hungry hungry hippos-handout -...

Hungry,HungryHipposPickyeatersversusproblemfeeders

SHAUJWOWONG,M.S.,CCC-SLPJUNG-SHENGLEE,M.S.,RD32nd AnnualSPINConference

Whoarethehungryhippos….

ShauJwo Wong,M.S.,CCC-SLPKapi‘olani MedicalCenterforWomenandChildrenRehabilitationDepartmentPhone:(808)983-8230E-mail:[email protected],[email protected]

Jung-ShengLee,MS.RD.PublicHealthNutritionistDepartmentofHealthPhone:(808)594-0060E-mail:[email protected]

Dothesesoundfamiliar…

MychildonlyeatsPlumOrganicpureedpumpkinandbananaWhatshouldIdo?Tianagaggedeverytime wefedherbabyfoodNoahonlywantstodrinkhisbottleandthrewatantrumwhensatdowntoeatsolidsMychildalwaysgagsandspitsupwhenItrytofeedhimricecerealJohnnywillnotdrinkoutofacup,butheisgonna bethreeGraciedoesnotliketotouchherfood.Sheisverycleanandneat.Willmychildgrowoutofthis?

Pickyeater?Problemfeeder?

Possiblecausestopickyeaterandsensoryfeeder

Oralsensorimotorimmaturityand/ordysfunctionGIissues:persistentGERDatanearlierageSensoryprocessingdisorderUnderlyingdysphagia– persistentchokingormicroaspiration

Complexmedicalhistory:– complexcardiaccondition,– historyofextremeprematuritywithchroniclungdisease– Respiratorysystemcompromisedwithtracheostomy,micrognathia– G-tubedependentwithneedforslowfeeds,lackofphysicalsensationofhungerandthirst– Shortgutsyndrome

PossibleSignsofaFeeding/SwallowingDisorderArcheshis/herbackorstiffenswhenfeeding

Criesorfusseswhenfeeding.

Hastroublebreathingwhileeatinganddrinking.Soundscongestedandgurgles

Refusestoeatordrink

Eatsonlycertaintextures,suchassoftfoodorcrunchyfood

Takesalongtimetoeat

Hasproblemschewing

Coughsorgagsduringmeals

Frequentspit-ups

notabletogainweightadequately

Fatigueseasilyduringfeeding,e.g.,Prader-Willisyndrome,lowmuscletone,Cardiac

FeedingandSwallowingDisordersinChildren.RetrievedMarch,162018,fromhttps://www.asha.org/public/speech/swallowing/Feeding-and-Swallowing-Disorders-in-Children/

WhatisSOSApproachtoFeeding(SequentialOralSensory):

Designedtoassessandaddressallthefactorsinvolvedinfeedingdifficulties– examinesandtreatsthe“wholechild”Philosophicallybasedontheideathat“thechildisalwaysright”– thechildisdoingwhatworksforhim/herAllowsthechildtoplaywithfoodwiththepurposeofteachingaboutfoodwiththegoalofeatingiteventuallyBuildskillsandincreasefoodrepertoireinaplayfulandnon-stressfulwayWearingyourfoodispartoftheprocessoflearningtoeatthatfood– ithelpsincreaseachild’scomfortlevelbyexploringdifferentpropertiesofthefoods,includingthecolor,shape,texture,smellandtasteParenteducationandinvolvementareanessentialpartofthisfeedingprogram

Feedingrelatesto…

AllorgansAllMusclesAllSensesLearning(style,capacity,history)DevelopmentNutritionalStatusEnvironment

Eatingisnota2stepprocess- itisa25–32 stepprocessthatbeginswithsensory

integration

Eatingisthemostdifficultsensorytasksthatchildrendo

Deborah:“tastelikepersimmonbutit’sdark”

Kimi:“yeah…likepersimmon”

Jordan:“prettygood”“letmetastesomemore”

Suzy:“whatisthat?”“kindoftastelikesweetpotato”

Mel:“onlyalittle.”

Caroline:“nothankyou”

Leni:“nope”

CognitiveDevelopment– Piaget

Birthto2/3years=Sensorimotor• Understandingoftheworldisbasedonphysicalexperience

• symbiosiswithprimarycaregiver

2/3yearsto5/7years=PreOperational Thinking• Pre-logicalandmagicalthinking• Connectionsbetweeneventsaremadebasedonclosenessintime(aren’tnecessarytrue)

5/7yearsto9/11years=ConcreteOperations• Logicalthinking• stillcannotcomplete“reverseoperations”• blackandwhitethinking,rule-based

9/11yearsandon=FormalOperations• abstractthought• canreversean“operation”directlyinthemindversusneedingtoactontheworld

• verynarcissistic.Theythinkthattheyaretheoneswhocomeupwiththebig

• thoughts

Emotionalvs.StressResponse

Whatwebelieveimpactsthedecisionmakingprocessfortreatment

Ifwebelievethechildhasanemotionalorbehavioralproblem,wewilltrytocontroland“fix”thechild

Ifwebelievethechildishavingastressresponsebecausetheycannotmanagethetask,wewillteachtheskillsinamannerthatrespectsthechild’sreadinessforthetask

MarshaDunnKlein(2010)

CognitiveFunctioningandStress

Whenwearedistressed/stressed,wedroptothenextlowestlevelofcognitivefunctioning

Whenwebegintreatmentwithfamilies,assumetheyarefunctioningcognitivelyinConcreteOperations

WritedownallrecommendationsDrawpicturesUse“bodybased”teachingexperiencesIttakes6– 8weeks,onceaweekinterventioninordertoestablisharelationshiptocomebackupalevelincognitivefunction

HowInfantsandYoungChildrenLearnaboutFood

Familiarizationthroughexposure:tastes,variety,texture,visualexposure.

Associativelearning.

Observationallearning.

Categorization.

Paroche,M.M.,Front.Psychol.,25July2017|https://doi.org/10.3389/fpsyg.2017.01046

Exposure:taste,variety,texture,andvisual

Repeatedexposurehasbeendemonstratedtobeeffectiveinencouraginginfantstoconsumemoreofatargetfoodduringtheweaningperiod.

Exposuretospecifictastesearlyinlifeisassociatedwithlatertastepreferences.

Repeatedexposurecanalsoincreaseinfants'intakeofaninitiallydislikedfood.


Exposinganinfantoryoungchildtoavarietyoffoodsatayoungageiseffectiveinpromotinglikingandintakeofbothexposedfoodsandothernewfoods.

Bymanipulatingthepresentationofvegetableswithinmealsanddays,demonstratedthatbothwithin-mealandbetween-mealvarietyenhance6-month-olds'acceptanceofanew(non-exposed)vegetable.

At6yearsofage,childrenwhohadbeenexposedtothehigh-varietyinterventionweremorewillingtotastenewvegetablesandlikedandconsumedmoreofthese.


Associativelearning

Flavor-flavorlearning:pairingofanewordislikedfoodwithafamiliarandlikedtaste.Flavor-nutrientlearning:pairedwithhigh-energydenseingredientstoenhancepost-ingestive satietysignals.Contamination:associationofanewfoodwithadislikedfood.Reward:associationofafoodwithpraise.


ObservationallearningObservationallearningfromadultmodelshasbeenshowntooccurfrom14monthsofage,whilepeermodelinghasbeenshowntobeeffectivefromabout2yearsofage.

Studiesshowthatchildren'sfoodrepertoiresaresimilartothoseoftheirfamiliesuntilatleast8yearsofage.

Parentalmodelingasadeterminantofchildren'slikingofvegetables.


CategorizationTheabilitytorecognizeafoodbyitsshapeandcolorisimportanttotoddlers.

Childrenpreferfoodstobepresentedseparatelyratherthancombinedwithotherfoodsorhiddeninsauce,andwhorejectfoodswhoseappearancedifferstoafamiliarpreparation.

Knowingthenameofafoodmightimpactonitsfamiliarity,andhenceonliking.


Step1:Tolerate

BeinginthesameroomBeingatthetablewithfoodontheothersideofthetableBeingatthetablewithfood1/2wayacrossthetableBeingatthetablewiththefoodapproximatelyinfrontofthechildLooksatfoodwhendirectlyinfrontofchild

Geng,L.TipsforPickyEaters.RetrievedMarch,162018,fromhttp://pursuitofresearch.org/tips-for-picky-eaters/

Strategies:Describethepropertiesofthefoodwhileitisinfrontofyou.Youmanipulatefoodinacreative/educationalwaynear/infrontofchild.Childwatchesfoodpreparationbecauseitisinteresting.Foodispassedinfrontofchild;directlyinfrontofface.Placefoodonanapkinortablenexttochildandmoveclosertochildastolerates (withoutdrawingattentiontothis,overthecourseofthemeal) placefoodonedgeofplateandmovecloserastolerates.Geng,L.TipsforPickyEaters.RetrievedMarch,162018,fromhttp://pursuitofresearch.org/tips-for-picky-eaters/

Step2:InteractionAssistsinpreparation/setupwithfood.

Usesutensilsoracontainertostirorpourfood/drink.

Usesutensilsorcontainertoserveself.


Strategies:Havechildpassfoodcontainertoanother.Havechildserveselforanotherfamilymemberwithautensil.Childhelpswithfoodpreparationusingutensils.Childstirswithautensilorotherfood(e.g.pretzelrod).Childmanipulatesouterwrapper.Childpushesonefoodwithanotherfood(makingatrain).Childputsonefoodintoanother(makingfaces,makingb-daycakeswithcandles).Childblowsonfoodtotipitoverormovealongtheplate/surface.


Step3:Smell

Odorinroom.Odorattable.Odordirectlyinfrontofchild.Leansdownorpicksuptosmell.


Strategies:Havechildinkitchenwhilefoodisbeingcooked.Helpspreparefoodswithutensilsorhands.Peeling,cutting,stirring.Wavingfoodinfrontofface(mimickingfans,airplanes,wiggleworms,“teachingphysicsoffood”).Bringingthefoodnearthenose(makemustaches,whiskers,beards,lipstick,clownnoses).Modelleaningdownandexaggeratingsmelling(“Hmmm…Ahhh”).


Step4:Touch

Fingertips,fingerpadsWholehandChest,shoulderTopofheadChin,cheekNose,underneathnoseLipsTeethTipoftongue,fulltongue


Strategies:Buildingwithfood(makingtrains,steps,bridges,rainbows,letters,shapes)Paintingwithfoods(shapes,letters,pictures,faces,etc)Drivingfoodsanddrivingfoodsunderotherfoods(peanutsmakegreatboatsandcars)Inchwormupthehand,arm,shoulder,cheeks,etcDrivingtothecave(mouth)Kissingfoods,foodskissingyouPretendingthefoodislipstick,rubbingfoodonlipsFlickingontoplate,intobowlServingyourselfwithyourhands


Stickingthefoodtopartsofthebody(forehead,cheek,hand,nose,chin)scrapingwithhandsintotrash;throwingawayfoodsonthetableMakingfoodintoobjectsyoucanwear(earrings,glasses,necklace,bowsinhair,rings,etc.)Smashing,crunching,breaking,ripping,tearingwithhandsCookiecuttersGivefoodhugsTappingthefoodontheteethBalancingthefoodonyournoseHangingthefoodfromlowerlipHoldingfoodon/aboveyourupperlipwithnohandsSlidingdowntheslide/skislope(=yournose)


Step5:TasteLickslips,tonguelicksfood,bitesoffpiece&spitsoutimmediately.

Bitespiece,holdsinmouthfor“X”seconds&spitsoutbites,chews“X”times&spitsout.

Chews,partiallyswallows,chews,swallowswithdrink, chewsandswallowsindependently.


Strategies:BeingapuppywithaboneHoldingfoodinteeth,nohandsKissingfoodDrivingintomouthBlowingoutofmouthHoldinteeththenpushoutwithtongueLicking(“makeitwet,likeapuppydoes”,lickitlikeanice-creamcone)Listentothenoisesitmakeswhenbiting/crunching


ImitatebrushingteethwithfoodMakingapoppingnoisepullingfoodsoutofmouthExaggeratedchewingwithnoiseandheadmovementLickingfoodfromfingersHoldbiteoffoodinbackteeth,spitoutBiteoffsmallpieces,thenspitoutquicklyTouchtotipoftonguefastPlayingpeek-a-booontongueCountingchews“1,2,3”everyonelicks,bitesetc.


Step6:Eating

Feedingguidelines:2-3years

Calories Milk/Dairy Meat/beans Fruits Vegetables Grains Oil

1000kcal 2cups 2oz. 1cup 1cup 3oz. 14g

Mealsandsnackspattern.RetrievedMarch,162018,fromhttps://www.choosemyplate.gov/preschoolers-meal-and-snack-patterns


Calories Milk/Dairy Meat Fruits Vegetables Grains Oil

Female 1200kcal 2cups 3oz. 1.5cups 1cup 4oz. 17-18g

Male 1400kcal 2cups 4oz. 1.5cups 1.5cups 5oz. 17-18g



Calories Milk/Dairy Meat Fruits Vegetables Grains Oil

Female 1600kcal 3cups 3oz. 1.5cups 2cup 5oz. 20-22g

Male 1800kcal 3cups 5oz. 1.5cups 2.5cups 6oz. 20-22g


MealPlanningGuide.RetrievedMarch,212018,fromhttp://www.fammed.usouthal.edu/Guides&JobAids/handouts/Metabolic/1800CalMealPlanningGuide.pdf

TakeHomeMessages

Peoplearen'tchoosingtodislikefood.Howtoresentthepatternoflikesanddislike:

NonjudgementContinuetotrythingsindifferentways

8-15exposuresareneededtoenhancenewfoodacceptance.Pleasant,funmealtimeshelpestablishalife-longhealthyrelationshipwithfoods!

Resources• Core NutritionMessages(USDA):www.fns.usda.gov/core-

nutrition

• KidsEatRight(AcademyofNutritionandDieteticsanditsFoundation):https://www.eatright.org/for-kids

• MyPlateKid’sPlace(USDA):www.choosemyplate.gov/kids

• Let’sMoveChildCare(TheNemoursFoundation):www.healthykidshealthyfuture.org

Questions

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