Workshop - more than picky eaters

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MORE THAN PICKY EATERS: FEEDING PROBLEMS IN CHILDREN WITH DISABILITIES Cindy Zuk Lowana Lee Olaf Kraus de Camargo on behalf of the EFCT (Eating and Feeding Consult Team) Photo by Lance Gross

Transcript of Workshop - more than picky eaters

MORE THAN PICKY EATERS: FEEDING PROBLEMS IN CHILDREN WITH

DISABILITIES

Cindy Zuk

Lowana Lee

Olaf Kraus de Camargo

on behalf of the EFCT (Eating and Feeding

Consult Team)

Photo by Lance Gross

WHAT HAPPENS INSIDE THE MOUTH?

OUR SENSES ARE THE CONNECTION TO THE WORLD

BRAIN INTERACTION

WORLD

Information

Hypotheses/Theories Physical world

OUR SENSES ALSO INFORM US ABOUT OUR BODY AND OUR BRAIN HELPS US UNDERSTAND WHAT IS GOING ON

BRAIN INTERACTION BODY

HTTPS://WWW.FEEDINGMATTERS.ORG

MORE FACTS ABOUT EATING AND FEEDING PROBLEMS:

WHY WE WERE FOUNDED

A Feeding committee formed in Spring 2008 with

representation from the various teams that see only

pediatric outpatients with various developmental delays.

Prevalence of complex feeding difficulties reviewed

varied 20% to 100% from each service.

The children with “mechanical” difficulties are seen

through the Feeding and Swallowing Team and receive

videofluoroscopy and pH probes etc.

It was found that there was a gap in service for the

children who had behavioural or sensory feeding

difficulties.

RESULTS FROM THE COMMITTEE

Several themes emerged from the committee

related to the gaps in service:

Multi-disciplinary approach needed

Expertise needed to address both the behavioural and

sensory components of the feeding issues

Large variability in the types of cases seen

Physician support needed

THE PROJECT

Due to the need the Eating and Feeding Consult Team (EFCT) was

formed in January 2010

Pilot would run for 1 year (now ongoing)

Team meets once a month for 1.5 hours

Referring clinician meets with the team and recommendations are

provided

Up to 2 cases are discussed, with the opportunity to return in the

future to review recommendations and discuss any changes

WHO’S ON THE TEAM

Allison Poole - Behaviour Therapist

Olaf Kraus de Camargo - Dev. Paediatrician

Dana Lehman - Early Childhood Resource Spec.

Lowana Lee - Occupational Therapist

Carole Kaufhold - Parent Therapist

Jamie Smith - Social Worker

Cindy Zuk - Speech-Language Pathologist

It was due to the team that we were able to recognize

conditions beyond the main complaint and make appropriate

recommendations:

Physician: able to look at medications, what was given,

should it be increased, what other types of medication

Early Childhood Resource Specialist: looks at development,

behaviour and supporting families in community programs

Behaviour Therapist: looks at behaviour and strategies to

implement

BENEFITS OF A MULTIDISCIPLINARY TEAM

THE PROJECT EXPANDS

In 2016 we added a clinic where the child and

their parents could come in for a “table-side”

assessment with the team.

REFERRALS

Internal from clinicians at RJCHC

External by medical referral to developmental

paediatrics

Referral form (clinician consult)

Intake Eating & Feeding Routines (clinic)

CASES SEEN BY DIAGNOSIS

30 are diagnosed with Autism Spectrum Disorder

10 have Delays in Development (i.e. Fragile X,

Down Syndrome)

6 had no official diagnosis

4 Mental health diagnosis (OCD, ADHD)

1 had a mitochondrial disorder

CONCERNS

43 cases listed the primary concern as limited intake of food or types of

food:

eats no fruits or veggies often reported

eats only a certain brand or food or type (only french fries from

McDonalds)

eats mostly soft foods

drinks only Pediasure® ️or only juice or only water etc.

drinks only from a particular container (i.e. bottle or a particular cup or

only from a certain juice box)

SECONDARY CONCERNS

6 reported problems with constipation

5 were G-tube fed

4 reported difficulties with chewing

11 reported difficulties with gagging/choking

1 was anemic

1 has ongoing throat infections and 1 had chronic congestion

2 reported frequent vomiting after eating

2 reported anxiety

Of those that reported “other” as their primary concern

2 ruminated

1 improved while on wait list

2 had PICA

1 therapist did not want to complete referral

RECOMMENDATIONS MADE:

52 Referrals to Professionals: (Physicians, Parental supports/workshops, Dietician)

15 Suggested Medications: (appetite suppressants/ stimulants, constipation, reflux) 39 Environmental Changes: (use visuals for cueing, change utensils, help with meal prep) 30 Changes to Foods: (food chaining, adding calories, increase protein) 15 Changes to Liquids: (add water to drinks, increase/reduce intake)

18 Behavioural Changes: (increase positive/ decrease negative reinforcement, stop force feeding)

CASE EXAMPLE

Darryl has always been very rigid with eating

Darryl was consuming 4-8 ounces of Pediasure Plus 3

times/day. These feeds typically took 1-2 hours each

Set routines must occur (to have his bottle, he must be

lying down in bed with the lights off, the music and fan on

etc.)

History of refusing to eat and not showing signs of hunger

or thirst

Regularly vomited

Regularly gagged when food was prepared, including

when the microwave beeped or fridge was opened

RECOMMENDATIONS:

Rule out underlying medical conditions: thyroid test

Clinician to gather more information about his vomiting to make sure

it is not cyclical

Start introducing new foods using the same consistency of those he

is already eating

Make changes slow and gradual- increasing first variety and then

texture

Change his Pediasure from the bottle to the sippy cup, introduce

other liquids later

CASE EXAMPLE

Narelle

9 years 1 month

All food needs to be blended, smooth puree without chunks

Drinking thickened fluids from spoon- able to take some sips from a straw, barely from a cup.

Does not seem to have a sense of smell

Very sensitive in her oral cavity- brushing her teeth is also a struggle.

Poor oral motor skills

RECOMMENDATIONS

Feeding needs to be safe and not struggle to get food down

Changes to be made gradually, use preferred taste, at the same time not to jeopardize nutritional intake.

Oral motor: hold spoon straight so she can use her lips actively to clean food off spoon.

Food thicker consistency, keep food separate

Use mashed soft food

Fluids Juice thickened, smoothies

Use cup- small amounts in small cups (shot glass size)

Work on straws and cups.

PICKY EATERS VS PROBLEM EATERS (ADAPTED FROM STAR CENTER)

PICKY EATERS PROBLEM EATERS

Decreased range and limited variety, has 30

or more foods in their food repertoire

Restricted range or food variety, usually eats

less than 20 foods

Food jagging but resume eating the food after

a few weeks break

Foods jagging and food not eaten again,

resulting in a further decrease of # of foods

eaten

Eat at least one food from most textural

groups (e.g. purees, proteins, fruits or

meltable foods)

Refuses entire categories of food textures or

nutrition groups

Tolerate new foods on their plate – would

touch or taste food

Cries, screams & tantrums when new foods

are presented, complete refusal

Often eat a different set of foods at mealtime;

often eats together with family

Almost always eat a different set of foods, eat

at a different time or place apart from family

Ability to learn to eat new food takes on some

steps to learn

Much harder to learn to eat new foods, takes

many more steps to learn

THE SOS APPROACH

Sensory Oral Sequential Feeding technique

Evidence-based

OTs and S-LPs at CDRP had been trained in this technique

Using a sequential approach in advancing the steps

Food chaining (colors, shapes, textures, taste) also used to expand the repertoire of food tolerated

GROUP CHARACTERISTICS

Visual exposure and tolerance are part of step 1 in eating

Using the sensory organs to explore the new foods (look, smell, touch, taste)

Giving the child permission to explore and to have control when to put into mouth

Using appropriate language to foster positive approach to food exploration and when trying new food

Modelling, talk through

Peers – monkeys see, monkeys do