat an age appropriate meal in an efficient manner. He needs to eat faster while still enjoying his time at the table with his family. Now that he has increased the variety of foods that he will eat, the purees will be faded out and the volume of chewable foods will be increased.



This Months Featured Author:Melanie Potock, MA, CCC-SLP

Melanie Potock, MA, CCC-SLP is the author of Happy Mealtimes with Happy Kids: How to Teach Your Child About the Joy of Food! With over 12 years’ experience treating children with feeding difficulties, Mel’s approach to developing feeding skills includes the fundamentals of parenting in the kitchen, such as how to avoid mealtime debates and creating more joyful mealtimes, even with a picky eater. Mel wrote this book in the same manner that she works with families; with an open heart and a touch of humor. She has also produced the popular children’s CD, Dancing in the Kitchen: Songs that Celebrate the Joy of Food. Both products are available on her website at www.mymunchbug.com, on Amazon.com and in the Mayer-Johnson catalogue. She can be reached at [email protected]


Tags: Article Feeding Disorders Newsletter Feeding Issues 29 July 2011