Deborah Howell (Host): Parenthood is challenging enough, so what happens when your child has feeding difficulties? I'm Deborah Howell, and our guest today is Lori Henderson, a speech and language pathologist at High Point Therapy at the Women's Hospital. Today, we'll learn some strategies about how to help our children with feeding difficulties. Welcome, Lori.

Lori Henderson: Hi!

Host: So glad you could join us today.

Lori Henderson: Glad to be here.

Host: So, what if my child has trouble gaining weight or has been diagnosed with failure to thrive?

Lori Henderson: So, I think if parents can get really scared when they hear this in the pediatrician's office, the first thing to do is to not panic. But the best thing would be to get an appointment with a feeding therapist, a speech therapist, or an OT, an occupational therapist, as well as a dietitian. Dietitian's always a really important piece when we're talking about nutrition, with these kiddos. So, the first thing would be to schedule that appointment. And what they'll basically do is just look at growth charts, look at what their diet is like, and kind of go from there as far as what might need to change as far as helping them gain weight.

Host: Understood. So, my child only eats foods prepared in a certain way. It has to be exactly the same every time. Is there any way to break this cycle?

Lori Henderson: Sometimes this can take a while to break the cycle. What we do in therapy is very subtle things initially and just gradually work towards trying those different foods, different colors of foods, different brands of foods. And we might try, say, they eat yogurt, Yoplait yogurt, out of the same container. The first time we might try to eat Yoplait yogurt from a bowl that's that same color. And then, we might try to eat it out of a divided plate with other foods and just kind of go from there.

Host: Sure. And try to make it fun in some way, right?

Lori Henderson: Yes.

Host: Put little googly eyes on, you know, just whatever you can do as a parent, cut your sandwiches into little shapes, you know, just...

Lori Henderson: Yes, yes.

Host: Entertain them.

Lori Henderson: Well, that's a big part of it, is making it fun. We don't ever want them to be aversive to foods and we want to make feeding fun. Like you said, doing fun, different things with them. Some of the smaller kids that are really aversive touching the food, you could put it on their tray, put it on their high chair, and let them just kind of play with it a little bit. Make little things out of it. You can make little crafts out of it sometimes. Sometimes I'll make a little fish scene with Goldfish and blue Jell-O, you know, like swimming, and just kind of the different textures to touch and feel.

Host: Right, right. And there's so much online that you can go to for ideas.

Lori Henderson: Yes.

Host: Now, a lot of children are overly selective and brand-sensitive. Do you have any solutions for this?

Lori Henderson: This is kind of similar to the previous question. One of the easiest things you can do is kind of mixing them together. So if there's a certain yogurt brand, I use the yogurt brand as an example, or a pudding brand or chicken nuggets is always a really big one. Chicken nuggets, mac and cheese, I have a lot of kiddos that only eat chicken nuggets like Tyson chicken nuggets or only chicken fries. So, you could do what we call food chaining and just slightly, slightly change it a little bit each time. And then, you can mix them together, if it's a drink, make it 75% the one they like, and 25% they want, and kind of mix it until you can gradually make it all a different thing. We do this a lot when we're transitioning kids from formula to milk. It's 75% formula, 25% milk, and then you slowly increase the percent of milk each time as you're going. Also if they like it temperature-specific, if they like something warm, a lot of kiddos like their formula warm. So, we warm the milk first and then slightly little bit less each time until it gets colder.

Host: Yeah. My kid, "Hot milk, mommy. Hot milk." I just remember that, those days. So, what happens when a child is unable to chew or swallow age-appropriate foods?

Lori Henderson: I feel like there's a lot of kiddos out there that if someone isn't a trained feeding therapist or a therapist who works with feeding kiddos, you don't really notice it. There's a lot of kids that just swallow their foods whole and don't chew very well. And they may be picky eaters, but it turns out that they don't really chew really well either. And it can get really dangerous because they could choke really easily.

So in therapy, there's kind of two different ways that our particular clinic goes about it. You can do what we call texture grading with purees when they're littler kiddos and we'll start with smooth puree and we'll gradually work up to whole foods. So, it's like smooth, then it's fine gritty, then gritty. So, there's a whole progression up to whole cut up foods. So, we'll just very slightly change the puree until they become stronger, better chewers. And then, at the same time, or another technique you can try, what we do is-- this is always really interesting to show parents. We chew in mesh, which is like tulle, like your wedding tulle if you think of it. And we have small whole, like very tiny mesh, and then we have bigger mesh and we take small pieces of it and put a little piece of food in there. And we hold it to like where their molars would be, and we have them chew as we're holding that, so just the taste comes out and a very small amount comes out as they are chewing it. We can teach them to chew that way.

We also do different exercises with their tongues, because that's a big part of chewing when you think about it, is with your tongue and we want them to have like what we call rotary chew, kind of around, and more kids have like a phasic really fast chew or more like munching sort of wallowing it around kind of chew and not vertical. So, we work to do those exercises and those things, the chewing with the mesh to help them progress to chewing correctly so they're not swallowing foods whole.

Host: This is just fascinating. I didn't know about the mesh or that there were so many different ways to chew. Who knew?

Lori Henderson: Yeah.

Host: All right. Now, some children gag or throw up at the smell, sight, touch, or taste of certain foods. What does this stem from?

Lori Henderson: That could definitely be from a lot of different things. I feel like the biggest thing, and you're hearing about it more and more is sensory processing. And some kids have very, very severe sensitivities to all kinds of textures temperatures when it comes to food, just touching it or when it's in their mouth. I've had kids be so extreme to all I'm doing is preparing the food next to them and kind of stirring the bowl and they'll start gagging. So, those are those things that in therapy we work towards what we call desensitizing them by doing like the different exercises. And then, we may even have to try to go all the way back to just a dry spoon, just do dry spoon trials. And these are things that we teach the parents in therapy, and they can take it home and be using them at home as well. And it sounds so simple and so slow, but we use a dry spoon, and we'll do several trials of dry spoons and getting them just used to the spoons. And then, we'll gradually work up to just dips of taste or we can even start with water or thickened water, and then gradually work up to more on the spoon for them to tolerate it.

At the same time, doing those chewing progression with the mesh and helping them chew as well and helping them get different kind of textures in their mouth. And we also have different oral motor tools that we use that they can chew on or some of them have vibration to get them used to that in their mouth.

Host: That's fascinating. Now, I've heard more than one mom say, you know, my child never seems hungry. Is this fairly common and is it something to be concerned about?

Lori Henderson: We do see this a lot. As I mentioned, the dietician is always a really important piece as well when it comes to feeding. And I feel like in some case it may be as simple as they may be drinking an excessive amount of milk a day, which when they're little and they're so used to just drinking formula or breast milk for a year and they love it. Some of those kiddos get over 20 ounces of milk a day. And so, they just fill up on milk and they're not hungry. So, we work towards like decreasing that. So, they're more hungry for the other foods with a variety of nutrition.

Host: That makes perfect sense. Now, do you have any tips for parents whose children have excessively short or really, really long mealtimes?

Lori Henderson: One of the things that we do that we try to teach in therapy too, we use a food rotation. We call it like our food circle with the little ones. We're like, "Eat your circle." We have like three or four foods in a circle, and we use a timer. The biggest piece in trying to get them to eat longer or shorter, we use a timer. Sometimes that can be a little bit hard for the little bitty ones. But it is fascinating how quick they catch onto the timer. So, we have a visual timer with a red, yellow, and green light. And we set it for various times, depending on the age of the child and that particular child. They catch on really quick to the timer and, you know, they may be eating for five minutes and try to get up from their seat if it's an older kiddo, try to fuss to get out of the high chair. But I always point to the timer, like, "Oh, our timer's still on. Our timer hasn't beeped yet." And then, the older kiddos, they catch on to that, and they really dawdle throughout this, and they like to dawdle with their parents. But that's where the timer is nice, because the older ones really understand that they know, if it stops, that it's even longer. So, sometimes, we'll even be like, "Oh, we can stop the timer," and then it'll be even longer, so then they'll know, "Oh, we got to keep going." And then, it also encourages the kiddos that may be a little bit pickier or maybe kind of getting full that the light's yellow like, "Oh, we're almost done," so it signals them like, "Oh, we're almost done." So, we don't have to go very much longer. And in therapy and at home, we always encourage the parents, that they can keep eating after the timer if they want to. They don't have to keep going past the timer. I don't like to say like, "Oh, when the timer is done, you have to take all the food away." You don't have to do that.

Some of those kiddos, we do work on trying to eat in the rotation a little bit quicker because they like to dawdle when they eat. So, another thing that we pull into therapy and that we also tell them to pull in at home is reinforcements. This could be anything simple as like bubbles or little toys or simple little games. Depending on the parent's discretion, maybe they can watch a little music. The kids love Cocomelon these days and those little cute little songs, they can use those. And this just is another little piece that goes in with the reinforcement. We also use this as well during therapy for encouragement. So, they get to take a turn in a game after they eat in their circle. They take a bite of each one of their foods and then they get to take a turn or they take a bite of each one of their foods. And then, they get to watch a few seconds of the video. And then, we start and stop it as a reinforcement. We do what we call continuous reinforcement, where we just keep on playing, or keep on watching something, or keep playing the bubbles. Or we do one-to-one reinforcement where we stop and start.

Host: Okay. Got it. So, what if my child is unable to eat with others?

Lori Henderson: So this is something that we see happen with kiddos. They may be great one on one with a therapist. And they have trouble eating with others more. Some kiddos you'll see at school, all they want to do is play or at daycare, they'll just want to play with their buddies next to them and they won't want to eat.

So during therapy, sometimes we combine two or three kiddos that may be at therapy at the same time, or maybe one of them may be coming, one of them may be going, and we schedule it to where we can practice part of the session where they're both eating together, and we can have several therapy sessions like that to where they're used to someone their age or similar to their age sitting with them. And sometimes we'll even grab one of our techs that are so great that keep our clinic nice and clean and going. And they'll help us and come in and hang out with us and just talk with the kiddo, so they have someone that they're not familiar with eating next to them.

Host: What an excellent strategy. I got to say, Lori, you are someone who has an incredible job and are doing an incredible job at it. Is there anything else you'd like to add to our conversation?

Lori Henderson: Just that I think a lot of parents take feeding for granted that have great feeders. And the parents that do have the kiddos that have issues with eating, to not get discouraged. And I think a lot of people don't know that there is feeding therapy out there. A lot of people, when I say what I do, I have to explain what I do because they didn't know that it existed. And a lot of people with older kiddos think, "Oh gosh, I wish I knew that was something that I could have done before." A lot of people don't realize there's different things you can do even from tiny little babies that are just leaving the NICU, there's strategies for them for eating all the way up until older kiddos that are really, really picky. There's different strategies to do for them as well. So, I think people just don't realize that there's tools out there and that early intervention is key, especially for those picky eaters or for those poor chewers and to get those skills to practice and develop those skills so they can be great eaters when they get older.

Host: There's help out there. Well, it's been such a pleasure, Lori. Thank you so much for being with us today to talk about feeding difficulties. We really appreciate you being here.

Lori Henderson: Oh, you're welcome. It was great to be here.

Host: And if you have concerns about your child's feeding, please know that you're not alone. For more info, go to www.deaconess.com/highpoint. And that wraps up this episode of the podcast series from Deaconess the Women's Hospital, a place for all your life. Please remember to subscribe, rate, and review this podcast and all the other Deaconess Women Hospital podcasts. For more health tips and updates, follow us on your social channels. I'm Deborah Howell. Thank you for listening and have yourself a great day.