Feeding Tips For Oral Aversions

RRichards
November 2005

Frequently, babies and children with reflux or GERD begin to have food and/or feeding aversions. The severity of these aversions can range from being a little picky sometimes to downright refusing all foods and requiring nourishment via feeding tubes. The following information is provided to help give you a general idea of what is considered normal eating habits and normal feeding development.

Developmental Food Continuum
Copyright 2002, Kay A. Toomey, PhD

• 0-13 months – breast/bottle
• 5 months – thin baby food cereals
• 5.5 months – slightly thicker baby food cereals + thin baby food puree/stage 1
• 6 months – thin baby food puree/stage 1
• 7 months – thicker baby food cereals and thicker baby food smooth purees/stage 2
• 8 months – soft mashed table foods and table food smooth puree
• 9 months – meltable hard solids (towne crackers, biter biscuits, graham crackers, Gerber’s cereal squares, fruit loops, captain crunch, baby cookies)
• 10 months – soft cubes (avocado, overcooked squash, kiwi, vegetable soup ingredients without the broth, Gerber Graduates fruits, boiled potatoes, peas, bananas
• 11 months – soft mechanical single texture (fruit breads, muffins, soft small pastas, cubed lunch meat, thin deli meats in small rectangles, soft pasta or soft meat soups without the broth, soft pretzels, barley, scrambled eggs)
• 12 months – mixed texture, soft mechanicals/stage 3 (mac and cheese, microwavable children’s meals, soft chicken nuggets (not fast food), French fries, spaghetti, lasagna
• 12-14 months – soft table foods in appropriate sizes and shapes
• 16-18 months – hard mechanicals (cheerios, thin pretzel sticks, ritz crackers, saltine crackers, pop tarts, most other chips, fritos, man

Common Eating Patterns

1-2 years

• Appetite drops as growth slows
• Learns to drink from cup, usually weaned
• May cut back to 2 cups of milk a day
• Likes to feed self but likely needs help
• Copies others and will mainly eat family foods
• When cutting teeth, may have difficulty chewing
• Has acute taste buds and can detect slight differences in foods
• Is developing likes and dislikes; likes sweets
• Likes to touch and play with food, responds to food texture
• Learns to say no and be more independent

2-3 years

• Improved muscle control, can use spoon and fork
• Desserts/sweets desired and asked for
• Will be willing to wait a bit for requests to be filled
• Usually will eat raw veggies, but may refuse salads
• Green veggies become more acceptable

4-5 years

• May return to food jags or go on food strikes
• Is influenced by others (i.e. children, tv ads, teachers)
• Likes plain cooking and foods separated on plate
• Dislikes most mixed food dishes and gravies
• By age five, often has fewer demands and will accept available food
• Appetite is gradually decreasing

If your child begins to have feeding difficulties and falls below the norm in their eating habits or even weight gain, the following information may be beneficial. Much of the info provided below was provided by Becky and was compiled by her son's feeding team for his feeding therapy. It is not meant as medical advice and may not work for all children.

Calorie Boosters for Children Needing Weight Gain
Copyright 1994 by Therapy Skill Builders, a division of The Psychological Corporation/All right reserved. Klein and Delanev. Feeding and Nutrition for the Child with Special Needs/076164332X

• Butter/margarine, vegetable oil, mayonnaise (34-40 cals/tsp): Add to baby foods, veggies, sandwiches, casseroles, soups, rice, pasta, etc.
• Wheat germ (25 cals/tsp): Add to pancakes, cookies, breads, and other homemade baked goods, as well as over yogurt, fruit, and cooked cereals.
• Powdered milk (25 cals/tsp): Add to ground meat, milk shakes, mashed potatoes, cooked cereals, casseroles, and yogurt.
• Sprinkle on cheese (100 cals/oz): Add grated cheese or cheese sauce to buttered toast, creamed veggies, mashed potatoes, rice, pasta, scramble eggs, cooked cereals, casseroles, meat, and fish.
• Cream cheese (50 cals/tbsp): Use it in dip for crackers, veggies, and fruits, and spread on baked breads and buttered muffins.
• Cooked egg yolk (60 cals/yolk): All kinds of foods.
• Whipping cream (heavy) (50 cals/tbsp): Add a touch to drinks and desserts.
• Peanut butter (100 cals/tbsp): Spread on veggies, crackers, toast, muffins, waffles, and add to milkshakes, cookies, and pudding.
• Sour cream (25 cals/tbsp): On potatoes or add to casseroles and sauces.
• Avocado (75 cals/quarter avocado): Add to veggies, on top of crackers, with meat or beans, and as guacamole dip.
• Salad dressing (65-85 cals/tbsp): Add to veggies and salads and over meats.

By food group

• Dairy: whole milk plain or with instant breakfast powders, whole milk cheeses, whole milk pudding, custard, ice cream, kefir, fruit yogurt, 4% milkfat cottage cheese, ovaltine, milkshakes, egg nog
• Meats: cheeseburgers, luncheon meats, hot dogs, fish sticks, fried chicken with skin, ham, spareribs, ground beef, breaded fish, dark-meat turkey with gravy, nut butters, fried beans
• Fruits/veggies: bananas, avocados, fruits canned in heavy syrup, coconuts (grated and milk), peas and corn (creamed or with cheese sauce), dried fruit (pureed for smoother texture), frozen juices reconstituted with less water
• Breads/cereals: pancakes, French toast, waffles (topped with butter, syrup, wheat germ, yogurt, powdered sugar, whipped cream; muffins (spread with butter and jam); sweet breads such as banana or walnut-raisin-date (served with cream cheese or peanut butter); cooked cereals with added butter, raisins, brown sugar, ground nuts); granola-type sweetened cereals with dried fruits and nuts; convenience potato, rice, or noodle mixes served with extra butter, cheese, whole milk, gravy, or wheat germ

Transitioning Off Baby Foods
Advice for Daniel from Toomey & Associates, Denver, CO

• Add spices to baby food purees. Each time he gets a particular baby food, the flavor needs to be changed in some way.
• Vegetables: Add a different spice, in order – salt, extra melted butter, pepper, garlic or dill or tarragon, dry gravy powder, smooth spaghetti sauce or smooth salsa
• Fruits: Add a different flavor, in order – jello or pudding powders (first match flavor, then add a different flavor), fruit-flavored syrups, jellies
• Next begin adding matching flavors of pureed table foods. Begin with 25% table food puree and 75% baby food, change by 25% increments every week.

Mealtime Routine
Advice for Daniel from Toomey & Associates, Denver, CO

• Verbal warning that mealtime is in five minutes
• Bring him to sink to wash hands or give him washcloth to wash on the way to the table
• Start with hard munchable (list of examples to come) already on the table
• Introduce first puree by putting it right on the table and encouraging “dip and lick” with hard munchable
• Begin co-feeding (child dip/licks while parent spoonfeeds puree)
• When he tires of puree, offer meltable hard solid (list to come), and continue co-feeding
• When he is tired of first puree, offer second puree, continue to dip/lick and co-feed
• Offer a drink by cup
• Begin clean-up routine (have child throw one piece of each food into the trash or scraps bowl)
• Give child washcloth or sponge to clean their space

Steps to Eating
Colorado Feeding Consortium, 11/98, 3rd Revision

NOTE: This is set up on a chart. You list the foods offered at meal across the top and then you can record how far he got with each food. I think it’s just kind of interesting to note all of the steps that a child with oral aversions must take.

1. Tolerates food in room
2. Tolerates food on table away from him
3. Tolerates food on table in front of him
4. Tolerates food on plate
5. Touches food with napkin/utensil/other food
6. Touches food with one finger
7. Touches food with two or more fingers
8. Touches food with whole hand
9. Picks up food to wave/tap/manipulate
10. Places food on hand, arm, or shoulder
11. Places food on head, neck, or ears
12. Bring food/liquid in close proximity to nose/mouth (to smell, blow on, blow bubbles in, etc.)
13. Puts food on chin, cheek, or nose
14. Touches food to lips
15. Licks lips
16. Holds food in lips
17. Taps food on teeth
18. Touches food with tip of tongue
19. Full tongue lick
20. Holds food in mouth
21. Gnaws on food
22. Bites food, spits or drools out
23. Bites food, chews/manipulates in mouth
24. Bites food, chews/manipulates, swallows some
25. Bites food, chews, swallows all

Oral Motor Play Ideas
Compiled by: Rose Pediatric Feeding Center, Rose Medical Center, Denver, CO, November 2000

Blowing

• Dandelions
• Cotton, dry corn meal, feathers or lightweight objects across the table
• Kleenex in the air
• Bubbles with a bubble wand
• Whistles, pinwheels, party horns
• Bubbles through a straw
• Blow up a balloon

Chewing/jaw strength

• Tug of war with licorice
• Make teeth marks on beef jerky, carrot, jicima, dried fruit, hard licorice
• Fruit roll-ups, fruit leather, fruit chews, gummy worms, gum, taffy

Tongue movement

• Licking popsicles, suckers, ice cream cones
• Lick food out of a bowl like a puppy
• Lick something sticky (peanut butter, honey, etc.) off a spoon
• Pretend to be a kitty and lick your paws
• Click your tongue
• Sing “la la la” to music
• Blow raspberries
• Use tongue to brush your teeth
• Touch tongue to corners of mouth while making silly faces

Lips (do in front of a mirror)

• Hold Cheerio in lips
• Tightly seal lips and say mmmmmm
• Tightly seal lips around straw, kazoo, whistle
• Apply puree lipstick and lick off lips
• Hold a food (pretzel rod, licorice) in lips without using hands
• Hum
• Alternate puckering and smiling (as if saying o-e-o-e-o-e)

Sucking

• Suck a thick milkshake through a straw
• Make a fish face

Desensitizing teeth

• Use vibrating toothbrush
• Count teeth using toothbrush or long food item
• Brush teeth with carrot, beef jerky, etc while talking and hitting the strong back teeth
• Make music bay tapping food in between upper and lower teeth
• Put vibrating toy on cheek

General Sensory Play Ideas
Conrad & Kurtz 8/02 – Updated Toomey 9/03

Present texture bins in order and hide a toy so child has to dig in. When child can immediately jump in and tolerate without finger splaying, introduce the next texture bin.

Dry texture bins (You can hide toys, make it rain through your fingers, stir, or drive cars and boats, or go digging for buried treasure like pennies or treats.)

• Plastic eggs
• Sponges or net bath puffs
• Styrofoam packing peanuts
• Yarn pom poms
• Various fabrics – velvet, burlap, lace, satin, flannel – all in one bin together
• Koosh balls
• Dry beans – kidney or pinto
• Dry split peas or chickpeas
• Mylar shreds or sheets of shiny mylar or Easter grass
• Feathers or feather duster
• Dry oatmeal or rye flakes
• Rice
• Corn meal or sand
• Flour

Wet texture bins (Have towels available for your child to wipe their hands. Allow child to use toys to interact if hesitant with their hands.)

• Playdough
• Water/ice of different temperatures and colors
• Bath foam or shaving cream
• Flour, corn starch, or corn meal mixed with water
• Oatmeal mixed with water
• Paper mache or plaster of paris

Food texture bins (Do only with therapist permission. This should clearly be a non-eating time and not done at the kitchen table.)

• Bread dough
• Whipped cream, pudding
• Jello
• Applesauce
• Wet pasta, oriental noodles
• Fruits – banana, peach

Other sensory play ideas

• Music boxes, chimes
• Ball pits at playlands
• Scarves
• Netting to make tents, parachute
• Playing with bare skin in the grass or sand box
• Explore by hand different fruits and vegetables (coconuts, pineapples)
• Light mist from squirt bottles
• Smelling games – hide scented objects in bags