Hungry, Hungry Hippos Picky eaters versus problem feeders SHAU JWO WONG, M.S., CCC-SLP JUNG-SHENG LEE, M.S., RD 32 nd Annual SPIN Conference
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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.
Paroche,M.M.,Front.Psychol.,25July2017|https://doi.org/10.3389/fpsyg.2017.01046
Exposinganinfantoryoungchildtoavarietyoffoodsatayoungageiseffectiveinpromotinglikingandintakeofbothexposedfoodsandothernewfoods.
Bymanipulatingthepresentationofvegetableswithinmealsanddays,demonstratedthatbothwithin-mealandbetween-mealvarietyenhance6-month-olds'acceptanceofanew(non-exposed)vegetable.
At6yearsofage,childrenwhohadbeenexposedtothehigh-varietyinterventionweremorewillingtotastenewvegetablesandlikedandconsumedmoreofthese.
Paroche,M.M.,Front.Psychol.,25July2017|https://doi.org/10.3389/fpsyg.2017.01046
Associativelearning
Flavor-flavorlearning:pairingofanewordislikedfoodwithafamiliarandlikedtaste.Flavor-nutrientlearning:pairedwithhigh-energydenseingredientstoenhancepost-ingestive satietysignals.Contamination:associationofanewfoodwithadislikedfood.Reward:associationofafoodwithpraise.
Paroche,M.M.,Front.Psychol.,25July2017|https://doi.org/10.3389/fpsyg.2017.01046
ObservationallearningObservationallearningfromadultmodelshasbeenshowntooccurfrom14monthsofage,whilepeermodelinghasbeenshowntobeeffectivefromabout2yearsofage.
Studiesshowthatchildren'sfoodrepertoiresaresimilartothoseoftheirfamiliesuntilatleast8yearsofage.
Parentalmodelingasadeterminantofchildren'slikingofvegetables.
Paroche,M.M.,Front.Psychol.,25July2017|https://doi.org/10.3389/fpsyg.2017.01046
CategorizationTheabilitytorecognizeafoodbyitsshapeandcolorisimportanttotoddlers.
Childrenpreferfoodstobepresentedseparatelyratherthancombinedwithotherfoodsorhiddeninsauce,andwhorejectfoodswhoseappearancedifferstoafamiliarpreparation.
Knowingthenameofafoodmightimpactonitsfamiliarity,andhenceonliking.
Paroche,M.M.,Front.Psychol.,25July2017|https://doi.org/10.3389/fpsyg.2017.01046
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.
Geng,L.TipsforPickyEaters.RetrievedMarch,162018,fromhttp://pursuitofresearch.org/tips-for-picky-eaters/
Strategies:Havechildpassfoodcontainertoanother.Havechildserveselforanotherfamilymemberwithautensil.Childhelpswithfoodpreparationusingutensils.Childstirswithautensilorotherfood(e.g.pretzelrod).Childmanipulatesouterwrapper.Childpushesonefoodwithanotherfood(makingatrain).Childputsonefoodintoanother(makingfaces,makingb-daycakeswithcandles).Childblowsonfoodtotipitoverormovealongtheplate/surface.
Geng,L.TipsforPickyEaters.RetrievedMarch,162018,fromhttp://pursuitofresearch.org/tips-for-picky-eaters/
Step3:Smell
Odorinroom.Odorattable.Odordirectlyinfrontofchild.Leansdownorpicksuptosmell.
Geng,L.TipsforPickyEaters.RetrievedMarch,162018,fromhttp://pursuitofresearch.org/tips-for-picky-eaters/
Strategies:Havechildinkitchenwhilefoodisbeingcooked.Helpspreparefoodswithutensilsorhands.Peeling,cutting,stirring.Wavingfoodinfrontofface(mimickingfans,airplanes,wiggleworms,“teachingphysicsoffood”).Bringingthefoodnearthenose(makemustaches,whiskers,beards,lipstick,clownnoses).Modelleaningdownandexaggeratingsmelling(“Hmmm…Ahhh”).
Geng,L.TipsforPickyEaters.RetrievedMarch,162018,fromhttp://pursuitofresearch.org/tips-for-picky-eaters/
Step4:Touch
Fingertips,fingerpadsWholehandChest,shoulderTopofheadChin,cheekNose,underneathnoseLipsTeethTipoftongue,fulltongue
Geng,L.TipsforPickyEaters.RetrievedMarch,162018,fromhttp://pursuitofresearch.org/tips-for-picky-eaters/
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
Geng,L.TipsforPickyEaters.RetrievedMarch,162018,fromhttp://pursuitofresearch.org/tips-for-picky-eaters/
Stickingthefoodtopartsofthebody(forehead,cheek,hand,nose,chin)scrapingwithhandsintotrash;throwingawayfoodsonthetableMakingfoodintoobjectsyoucanwear(earrings,glasses,necklace,bowsinhair,rings,etc.)Smashing,crunching,breaking,ripping,tearingwithhandsCookiecuttersGivefoodhugsTappingthefoodontheteethBalancingthefoodonyournoseHangingthefoodfromlowerlipHoldingfoodon/aboveyourupperlipwithnohandsSlidingdowntheslide/skislope(=yournose)
Geng,L.TipsforPickyEaters.RetrievedMarch,162018,fromhttp://pursuitofresearch.org/tips-for-picky-eaters/
Step5:TasteLickslips,tonguelicksfood,bitesoffpiece&spitsoutimmediately.
Bitespiece,holdsinmouthfor“X”seconds&spitsoutbites,chews“X”times&spitsout.
Chews,partiallyswallows,chews,swallowswithdrink, chewsandswallowsindependently.
Geng,L.TipsforPickyEaters.RetrievedMarch,162018,fromhttp://pursuitofresearch.org/tips-for-picky-eaters/
Strategies:BeingapuppywithaboneHoldingfoodinteeth,nohandsKissingfoodDrivingintomouthBlowingoutofmouthHoldinteeththenpushoutwithtongueLicking(“makeitwet,likeapuppydoes”,lickitlikeanice-creamcone)Listentothenoisesitmakeswhenbiting/crunching
Geng,L.TipsforPickyEaters.RetrievedMarch,162018,fromhttp://pursuitofresearch.org/tips-for-picky-eaters/
ImitatebrushingteethwithfoodMakingapoppingnoisepullingfoodsoutofmouthExaggeratedchewingwithnoiseandheadmovementLickingfoodfromfingersHoldbiteoffoodinbackteeth,spitoutBiteoffsmallpieces,thenspitoutquicklyTouchtotipoftonguefastPlayingpeek-a-booontongueCountingchews“1,2,3”everyonelicks,bitesetc.
Geng,L.TipsforPickyEaters.RetrievedMarch,162018,fromhttp://pursuitofresearch.org/tips-for-picky-eaters/
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
Mealsandsnackspattern.RetrievedMarch,162018,fromhttps://www.choosemyplate.gov/preschoolers-meal-and-snack-patterns
Feedingguidelines:4-8years
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
Mealsandsnackspattern.RetrievedMarch,162018,fromhttps://www.choosemyplate.gov/preschoolers-meal-and-snack-patterns
Mealsandsnackspattern.RetrievedMarch,162018,fromhttps://www.choosemyplate.gov/preschoolers-meal-and-snack-patterns
Mealsandsnackspattern.RetrievedMarch,162018,fromhttps://www.choosemyplate.gov/preschoolers-meal-and-snack-patterns
Feedingguidelines:9-13years
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
Mealsandsnackspattern.RetrievedMarch,162018,fromhttps://www.choosemyplate.gov/preschoolers-meal-and-snack-patterns
Mealsandsnackspattern.RetrievedMarch,162018,fromhttps://www.choosemyplate.gov/preschoolers-meal-and-snack-patterns
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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