Practical Strategies for Treating Children with Feeding Issues and Sensory Processing Disorders
Lisa van Gorder, OTR/L, CEISOccupational Therapist [email protected]
Why Children Do Not Eat
•Sensory Processing Issues
•Tone, decreased coordination or physical limitations
•Lack of good positioning, routines and reasonable portions
•Child fails to read hunger sensation appropriately
Where to Start
•What to assess:
–Child’s sensory system with regards to modulation vs. discrimination.
–List of tastes, textures and amounts
–Observe how child moves the bolus of food (observe different types of food)
–Observe how child moves through their environment, tone and strength.
–Positioning during all meals
–Review and observe eating routines
–Review family’s goals
What is Sensory Processing?
•The action of our nervous system in identifying and integrating information from our 5 senses.
•When an individual is unable to perform developmentally appropriate tasks due to their inability to integrate input from the environment they have a Sensory Processing Disorder.
•The functional fluctuation in response to changing environmental conditions.
•What you see overall:
–Tactile or auditory defensive
–Constantly in motion or unable to become motivated
–Inability to focus on tasks
–Issues with affect
–fine one minute and crying the next or the same affect all the time
–Increases verbalization and participation after movement activities
•What you see with feeding:
–Defensiveness to certain tastes or textures
–Defensiveness to being fed by someone else
–Craving only one type of food group
–Very limited variety of foods
–Foods requiring a specific type of presentation
–Decrease in volume of food
–Stuffing and/or swallowing food whole
•Idea of therapy is to feed the sensory system so that the child learns to identify their own needs and eventually their system can regulate independently.
–Treatment assist the child to find a regulated state so that they can focus on developmental milestones.
–Deep touch/proprioceptive input/heavy work
–Consistent or rhythmic proprioceptive input
–Reduction of visual or auditory stimulation–Slow paced/rhythmic music
–Simple language and preparation of transitions
–Using routines throughout the day and during mealtimes
–Changing the position of the semicircular canals through rotational movement
–Multiple visual or auditory stimulation
–Fast paced music
–Complex language–Lack of clear expectations
•Job is to sandwich vestibular with proprioceptive input to modulate the system before the child sits down to eat.
•Try to always start your sessions with this cycle
–Once you have given sufficient input then engage child in a focused task that involves some textured activity.
–This can either be done in-between movement activities or at the very end of a session (i.e. with a snack)
Home Adaptations for Modulation
•Area with pillows, bean bags, old crib mattresses, foam chair/sleeper, heavy blankets
•Small one person tent
•Large bucket of rice and beans (for sitting), laundry basket/plastic box/large bucket, soda bottles of water or sand
•Nylon or other stretchy material
•Tunnel, yoga sized ball
•Tape or CD player for calming music (50-70 beat rhythm)
•Chin-up bar with nylon swing
Tactile Issues and Modulation
•When you have modulation paired with feeding you have some level of tactile issues.
–Goal is to start with the least offensive texture and work forward
Tactile Play and Modulation
•Goal is to play with different textures –this also includes textured toys made of different materials
•Placing previous textures on any toy –shape sorter, cars, etc..
•Bumble ball, massager, vibrating doodle pen, vibrating snake, vibrating toys, jiggler
•Difficulty with the ability to qualify sensations (detecting similarities and differences between sensations)
–Difficulty with bilateral integration
–Poor timing and sequencing
–Poor body awareness
–Some gravitational insecurities
–Ocular challenges (poor visual scanning)
•What you would see with feeding
–Stuffing or swallowing food whole
–Fatigue and/or poor tongue coordination
–Difficulty with picking up and manipulating pieces of food
–Poor timing and sequencing with utensils, straw or cup
–Poor oral motor abilities
–Poor ability to scan tray or table for items
•You do the same movements/input as with modulation but you are adding additional focused activities.
–Challenges to gravitational issues
–Body awareness activities
–Timing and sequencing
Referral– has difficulty gaining weight, possible fine motor issues, nutrition is in the home, poor variety of tastes and textures.
Discovery-history of sever reflux (currently untreated), history of poor intake past bottle, refusal of puree, screams when in high chair more then 5 minutes, requires water to be present at every meal (water keeps him in the high chair longer), becomes upset with puree or mash on his tray, decreased body awareness, tactile issues, poor chew, displays modulation and discrimination issues.
Referral –breathing issues (tracheotomy–suction approximately every 5 –10 minutes), gastric button, moderate hearing loss, sever low tone, decrease in motor planning,,
Discovery-history of sever reflux, history of poor intake with bottle, decreased body awareness, poor coordination, visual motor and visual perceptual issues, tactile defensive, poor oral motor, gravitational issues, auditory defensive, displays modulation and discrimination issues.
Food as Therapy
•Eating the food is not the focus–experimentation and interaction in a safe environment becomes the focus
–Children require an outward-inward approach to dealing with feeding.
•If the child is not comfortable with it on their hands or face they will rarely increase their interactions with food. This includes the child being comfortable with textures touching their face, hands and body.
•Tastes and Textures
–You have the ability to change the taste or texture of the food.
•Make sure when you are increasing texture you do it in a measurable way
•Food Texture Spectrum
–soft mechanicals and cubes
–meltable hard solids
Food: Tastes and Textures
–Peas, asparagus, salsa, anything with ranch dressing on it, pasta with sauces
•No carrots, bananas, oatmeal, yogurt, etc..
–Yogurt, mashed foods, most fruits, some crackers, stuffs mouth
•No meats, toasts, pasta, everything must be cut up
Grading Food Tastes
•Grading food tastes
–In addition to concept of salt, sweet and sour foods tend to fall into groups of having either a mild or high tastes sensation.
•Example mild tastes: oatmeal, rice, avocado
•Example high tastes: asparagus, hummus, salsa
•Children who need a better sense of what they are eating need high taste foods.
•Add baking spices to foods.
•Give the child the opportunity to try “adult” tastes.
•Foods that have mixed tastes.
Grading Food Textures
Referral– has difficulty chewing, poor variety of tastes and textures, significant low tone.
Discovery–Only wants to eat puree, mash or dissolvable foods, decreased body awareness and motor planning, tactile issues, poor chew, displays discrimination issues.
Tools for Eating
–Same as with the bottle there is no such thing as the “perfect” nipple. Many times it is what works best for the child.
–Larger base so the child has ability to stabilize.
–For most children a nipple with a longer teat is easier.
–Never cut a nipple
–No such thing as the “perfect” bottle. There are some specialty bottles for children with nursing issues.
–Some Specialty bottles:
•Haberman™ Feeder–For babies with a weak sucks, also has a one-way valve and slit to control the amount a baby gets so they do not become over whelmed.
•Hazelbaker™ Finger Feeder–feeding method that provides the touch of human skin while enabling babies to learn to suck
•Baby teething Feeder
–Gives the child the opportunity to practice biting and chewing food without pieces breaking off.
–Thick or large handles
•Note: an infant spoon is smaller than a toddler spoon but the toddler
•When feeding with spoon:
–Give the child the opportunity to use their lips to remove the food from the spoon.
–Can use verbal cue “lips” with touch cue with spoon.
–Can use the side of the spoon at the corners of the child’s mouth.
•Open cups or straws should be the first choice after breastfeeding or bottles.
–Strategies for open cup:
•Flexi-cut cup (nosie cup)
–Strategies for Straws
•Rubbermaid Kids Juice Boxes
•Don’t forget –if the child is able, let him/her hold the item and investigate it first. Start by touching the child’s arm, hand, and cheeks before moving on to the child’s lips or mouth.
•The child should be sitting upright
•Hips/Knees and Feet at 90 degree angle
•The tray should be at waist height so that the child’s elbows can rest on it.
•Feet should always be supported for better abdominal control
•Strategies for good positioning:
–Use towels on both sides of their body and thighs.
–Place towels or foam padding under them.
–Use soft stacking blocks, cardboard building blocks, towels or other items that can be adhered to the high chair with packing or duct tape.
•Strategies to increase volume
–Do not to fill a large bowl with food
•It overwhelms the child.
•Give the child the opportunity to ask for more food.
•Be quiet and wait for child to interact with food.
•On average* –toddlers should only be drinking between 24 –32 oz of liquid a day.
•Just like play meals should have a beginning, middle and end
–Children should only be expected to sit for 15-20 minutes therefore prep is a must with meals
–For older children family style meals gives them exposure to all tastes and textures
•Establish a schedule
–Be aware children usually eat 1 ½ to 2 good meals/day
–Children tend to eat less as the day continues.
–Eat with the child at the chair and/or table the child is using
–this is how they learn to eat.
–Keep distractions to a minimum such as TV, toys, animals, other siblings.
•Younger children should be positioned so that at least one hand is on the bottle. For older children all meals should occur while the child is sitting.
–When a child does not engage in the meal time processes they fail to become invested in eating.
–For older children the movement becomes the required distraction.
–This should include snack times if sitting is a problem.
–Families must be consistent with expectations. With inconsistency the child becomes confused and frustrated.
•Strategies to increasing sitting time:
–If a child refuses to sit for any part of the meal then start with them only sitting for 1 minute.
–When they leave the table the food does not follow them.
–If the child is only able to sit for a portion of the meal add a minute to their usual time limit.
–For some children having a timer present helps.
–Have the child “wash” their hands in a bowl of water and assist with cleaning up their tray to increase time sitting.
–Remember: the goal is to establish expectations along with a routine.
List of Modulation Activities
•Deep Pressure Activities/Items
Swaddling, Rub down with lotion, Bear hugs, steamroller games with ball or stuffed animal, large body pillows, heavy quilts or blankets, brisk towel rub, deep lotion rub, log rolls in a blanket and wriggling out, weighted 1 pound ankle or wrist weights, weighted backpack or satchel, body sox, nylon wrap, pressure vest, weighted vest –blanket –toys, sitting in a box of beans that cover up to feet/ankle, Wilbarger Deep Pressure Protocol
•Proprioceptive/Heavy Play Activities
Pushing/pulling laundry basket/bucket with soda bottles filled with sand or heavy items with which to build, tug-o-war, bouncing on ball with a slow rhythm, bouncing on a ball on a trampoline, hippity hop ball, Rody Pony, carrying buckets of sand from a sandbox, carrying in bags of groceries, carrying bag/bucket of bean bags
•Linear Vestibular Movement
Tunnels, rocking horse, scooter board activities, swings (platform, playground, bolster, net, etc…), hammock, see-saw, slides, laying over a ball, laying over the outside of a Tumble Form tube, climbing up and then down inside a tunnel.
•Rotary Vestibular Movements
Sit-n-spin, merry go round, swings that rotate, trampolines, log rolls down a ramp, rolling inside a tumble form tube.
List of Tactile Play Ideas
•Koosh/spiny balls, tactile books/puzzles, aquarium or river rocks, leaves/acorns, pinecones/twigs, play dough, theraputty, silly putty, non-hardening clay, bean/rice/birdseed/corn kernels bins, cereal, dry oats/oatmeal, raw pasta, cotton balls/pom poms, packing peanuts, basket grass, sand, non-hardening sand, flour, dirt, potting soil, non-hardening foam, snow, cornstarch and water (oobleck), bubbles, silly foam, shaving cream, cooked pasta, bread dough, wet pumpkin seeds, finger-paint, tub paints, mud
Tactile Play with Food
•Strategies for interactions with food
–Let them help you make something and then eat it latter.
•This can be something that they may eat at a latter date, or something for someone else so they are not required to eat it
–Paper plate with pictures drawn on them with a sharpie
•Use puddings, sauces, veggies, fruits, etc.. To decorate the plate/picture as an art project
•Use an easel and paper and “paint” with the food.
•Make a “town” of food
–Example: the road is Pirate Booty with a sauce/condiment mixed with it as cement. The Bananas are people who ride in a bell pepper boat with raisin’s as hats.
•Recreate a book
–Example: Make pictures out of food items that go with the book
•Make a “silly” pizza
–Use baloney or lettuce for the dough, different
condiments for the sauce and veggies and fruits for the toppings.
•Go to the “mountains” to find items
–Make mounds of spaghetti or potatoes and have trucks or plastic characters walk, drive and play in the mix.
•Swing, bounce or jump with the child in between making different parts of the picture (i.e. eyes –swing –nose and mouth –swing)
•Always remember to grade the child’s interaction the food.
–The idea is to give them the opportunity to be successful with what they are doing at that moment.
•Children instinctively do not like foods that are different or look new.
List of Discrimination Activities
•Toys/Activities that encourage eye hand, scanning and ocular motor work:
–Magnetic dart board, flannel board or glove with velcro balls, bean bag and targets, colored/shaped mats for making a jumping or walking road, swinging while throwing or grabbing an object, scooter board play, balancing on one foot with the other on a cone, kid’s yoga, infinity walk, pin-the-tail on the animal, scanning room for plastic colored Easter eggs, contrasting contact paper on tray or table top, bowls with contrasting color for food, bringing visual item so that it starts at an arm’s distance
•Toys/Activities that encourage bilateral work:
–Mr. Potato Head, Bead Snake or Lacing City Blocks, Young Builders Play Cubes, Legos, balloon pump, Play Doh’s Confetti Maker –EZ molder –Squeeze n’ Popper, pop tubes, electronic sound blocks, single bubble containers, rolling play dough, washing hands with soap
Books on SPD and Activities
•Heller, S. (2003) Too Loud, Too Bright, Too Fast, Too Tight: What to Do If You Are Sensory Defensive in an Over stimulating World.
•KranowitzC. S. (1998), The Out-of-Sync Child: Recognizing and Coping with Sensory Integration Dysfunction. Perigee,
•Kranowitz, C.S. (2003), The Out-of Sync Child Has Fun: Activities for Kids with Sensory IntergrationDysfunction. Perigee,
•Smith, K. A, Gouze, K. R. (2004) The Sensory-Sensitive Child: Practical Solutions for Out-of-Bound Behavior
Books on Feeding
•Klein, Marsha D., & Delaney, Tracy A., Feeding and Nutrition for the child with Special Needs: Handouts for parents. Therapy Skill Builders a division of The Psychological Corporation. Catalog No. 4332
•Satter, Ellyn, How to Get your Kid to Eat…but not too much. Bull Publishing Company, Boulder, Co. 1987
•Morris,Suzanne E., &KleinMarsha D.,Pre-Feeding Skills: A Comprehensive Resource for Mealtime Development. 2000 2nd Edition,
•Wolf, L & Glass, R., Feeding and Swallowing Disorder in infancy, Assessment and management.
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