Feeding Difficulties

By Angela Kurdzhukyan MS, OTR/L

Have you ever wondered why your toddler refuses to eat certain foods? Or why they have a limited repertoire of food? Feeding difficulties can arise due to many different reasons. Below are few of the reasons a child may have problems with feeding or be seen as a “picky eater”. 

Sensory Processing Disorder: Children who have difficulty with sensory processing may find feeding difficult due to the qualities of certain foods or because it is hard for their body to recognize that there is food inside the mouth. Children may be avoidant of certain foods because of their color, texture, or even temperature. Difficulty with sensory awareness can also lead to pocketing of food/liquids and/or drooling. 

• What you can do: 
  1. Provide cold/sour foods to increase awareness of the food in their mouth
  2. Provide sensory input to the mouth prior to feeding (e.g. Nuk brush, Z-vibe)
  3. Provide small portions at a time to prevent choking
  4. Introduce new smells and tastes gradually 
  5. Start with new foods that are similar to the child’s preferred foods (e.g. if your child enjoys eating potato’s, you can try sweet potatoes which are similar in color and can be prepared the same way)
  6. Introduce new foods at the beginning of meals, as eating new foods when the stomach is empty limits the likelihood that gagging will lead to vomiting 
• Healthcare professional: Occupational therapists are professionals trained to work with individuals with sensory processing disorder. 

Oral motor weakness: Feeding involves using oral motor skills. Just to name a few skills, a child will need to know how to properly close the lips, chew food, make a bolus (ball of food), and incorporate tongue lateralization (move the tongue side to side). All these skills require good coordination and control of their mouth, jaw, tongue, lips, and cheeks. Additionally, the thickness of foods and liquids determines how difficult that item will be to manipulate in the mouth. For foods, pureed are the easiest to eat followed by mashed, soft dissolvables, chopped, and regular foods. For liquids, thinner liquids such as water are harder to control compared to thicker liquids like nectar/honey consistencies. 

• What you can do: 
  1. Work on oral motor skills
     • Puckering lip exercise such as blowing a kiss/bubbles
     • Tongue movements by have the child hold a lollipop/popsicle to the left and right corners of the lip and trying to lick it
     • Encourage lip closure by providing input (e.g. Z-vibe) or using your own hands to control their jaw
       • Correct positioning of the hand when assisting in feeding: Index finger under lip, middle finger under jaw, thumb on lateral mandible
     • Provide opportunities for strengthening structures such as chewing without the demand of having to swallow (e.g. resistive chew toys and mesh feeding bags can allow the child to practice chewing without risk for choking)   
  2. Present difficult foods/liquids first as this is when the child is less fatigued
  3. Explore foods with an even consistency, uniform texture, and thicker liquids
  4. Avoid foods with skins and multiple textures, foods that are sticky, tough, stringy, and hard, and thin liquids 
• Healthcare professional: Occupational therapists and Speech Language Pathologists are educated to work with individuals with oral motor weakness. 

Difficulty with swallowing: Food travels in 4 different phases. The oral preparatory, oral, pharyngeal, and esophageal phases. The first phase, oral preparatory, involves using oral manipulation skills to create a bolus. In the second phase, oral, the tongue is used to push the bolus posteriorly (backwards). In the third phase, pharyngeal, a swallow is reflexively triggered while the epiglottis closes to prevent aspiration of food into the lungs. In the last phase, esophageal, food now enters the stomach. Difficulty in any one of these phases can make feeding frustrating for children and a concern for parents. 

• What you can do: 
  1. Difficulty with swallowing will likely require medical attention to assess the structures involved in the phases of feeding. A medical doctor may request for a swallow study to be conducted to see if there is a problem, and if so, what structure(s) the problem is occurring in
  2. A chin tucked position is optimal for swallowing, as well as appropriate seating of 90-degree of hip flexion and the head in midline
• Healthcare professional: Speech Language Pathologists and Occupational Therapists with advanced practice certification in swallowing are specialists who work with individuals that have difficulty swallowing. 

Behavioral: Children may refuse to eat because of behavioral components such as gaining attention and access to tangibles (items). Refusal to eat typically causes anxiety for parents leading to increased attention towards the child, which a child may enjoy. Additionally, child may learn that refusal to eat can earn them access to items such as an iPad. 

• Healthcare professional: Behavioral analysts/therapists use applied behavioral analysis to help children with behavioral concerns.  

Overall tips:

• Environmental adaptations: Stick to a routine (feed during the same time, place, using the same utensils to provide structure
• Reduce snacking throughout the day and decreasing excess liquid consumption 
• Use social modeling: eat together with your child during mealtimes to model the expected behavior
• Play: play with foods that have different textures, have your child help prepare the meals
• Make feeding manageable: Try 1 new food at a time, first introduce the new food on the table before any expectations for the child to have to eat it, and make sure the food is in small quantities and is a food the child is able to eat given their skills (e.g. oral motor skills; can the child physically chew the food)
• Repetition: Chances are high that it will take multiple presentations of a food before a child feels comfortable enough to eat it 
• Follow through: Telling the child this is their last bite for 4 bites in a row can lose a child’s trust. If you promise a reinforcer after compliance with eating, follow through with the promise. 

Case Study: Ben is a 30-month-old boy with picky eating behaviors. He will independently grab preferred snacks/drinks off the table and from the refrigerator but refuses to eat certain foods presented by family (e.g. meat). His family does not stick to a routine during eating and does not eat at the same time as Ben. Additionally, when Ben refuses to eat and wants to leave to go play they allow him to escape. Family concerns include that Ben will not eat all day sometimes until he is starving. 

Intervention: It became apparent that Ben enjoys tactile play with items of various textures. He also demonstrated a liking to pretend play with food items. Ben was not forced to eat but given sensory rich opportunities to interact with real food by being an active participant. When given the opportunity, he helped mix the food and independently used his finger to try the food. By snacking less throughout the day, sticking to a routine, and following through with promises Ben was able to increase his duration of feeding and increase his repertoire of food.   

If you feel that your child is having trouble with feeding, reach out to us to schedule an occupational therapy and/or speech therapy consultation!