Play Picnics as a Solution for Fussy Eaters

1. Play Picnics as a Solution for Fussy Eaters Alison Spurr August 2014

2. OUTLINE OF PRESENTATION • Normal Development • Food continuum • Role of sensory skills • Problem Feeders – • Prevalence Data • Picky Eaters vs Problem Feeders • Feeding Therapy • Play Picnics • SOS Approach

3. NORMAL FEEDING DEVELOPMENT

4. DEVELOPMENTAL FOOD CONTINUUM Breast/bottle 0-12 months  Thin Baby food cereals 5 months  Thicker Baby food cereals 6- 7 months and purees  Soft Mashed Table Foods 8 months

5. DEVELOPMENTAL FOOD CONTINUUM Hard Munchables 8 months  Dissolvable Hard Solids 9 months  Soft Cubes 10 months  Soft Mashed Table Foods 11 months  Soft Table Foods 12-14 months  Hard Mechanicals 16-18 months

6. DEVELOPMENTAL FOOD CONTINUUM • The developmental progression in learning to eat various food textures requires advancing BOTH oral-motor functioning and sensory processing • Taste Balance • Smell Proprioception • Sight Interoception • Sound • Touch Sensory processing requires the ability to take in information from all of the senses, process that information and then produce an adaptive response.

7. Eating is the most difficult sensory task that children do

8. SENSORY MEAL • Eyes – visual information changes with every bite and every chew • Smell – closely linked with preferences • Touch- fingers, mouth ,tongue, internal • Taste – pre, during and after swallow • Sound – crunching, slurping etc.

9. Causes of Feeding Problems

10. FIELD, D., GARLAND, M. & WILLIAMS, K (2003) N = 349 CHILDREN Medical diagnosis%Major Feeding Issues GERD 51 Food refusal Neurological 30 Oral/dysphagia Cardiopulmonary 27 dysphagia Food allergy/intol 21 selectivity Constipation 15 Diarrhea 6 Anatomical anomal 6 oral motor Delayed emptying 4 Renal Disease 3

11. ARE FEEDING PROBLEMS CAUSED BY PARENTS? • Gueron-Seal et al. (2011) • N=55, ages 1-3 years, mean = 2 years • 27 children in the feeding disorders group • 28 children in the control group (Matched by age, gender, birth order, maternal education) • “having a child with a feeding disorder puts the mother-child relationship at risk for more negative feeding interactions” p833 • more intrusive and less structured • The more worried a Mother was about her child’s weight, the more her interactions with her child at mealtimes were impacted

12. Are Feeding Problems Caused by Environment? Pridham et. al (2001) 47 full-term; 52 preterm infants Videotaped at 1, 4, 8 and 12 months Looking at Mother’s working model of feeding her child, along with Mother’s positive affect, sensitivity and responsiveness. As the child’s weight became less deviant, a Mother’s feeding affect and behaviour BECAME more positive There were NO significant associations with Mother’s symptoms of depression in either group or across afes on the Mother’s feeding affect of behaviour

13. WHAT DOES A FEEDING PROBLEM LOOK LIKE?

14. EDMOND ET AL(2010) FEEDING SYMPTOMS, DIETARY PATTERNS, AND GROWTH IN YOUNG CHILDREN WITH AUTISM SPECTRUM DISORDERS, PAEDIATRICS, 126, 337-342 • Avon Longitudinal Study of Parents and Children in England • 14,062 live births: 13,971 survived to age 5 years • Food Frequency questionnaires at 6, 15, 24, 38 and 54 months of age • Content of diet assessed at 38 months • Weighed and measured at 7 years of age

15. PICKY EATERS VS PROBLEM FEEDERS • Picky Eaters Problem Feeders Decreased range/variety of foods but Restricted range or variety of foods, usually will eat > 30 foods <20 foods Foods lost due to “burn out” usually foods lost are NOT re-acquired regained after 2 weeks Tolerates new foods on plate and cries/tantrums with new foods usually can touch or taste them Eats > 1 food from most all food refuses entire categories of food textures or texture groups or nutrition groups nutrition groups

16. PICKY EATERS VS PROBLEM FEEDERS • Picky Eaters Problem Feeders Adds new foods to repertoire in Adds new foods in > 25 steps 15-25 steps Typically eats with family, but frequently Usually eats different foods than family and eats different foods than family often eats alone Sometimes reported as “picky eater” Persistently reported as “picky eater” across at well child checks multiple well child checks

17. Parental Practices for Problem feeders Force feeding – associated with lower child weight status in both cross-sectional and prospective studies (Farrow & Blissett, 2008; Keller, Pietrobelli, Johnson, & Faith, 2006) Distraction feeding – using toys, TV, and movies, and feed while child is distracted Use food as a reward Punishment feeding – taking rewards, toys away for poor feeding *Parents do what they are doing because it works for them on some level

18. FEEDING THERAPY • Play Picnics • SOS • Applied Behavioural Analysis (Behavioural modification) • Inpatient Intensive Fussy feeding • Tube Weaning • Graz • Inpatient tube wean • Day patient program Unfortunately limited studies comparing different approaches to feeding therapy especially post discharge.

19. PLAY PICNICS – PRIMARY GOALS • Allow the child to lead, regain control and enjoyment of the feeding process • To teach parents to allow the child to lead in feeding (and other areas) • To promote the child’s curiosity in food by providing positive, non threatening, oral experiences. This, along with hunger, will provide internal motivation to eat and drink.

20. PLAY PICNICS - SECONDARY GOALS • Promote a positive carer-child relationship • developing attachment, • giving child better emotional health and • relationship building skills. • Reduce the severity of feeding problem. • Increase the parent’s capacity to cope with child with severe feeding problems, due to both the treatment and the opportunity to meet other parents with issues in common.

21. PLAY PICNICS - INCLUSION CRITERIA • Age between 8 months to 18 months. • Safe swallow for some type of oral intake • Must have primary carer attend each time. • Capable of self feeding- gross motor skills to access food/ fluid in exploration. Parent can then hold/support as necessary. • If tube fed: Tolerating bolus feeds during the day, ideally at minimum of 3 hours apart. (ie child has sense of hunger)

22. PLAY PICNICS - EXCLUSION CRITERIA • NBM or high aspiration risk • Infection • Parents who can not commit to attendance • Carefully watch and plan for Food Allergies

23. FACILITATOR’S ROLES • Coach parent re cue reading – child’s sensory preferences, aversion, preferences, enjoyment • Select oral experiences/ available options for children- foods, textures, equipment. • Look at oral defensiveness, oral hypersensitivity, coordination and strength of oromotor movements and swallow strategies (?referral to SP). • Look at positioning (?referral to PT). • Look at sensory aversion (?referral to OT). • Conduct pre and post assessments

24. PLAY PICNICS - PROCESS • Age and allergy appropriate food placed on clean floor • Children are placed on the floor with parents sitting around the outside • Parents are not to intervene unless there is a safety issues • Therapists provide support for parents and help with learning to read their child’s cues

25. LET THE CHILDREN PLAY • Anything goes • Children define the rules • All initiative is in the children’s hands • Nothing has to happen • No playing, just observing • Not touching, just smelling • Not eating, just playing • No play picnic • It is the child’s choice

26. SOS approach Sequential – Oral - Sensory Dr Kay Toomey and Dr Erin Ross Designed to assess and address all the factors involved in feeding difficulties (examines and treats the “whole” child) Multi-disciplinary approach Based on normal development of feeding, accessing the cognitive development of the child and play-based therapy Systematic Desensitisation The use of competing relaxation responses during exposure to a graduated hierarchy of anxiety producing stimuli to help a patient learn to overcome their fears.

27. SOS • Treatment of feeding problem is based on the belief that the child is having a stress response because they can not manage the task. • Therefore we try to teach the skills in a manner that respects the child’s readiness for the task • There are 32 steps to food acceptance and children are encouraged to move up the hierarchy one step at a time • If a child can not tolerate an exposure level, he/she “signals” the therapist who drops back to a “safe” level of interaction which allows the child to “relax”

28. STEPS TO EATING – 32 steps to food acceptance 6 broad acceptance levels Eating Taste Touch Smells Interacts with Tolerates

29. FOOD PLAYGROUP GOALS Learn to have positive experiences with food Learn mealtime routines and cues to eating Decrease resistance to touching, tasting and swallowing food Increase range of foods a child will try Increase volume of food ingested (SKILL DRIVES VOLUME) Individual goals developed with parental input

30. GROUP SCHEDULE Sensory Preparation– 15 minutes Children participate in ‘obstacle course’ for sensory organization and body awareness Children participate in sensory ‘calming’ singing songs (for the older children parents leave the room and watch behind a 1 way mirror) ** ENDORPHINS COUNTERACT ADRENALINE - We want to avoid a fear response as adrenaline is an appetite suppressant

31. STARTING ROUTINE • Every child washes & dries hands & face (tactile exercise, hygiene, facial warm up, establishes routine) then sits at table • Blow bubbles: oro-motor exercise, endorphins, reinforcement • Given a damp face washer and “clean the table” also use to wipe hands throughout session if needed (routine, sensory organisation) • Each child is passed plates and napkins (social learning, turn taking, routine) • Each child serves themselves from a plate/bag

32. FEEDING • Lead Therapist presents each food, one at a time (may also be a supporting therapist in the room to help and a therapist in the room with parents providing education) • Therapists model sequence of steps to accepting new foods (begins with visual tolerance, interacting, smelling, touching, tasting, eating) • Children are positively reinforced for all levels of interaction (imitation, touch, praise, clapping, cheering, praise of others) CHILDREN ARE NEVER FORCED TO EAT

33. FEEDING • Parents and staff use positive language i.e. “you can” rather than “can you?” and “we” rather than “don’t” i.e. ‘we sit in our chairs’ rather than ‘don’t leave the table’ • Rule for food presented: • 1x meltable solid (i.e. green jelly) • 1x hard munchable (ie green apple slices) • 1x puree (apple puree) • 1x drink: (green cordial) There should also be a: starch, protein, dairy, fruit/veg at each group & foods need to be linked in some way (i.e. colour, shape)

34. FEEDING • A recording sheet is used to track where each child enters (#1) and exits (#2) the steps to eating & recorded for progress

35. PACK UP • Leader signals “all done” • Each child ‘kisses’ ‘blows’ 1 piece of each food in bin (helps to move further up the hierarchy) • All other material thrown away • Wash the table with cloth • Each child washes & dries hands • Good bye song

36. DISCHARGE CRITERIA • 30 different foods consistently in food repertoire • Enters the Steps to Eating hierarchy at ‘tastes’ 80-90% of the time, if presented with new food • Child is on growth curve in which child’s length-weight ratio is appropriate, and child has been able to maintain growth on or above that curve for at least 4-6 weeks • Family no longer battles at most meals • Prefer – at least one illness with weight loss and re-gain pattern seen in typically developing children

37. SOS STUDIES • Erin Creach, CCC-SLP (2006) • N=10, age range=17-31 months • 7 meals with same 7 foods • SOS style therapy • Behavioural coding system • Results • Signif increase in positive meal time behaviours eg.smiling, vocailizing, interactions with caregivers • Sig increase in food interaction eg. Touch, stir, pick up • No sig difference in self-feeding • Sig decrease in neg meal-time behaviours

38. SOS STUDIES • Own data from SOS clinic • 2000-2005 (internal audit) • Average for children transitioning off G tubes, who entered Feeding Therapy with some oral intake = 12 months from start of treatment (depends on age and step on eating hierarchy that child entered) • *cost for 1 x per week therapy for 12 months = approx $9500 for individual therapy and $4500 for groups • QLD study due out next year

39. LIMITATIONS OF SOS PROGRAM • Parents need to be committed • Adapting own structure at home • Regularly attend • Be able to learn ‘lessons’ in group • Time/staff intensive – 2 therapists, 2 assistants • Handouts • Scoring • Medical notes • Planning • Shopping • Liaising with other professionals involved in care

40. ABA • Used with ASD for multiple social behaviours including teaching • Child gets rewarded for eating/trying new foods – food rewards, or toy rewards • Williams, Field and Seiverling (2010) • Reviewed 38 treatment studies of Food Refusal from 1979-2008 • 218 Children across 38 studies (average= 5.7 children) • 190 of 218 on supplemental tube feedings (87%) • 113 of 190 (59%) weaned from tube feedings by study end = weeks to months depending on study

41. INPATIENT FUSSY FEEDING • Fay et al, (infants and young children, 9, 26-35, 1997) • Study of 19 patients at Baylor Medical Centre with NG and G tubes • 3 weeks inpatient • Issues • 12 out of 19 successful (failures = premature, Developmental delay and GORD) • All children on pureed foods (no discussion about developmentally appropriate foods) • Cost for 3 week intensive stay = $33,000

42. TUBE WEANING PROGRAMS • Graz • Inpatient wean • Outpatient day service

43. EARLY REFERRAL =PREVENTION • Encouraging positive feeding relationships • Ideas to provide pleasant oral experiences • Assist in transition from tube to oral feeding • Information about transitioning to solids