Ingredients for Success

Physical therapists can be an effective part of the treatment team for feeding problems

Whether they're munching Cheerios or chocolate chip cookies, eating is a common childhood pursuit. For everyone, child and adult alike, "Feeding is one of the most important and complex tasks for daily living," said Pamela Modugno, OTR/L, Bacharach Institute for Rehabilitation, Pomona, N.J.

Yet due to physical and neurological issues beyond their control, the simple joys of eating are beyond the grasp of some children. Pediatric feeding programs guide parents in helping both picky eaters and problem feeders.

Degrees of Difficulty

Many toddlers exhibit selectivity when it comes to food. Some experts estimate almost 50% of 18-to-23-month-olds can be classified as picky eaters, eating fewer than 30 foods, but eating at least one food from almost all texture groups, and after repeated exposure, willing to try new foods.1

Problem feeders, on the other hand, will avoid certain food groups or textures entirely. This lack of variety can lead to nutritional deficits that can be costly down the line.

Pediatricians and parents should be concerned when infants show signs of irritability or significant vomiting after bottle or breast feeding, as those are red flags for acid reflux. Untreated reflux can influence feeding patterns.

With toddlers and school-age-children, any time they narrow their preferred food list to five or less, it's a problem. For all ages, constipation, sudden weight loss, and rapid jumps off the growth chart are red flags.

Some problem feeders have physical oral-motor problems that create difficulty in manipulating foods. Pediatric feeding programs often assess children with cerebral palsy or other issues related to muscle tone abnormalities of the mouth, throat and stomach.

"Breathing is their priority, not eating, and it's hard to do two things at the same time," explained Carissa Snelling, MS, OTR/L, who works at the Good Shepherd Pediatric Feeding Program in Allentown, Pa. Children who were born prematurely are also susceptible to feeding difficulties. As with other aspects of development, it takes them a long time to catch up with their peers, since they did not start their feeding experiences with strong foundational skills.

Beyond structural issues, autism is another common co-diagnosis of problem feeders. Kids on the spectrum thrive on routine and sometimes will eat only pre-packaged foods, as they are always identical. They also will eat the same food over and over and are at risk for having a "food jag" when that food is totally eliminated from their diet.

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Pam Modugno, OTR/L, founder of the Pediatric Feeding Skills Program at the Bacharach Institute for Rehab in Pomona, N.J., encourages 9-year-old Andre Sulit. "Feeding is one of the most important and complex tasks of daily living," said Modugno. Occupational therapists work to help children tolerate food, often the first step in addressing a feeding disorder.

Successful Eating

Modugno founded the Pediatric Feeding Skills Program at Bacharach in 2012. She begins with a medical history and an evaluation of the sensory and motor development, swallowing, and hand-to-mouth coordination of each client. "Can they tolerate seeing, smelling, touching and tasting food?" she said.

Occupational therapists look at children's feeding schedules and their posture and positioning at the table. Specialty feeding chairs position them properly, giving them good postural stability and making it easier for children to be independent with self-feeding.

After the evaluation, the children attend Bacharach's outpatient food school for 12-week sessions. The more medically complicated cases, and toddlers and infants under 18 months, have one-on-one sessions. The rest attend group sessions, which are preferred. "They learn very well among peers," Modugno said of her young patients.

"We make sure the child is comfortable. There's no force feeding. It's all about learning about the food and enjoying eating," Modugno emphasized. In the most extreme cases, the child can't tolerate being in the same room with the food. An occupational therapist presents 10 to 14 foods at each session and grades the child on each food presented.

Much of the outpatient feeding program at Good Shepherd operates the same way. Can the child open packages, bring food to his mouth, chew, swallow, request more, and refuse food? Weekly sessions can include chewy food to improve jaw strength, and pureed food to address textural intolerance.

Good Shepherd also has an inpatient feeding program for medically complex patients, such as those on oxygen, those who are tube-fed and want to transition to oral feeding, those with severe aspiration, and those with severe muscle-tone issues.

Family Affair

Parental involvement is needed for a successful feeding program. At Bacharach, "They participate the whole time. They're right there with us, modeling," explained Modugno. During the group sessions, the parents view their child on a video monitor. It's important that parents carry over therapy techniques. Families are encouraged to have meals together at home.

"The parents are the guiding members of the feeding team. It's an investment and as much as they put into the process, they get out of it," said Snelling. Clinicians develop relationships with parents to help them realize how they can help their child. Parents must buy into the treatment, as they spend more time eating with their child than the occupational therapist. For the weekly therapy sessions at Good Shepherd, the parent is responsible for bringing the preferred and the new food for the child.

Before a child even enters the program at Good Shepherd, parental involvement begins. The family fills out a questionnaire, including a detailed medical history and a food diary. Snelling or a colleague has conversations with parents about their concerns, to make sure the feeding program addresses the specific issues their child struggles with.

"We have a two-way mirror, and in just a few minutes watching the parent and child have a snack, you can learn so much about their dynamic," Snelling observed.

Strong Collaboration

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Mora Pluchino, DPT, pediatric program coordinator at Bacharach, plays in the ball pit with patient Hannah Halsey. Children in the feeding disorder program are usually also seen by a physical therapist for concurrent issues.

"We love to have that interdisciplinary approach because everyone brings something different to the table," noted Sarah Wanuga, MS, CCC-SLP/L, who works alongside the occupational therapists at Good Shepherd. Every child and every diagnosis is different, so treatment takes a lot of people working together and approaching it from different perspectives.

In the inpatient setting, SLP, OT, PT, nursing, respiratory therapy, recreational therapy, a dietician and a physiatrist all work together, meeting weekly to discuss each patient's plan of care. "There's a really strong collaboration," noted Snelling.

"The knowledge [speech-language pathologists] bring in relation to the anatomy and physiology of all the structures involved with feeding are very important," she added. SLPs such as Wanuga know what the structures involved in chewing and swallowing are supposed to look like, and what they're supposed to be doing.

Some of the outcome scales for occupational and speech therapy cross over. Wanuga has her own set of measurements, such as how the child retrieves and manages a variety of foods and liquids, and how safe the child's swallowing function is in terms of feeding. At the initial evaluation at Good Shepherd, speech-language pathologists conduct an oral-motor exam to look at the structure and function of oral motor mechanisms.

At the weekly therapy sessions, Wanuga sometimes prescribes jaw-strengthening exercises for chewing, and tongue exercises to transfer food from side to side in the mouth. If warranted, at subsequent sessions speech-language pathologists can perform neuromuscular electrical stimulation to increase sensation and performance, which decreases signs of aspiration.

SLPs are responsible for coming up with the safest diet to prevent aspiration for each child. In that regard, Wanuga consults with a dietician. "A lot of kids we see are gluten-free and casein-free," she explained, and a dietician helps with those specialty diets.

While speech-language pathologists commonly participate in pediatric feeding programs, Bacharach has a unique twist, with a physical therapist involved. "I would love to have more PTs who are educated in feeding," said Mora Pluchino, DPT, pediatric program coordinator. "It's been a learning experience for me because it's been more of an OT-type skill."

Feeding problems can stem from physical difficulties and often, children treated for feeding problems are in physical therapy concurrently. If a child has hypotonia in the trunk or legs, he could have it in the mouth or jaw as well, making chewing and swallowing difficult. If children are not getting the proper nutrients, their muscles and bones won't heal as well after injury, and they will have a harder time in physical therapy.

In the feeding clinic, Pluchino works on gross-motor planning and posture. The latter is especially important for addressing swallowing and reflux issues. She's certified as an SOS (sequential oral sensory) feeding therapist because prior to her certification, Modugno was the only SOS therapist at Bacharach. Pluchino will treat kids alone, but occasionally works with them in groups, as does Modugno.

Feeding difficulties can make mealtime stressful. "I never realized how much of a problem feeding was," Pluchino acknowledged. Although it's a step outside the comfort zone for most of them, she encourages her fellow physical therapists to become involved in pediatric feeding therapy.

OT Hallmark

Beyond the needed input from other disciplines, feeding therapy is an occupational therapy hallmark. Eating is one of the activities of daily living, which are OT's strong suit. "We look at the child at all levels - sensory, cognitive, motor etc.," explained Modugno.

"Occupational therapists have excellent understanding of how to make activities less difficult," added Snelling. They adapt activities so the child can be successful. They assess the environment and see how it can be changed to make a better eating experience. Should the lighting be altered? Does the food need to be presented in a different manner? Is the child positioned at the table in a way that maximizes function? With their knowledge of environmental modifications, these are questions occupational therapists such as Snelling and Modugno are uniquely qualified to answer.

Success in pediatric feeding programs is highly individualized. Generally, the young patients at Bacharach are discharged when 10 different fruits/vegetables, proteins, and starches have been added to their diet. Although occasionally, additional sessions will be recommended. Other issues to consider are whether they are gaining weight and generally thriving.

Feeding therapy programs stress quality over quantity. The outpatients at Good Shepherd are assigned scores from 1 to 5 on topics such as food variety, ability to self-feed, and positioning, and are reassessed six months after their weekly sessions to chart progress.

Given the proper guidance, picky eaters and problem feeders can expand their preferred food lists. "They make a better quality of life for children and parents," Pluchino said of pediatric feeding programs. Toddlers, parents and her therapy colleagues would certainly agree. 

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1. Heim K, et al. "Mealtime Fear Factor: Helping children when food becomes a fight." http://www.eatrightcpda.org/documents/MealtimeFearFactorHandout.Sept2012.pdf. Accessibility verified Dec. 11, 2013.

Danielle Bullen is on staff at ADVANCE. Contact: dbullen@advanceweb.com


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