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The Therapy Tool Box: Treating Feeding Aversion With Pre-Chaining and Food Chaining

Facts About Feeding Problems in Infants and Children

Feeding Problems affect approximately 25% of infants and young children March 2011

Severe feeding problems including poor weight gain, refusal to eat or vomiting affect 1 to 2% of infants younger than age 1 yr. 70% of those affected will have persistent feeding difficulties 4 to 6 years later Nutrition should be #1 priority in treatment programs/goals A well nourished child will make more gains in treatment than a child struggling to maintain his nutritional status Appropriate appetite manipulation comes from adequate weight, structured meals and snacks, scheduled liquid intake and modifications of supplemental feedings as approropriate Food allergy and Eosinophilic Disorders are on the rise Cervical auscultation is a great subjective method to evaluate the swallow during treatment sessions. Video oropharyngeal swallow studies and FEES are indicated to document swallow integrity

Feeding Team Clinic

A feeding team offers a variety of services (inpatient, out patient, clinic, short-term, longterm) utilizing a variety of specialists including, doctors, therapists, and psychologists to help children develop normal feeding skills, increase intake of food and drink and manage sensory / developmental problems.

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Food Chaining and Prechaining Programs

Copyright protected 2010

Cheri Fraker and Laura Walbert

Indications for referral

· · · · · · · · · · ·

Food refusal-turns away, spits out food. Extreme food selectivity-eats only a few foods or kinds of food. Gastrostomy or Nasogastric tube dependence Accepts little or no food by mouth. Behavioral problems related to mealtime crying, gagging, vomiting, throwing food. Poor hydration/fluid intake-doesn't drink enough fluids Poor intake of food leading to failure to thrive Significant respiratory Oral-motor problem-tactile defensiveness, gag, swallow, suck dysfunction. Delay in the development of self-feeding skills. Consistently missing 2 or more food groups

Urgent Assessment: Aspiration Failure to Thrive Severe Dysphagia

Non-urgent Assessment: Vomiting / Gastroesophageal reflux Aversive feeding habits Sensory issues Rumination

Core Team and Team Roles


Medical Evaluation: Pediatric Gastroenterologist, Primary Care Physician, Designated subspecialties (gastroenterologist, ENT)

Treatment Options:


· · · ·

Nutrition Evaluation: Pediatric Dietician Feeding Evaluation / Oral Motor and Swallowing: Pediatric Speech Language Pathologist Sensory Evaluation: Occupational Therapist Behavioral Evaluation: Behavioral Psychologist

Determine which option best meets the needs of the child and family Outpatient management, intensive outpatient, inpatient, consultative care and telemedicine Nutrition Therapy Sensory Processing Evaluation / Treatment and Behavior Management Parent Educations Programs and Support

The team completes assessment to develop a program to address the following: · · · · · · · ·

Determine treatment modality (inpatient, outpatient, clinic or consultative) Additional Medical Evaluation (VFSS, ph-probe, labs, diet modifications) Referrals VOSS/FEES assessments Diet change/Intake modifications Change in method of feeding (bottle/cup/spoon or thickening options) Positioning/Equipment Needs Pre or Food Chaining Program (as needed)

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Food Chaining and Prechaining Programs Copyright protected 2010 Cheri Fraker and Laura Walbert

Per Contemporary Peds 2005 regarding best practice for assessment and treatment of Pediatric Feeding Disorders:

Perform a "functional analysis" What is it about my child's foods that he or she likes? Emphasize attributes regarding temperature, texture, and flavor. Provide a pleasant mealtime atmosphere Find setting most conducive and non-distracting to meal time goals (calm, background music, etc.) Exposure to good role models who eat a wide variety of foods, includes parents, peers, siblings Avoid pressure situations or criticism Encouragement, positive and nurturing environment that can be sustained throughout treatment Avoid using foods for reward Offer a new food repeatedly (8-15 efforts) Food Chaining Emphasizes Learning About Food, Dole 5 a Day Program, Milk Matters website, video learning, Books/Songs, play food, pictures, gardening, cooking shows, shopping for food and hands-on experiences with food as tolerated for functional life skills. Choose food items wisely Repeated attempts may be necessary Be judicious and don't create battleground Provide information about the food Let child be involved in menu planning, etc.

Food Chaining Fits that Model of Care:

A systematic, child specific, home based treatment program Builds on successful eating experiences One part of a comprehensive treatment program Foods are used as desensitization tools in treatment Foods are selected based on the child's preferences, this reduces the risk of refusals Currently accepted foods, rejected foods and previously accepted foods are analyzed for patterns in taste / texture / consistency New food items are introduced that are very similar to foods / liquids in the core diet. Chains can be simple or extremely complex.

Food Chaining helps the Therapist to determine:

Core Diet: Foods child eats on a regular basis, consistently accepted. Patterns of Intake: Grazing, excessive liquid intake, food jags, refusals. Consistency of Intake: With par ent, in the home, extended family, at a restaurant, at school, with peers--is there any difference? Goal food items are selected that have similar features (taste texture temperature) to those in the child's core diet (consistently accepted foods) What Food to Select Next: Rating scales (1-10) are used weekly to: measure reaction to new foods, measure change in preferences over time to help select next targeted food items. How to Implement the Program: Parent implements the program at home under direction of the therapist. Feeding therapy continues at school.

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Food Chaining and Prechaining Programs Copyright protected 2010 Cheri Fraker and Laura Walbert

Precautionary Care: Pre-Chaining Programs

Contact us: Koke Mill Medical Center 217-862-0403 Springfield Illinois Read More about Pre-Chaining and Food Chaining on our blog

Pre-chaining programs are for children with severe challenges such as the non-oral feeder. These programs emphasize staying on track developmentally as much as possible throughout the critical periods of the first year of life. This form of treatment is primarily therapeutic tastes. Oral motor therapy emphasizes development of pre-cup, spoon and solid feeding skills often many months before liquid or food items are offered for the purpose of nutritional intake at meals.

Why Pre-chaining?

In 1937 Lorenz described "imprinting" behaviors, follow studies in mice have demonstrated a use it or lose it theory. We are born with excessive synaptic connections. Excess lasts during development. These synapses are preserved by patterned neuronal activity. This is part of the idea of critical periods for development as the brain does not show the same plasticity when the child is older.

Select the Correct Flow RateCritical Aspect of Treatment: OP Matthew J Peds 1991 Lau, et al, Journal of Pediatrics 1997 The effect of Flow Rate Restriction on Feeding

Food Chaining Includes Techniques to Make Food More Enjoyable for the Child

Flavor Mapping involves analyzing the child's preferences. Are there pat terns between favorite foods? Does the child seek strong or more bland flavor of food? What is the most com mon texture of food. Transitional Foods involves using favorite foods between bites of new food to encourage the child and help mask after taste of a new food item. Flavor Masking involves finding flavors that can be used on a variety of newer food items. Masking allows the child to experience a known accepted taste paired with the new food item. Masks are then faded as the child tolerates the targeted food items. (Example: Ranch Dressing). Other Recommended Readings Articles:

Arvedson, JC 1998. Management of Pediatric Dysphagia. Otolaryngology Clinics of North America. 31 (3): 453-76. Rudolph, C and DT Link, 2002. Feeding disorder in infants and children. Pediatric Clinic of North America. 49 (1): S116-S124. Ruark, JL, GH McCullough, R Peters and CA Moore, 2002. Bolus Consistency and Swallowing in Children and Adults. Dysphagia. 17: 24-33. Books: Glass R and L. Wolf. 1992. Feeding and Swallowing Disorders in Infancy. Tuscon: Therapy Skill Builders. Kedesky J. and K. Budd Childhood Feeding Disorders: Biobehavioral Assessment and Intervention. Baltimore: Paul H. Brookes Publishing Company. Kranowitz, CS 1998. The Out-of-Sync Child: Recognizing and Coping with Sensory Integration Dysfunction. New York: Pedigree.

Copyright protected 2010 Cheri Fraker and Laura Walbert

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Food Chaining and Prechaining Programs


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