By Samanta Rivas-Argueta, University of Toronto occupational therapy student
Edited by Karen Don MSc. OT Reg. (Ont) with appreciation
Are you struggling to get your child to eat? Is your child constantly asking for the same food and doesn’t seem to tolerate anything new? You are not alone. Eating difficulties are common amongst children. Approximately 5%-20% of all children and 40-80% of children with developmental disabilities experience some type of eating problems.
(Nationwide Children’s Hospital, 2020)
The aim for this blog is to gain a greater understanding of feeding by discussing the complexities of feeding, the six skills required, three feeding myths, and some general tips to help your child engage in eating at home. We will also introduce how OCCUPATIONAL THERAPY can help children with feeding challenges.
What is involved in eating?
First, it is important to understand why eating can become so difficult for our little ones. We often think of feeding as something that comes naturally to us, without any effort. But is it really? Did you know that feeding is one of the most complex occupations for human beings? It is so complex and difficult it requires all organs, all muscles, and all senses.
When feeding, your body uses every single internal organ; the lungs, the heart, the brain and all digestive organs. A single swallow requires up to 26 muscles and 6 cranial nerves working together to move food from outside to inside your body.
We use our external muscles to keep us upright and manipulate the food to our mouth. In addition, we use all of our internal muscles, starting with our tongue, to contract and move the food along our digestive tube.
Feeding requires all eight senses. You read it well! All Eight Senses. You may only be familiar with the first five senses; sight, hearing, smell, taste and touch, but proprioception, vestibular and interception are also involved.
- Proprioception: When eating, we need to be aware of our position, location, orientation and movement of our body muscles and joints.
- Vestibular: We need balance and orientation in space to keep us from falling when eating.
- Interoception: In order to eat, we need the ability to understand our internal body signals (appetite, thirst, toileting, etc.)
(Toomey, 2019; Bass & Morrell, 1992)
Important Note: All organs, muscles and senses are controlled by different parts of the brain, and all these different parts have to work together in perfect harmony in order to eat smoothly. So, our brains are extremely active while feeding. Imagine how much work this takes.
What else is required?: Six Skills For Eating
To further understand the process of eating, let’s look at six skills your child needs in order to eat successfully.
- Sensory Tolerance/Exploration – The child needs to experience food with all of their senses in order to fully engage in the eating process. They need to see the food, smell it and touch it, often before even tasting it. A child can also experience hearing how loud a food is when being chewed. If your child is oversensitive or undersensitive to sensory input (i.e. texture, taste, smell, colour, etc.), they may experience difficulty trying new foods and/or eating enough food resulting in low food tolerance, poor nutritional consumption and increased fatigue.
- Postural Stability – To allow optimal eating, the child needs to effectively use their core and stabiliser muscles to maintain an upright posture. If your child has low muscle tone or lack of strength in large muscles, they may be using all of their energy not to fall from their chair, and therefore, neglecting eating.
- Tongue Tip Lateralization – The tongue needs to be strong and flexible to move food to the back molars either on the right or left side of the mouth. This skill will be impacted if your child experiences reduced oral motor function.
- Rotary Chewing – In order to chew solid foods, the jaw needs to be strong enough to move from one side to another. This skill will be impacted if your child experiences reduced oral motor function.
- Hand Coordination and Hand Dexterity – In self-feeding, the child needs to use both hands simultaneously in order to pick up food or hold utensils while holding the plate or cutting with a knife. They may also need to hold the food with both hands and bring it to their mouth (i.e. hamburgers). Poor fine motor skills may hinder your child from becoming independent eaters.
- Positive Mindset – In the best-case scenario, the child should approach eating willingly, with interest and curiosity. If your child perceives eating as a difficult task, they may decide to avoid it in order to prevent discomfort.
Pediatric Occupational Therapists can help in all of these areas.
(Toomey, 2019; Arts-Rodas & Benoit, 1998)
Debunking Eating Myths
Here are some common feeding myths that may hinder our understanding of our child’s difficulties with eating.
- Eating is instinctive
Appetite instinct and eating reflexes for eating are only present in the first 6 months of life. After that, the child has to learn how to eat. FACT: Eating is a LEARNED behavior. Therefore, one factor to consider is the development of good eating habits through teaching and modelling.
- Eating is the body’s #1 priority
Although eating is what allows us to get all our nutrients for our body to function in the world, it is not the first or second priority. FACT: Our body’s priority #1 is to keep us breathing and priority #2 is to keep us from falling to the ground (postural stability). Therefore, our bodies will first focus on breathing and keeping us from falling before considering eating.
- Children only need to eat 3 times a day
A child needs up to 11 meals per day when they are 6-12 months, including breast, bottle and solids feedings. By 12-24 months, a child requires an average of 7 meals per day. FACT: Children need to eat more than 3 times a day. Eating too little contributes to poor nutrition and decreased energy, hindering the child’s ability to engage in daily occupations.
(Toomey, 2019; WHO Multicentre Growth Reference Study Group, 2006)
GENERAL TIPS FOR HOME
Here are some general tips that you, as a parent/caregiver, can implement at home to help your child engage in feeding;
- Make feeding interesting– Cut the food into interesting shapes and characters to make it playful. The child will be more motivated to explore it.
- Involve the child during mealtime – If possible, try to involve the child in meal prep or meal serving, increasing all possible interactions with the food.
- Make sure there is at least one preferred food – The child will be more comfortable if there is one food they can tolerate on their plate.
- Follow a regular schedule – It helps cue the child to eating.
- Use family style serving – This is another opportunity for the child to interact with the food.
- Consider the environment – How the child is sitting or how high is the table can impact the child’s ability to eat.
- Be the teacher – A child needs to learn how to eat. Don’t be ashamed to exaggerate movements or sounds, and make the process engaging for your child.
“Every meal is a class.
You are the professor.
Your child is the student.
Food is your subject”
OCCUPATIONAL THERAPISTS AT TCTC CAN HELP!
If your child is experiencing difficulties with feeding, pediatric occupational therapists are well-positioned to assist you with the following:
- Assessment and treatment of feeding, eating and swallowing difficulties;
- Monitoring and adaptation of treatment plan;
- Implementation of effective at-home strategies;
- Recommendations for assistive devices, resources and services;
Occupational therapists utilize three effective and complementary approaches to maximize therapeutic outcomes;
- A holistic approach, which recognizes the physiological, psychosocial, cultural and environmental factors involved in the process of eating;
- A family-centered approach, which acknowledges that collaboration between the child, parents/caregivers and therapist is essential for optimal therapeutic outcomes.
- A strength-based approach, which emphasizes the child’s determination, abilities and strengths to allow for a positive and uplifting learning environment.
The goal of occupational therapy in feeding is to understand your child’s feeding needs and collaborate to create goals, develop a plan and provide optimal eating conditions for your child. Some of the specific areas OTs work on include, but not limited to;
Sensory Processing – Increasing sensory processing experience and ability (i.e. improving texture, taste, smell tolerance and processing, increasing food variety).
Oral Motor – Promoting greater oral motor function by strengthening the muscles of the mouth.
Gross motor – Developing optimal postural stability by strengthening larger muscles of the body.
Fine motor – Encouraging independence while eating by increasing hand dexterity to grasp food and use utensils.
Behaviour – Addressing food refusal and defiance behaviours while promoting good eating habits.
Environment – Promoting an engaging and optimal eating environment.
(Boop & Smith, 2017)
In summary, feeding is an extremely complex occupation. If feeding your child has become an overwhelming task in your household, you may benefit from the help of occupational therapists (OTs). The OTs at TCTC are trained in feeding; they help your child develop the necessary skills and enable participation and engagement in that occupation.
Please contact us if you have any questions regarding your child’s feeding performance and learn how occupational therapy can help your child reach their occupational goals. If you are looking for more support, there is currently a Parent Workshop available at TCTC offered in a group format, where parents can connect with one another, discuss common challenges and problem solve together. This workshop provides tips and strategies to help introduce more textures into your child’s food repertoire, it provides helpful insight on how to navigate challenges during mealtime and it’s the perfect occasion to ask any questions. DON’T MISS OUT ON THIS OPPORTUNITY! For more information, visit our to learn about our available OT programs.
Arts-Rodas D., Benoit D. (1998). Feeding problems in infancy and early childhood: identification and management. Paediatr Child Health; 3(1): 21–27. doi: 10.1093/pch/3.1.21
Bass, N.H. and Morrell, R.M. (1992). The neurology of swallowing. In: M.E. Groher (Ed.), Dysphagia, Diagnosis and Management. Butterworth–Heinemann, Boston, MA, pp. 1–29.
Boop, C., Smith, J. (2017). The Practice of Occupational Therapy in Feeding, Eating, and Swallowing. American Journal of Occupational Therapy. Vol. 71, 7112410015. https://doi.org/10.5014/ajot.2017.716S04
Goday PS, Huh SY, Silverman A, Lukens CT, Dodrill P, Cohen SS, Delaney AL, Feuling MB, Noel RJ, Gisel E, Kenzer A, Kessler DB, de Camargo OK, Browne J, Phalen JA. (2019). Pediatric feeding disorder: consensus definition and conceptual framework. JPGN;68(1):124-129.
Nationwide Children’s Hospital. 2020. What are feeding disorders? Retrieved from: https://www.nationwidechildrens.org/conditions/feeding-disorders
Toomey K. A. (2019). SOS Approach to feeding: parent/caregiver workshop [Video file]. Retrieved from https://sosapproachtofeeding.com/parent-workshop-when-children-wont-eat/
Whitlatch M. M. (2012). Behavioral Feeding Disorders in Infants and Children Michelle M. Whitlatch. Retrieved from: https://opensiuc.lib.siu.edu/cgi/viewcontent.cgi?article=1271&context=gs_rp
WHO Multicentre Growth Reference Study Group. (2006). Complementary feeding in the WHO Multicentre Growth Reference Study. Acta Paediatr Suppl; 450:27-37. doi: 10.1111/j.1651-2227.2006.tb02373.x