Great article for parents of non-eaters

[Anonymous]

My OT gave me this article and I thought I would pass it on. It has a lot of useful information.

When Children Won’t Eat: Understanding the “Why’s” and How to Helpby Kay A. Toomey, Ph.D.

When people talk about feeding difficulties, they often try to put the children into one of two categories; those who have “organic” or “physical” problems and those who have “behavioral” problems. In our work at Rose Medical Center in Denver, we find that dichotomizing our children is not helpful. One reason is that there is an implication of blame in this system. We don’t believe it is accurate or useful to support a blaming stance with children who won’t eat. Second, these are not true pure categories because children with physical difficulties often develop “behavioral” problems after their attempts to eat don’t go well, and children with “behavioral” eating difficulties develop physical disorders after having poor nutrition for a period of time. So, the first thing we need to do is to get rid of the notion of trying to force children into categories where they don’t belong. Instead, we find it most helpful to think about children who won’t eat as having had poor learning experiences with food.

Many people believe that eating is completely instinctual and that no matter what happens a child will eat. This is another myth in the food world. Actually instincts only start the process, and that is if you are lucky enough not to have your instincts not interfered with by prematurity, a physical disorder, or disruptive procedures needed for survival. Eating is, in reality, a learned behavior. Just as children learn to eat, so can children be taught to not eat by the circumstances of their lives. But how does this learning take place?

Research shows that learning about food happens through two main ways. The first is when a connection is made in time between one natural event, behavior, or object (=stimulus) and another neutral stimulus. For example, we know that feeling sick to your stomach causes a physical reaction of appetite suppression. This is the natural event. If we consistently connect feeling nauseous with a food (previously a neutral thing), pretty soon that food itself will make us sick. Drinking too much alcohol and then never being able to go near that drink again without an upset stomach is a firsthand experience that many people have had. Another example is, when someone is in pain or discomfort they try to escape or avoid that pain (natural event). If this pain is then paired over time with food, the person will learn to escape the eating situation. Gastroesophageal reflux (GER) is a good example of this type of learning.

The second way we learn is through reinforcement and punishment. Here are some examples of these types of learning about food:

Eating—>followed by praise or imitation (= positive reinforcement)—> leads to more eating

Refusing to eat —>followed by lots of attention & interaction(= positive reinforcement)—> more refusal

So you can see that positive reinforcement can cause more of an undesired behavior, as well as increasing wanted behaviors!

Now, how about some punishment examples ?

Eating—>followed by choking and fear (= punishment)—> less eating

Eating—>followed by being yelled at (= punishment)—> less eating

Punishment around food is very powerful. Booth (1990) showed that if the learned reaction to food is negative, there is a physical effect of appetite suppression. That is, if the learning about food is unpleasant, our bodies will turn off our appetites. Also, Weingarten and Marten (1989) showed that if you make negative connections to the cues to eating (e.g.. sitting down at the table, the utensils you use, the people present, the room where you eat), you will learn to avoid the feeding situation completely. The power of punishment is why we do not support force feeding, except in very special circumstances. We find that children who are force fed may learn to eat some foods to avoid being punished, but that this is not a normal way of eating (it is actually escape learning). In addition, often times after the punishment is removed, the child stops eating again.

What about learning to eat new foods? This takes place through a process of presenting the new food over and over again along with positive reinforcement for ANY interaction with the food. Birch (1990) showed that it takes up to 10 repeated presentations of a new food with positive reward before a child will begin to eat that food regularly. Many people make the mistake of taking that first rejection of a new food as the final word, but it is not.

It is important whenever we work with children who have feeding problems to first figure out how they learned to not eat. Were they premature and constantly had people sticking things in their face? Did they have pain every time they ate? Were they always congested so that they could never breathe while they were eating? Did they have motor problems so that it was hard to coordinate eating and they were always frustrated? Do they have a sensory integration disorder so that it is hard for them to understand all the different pieces to eating? The reasons children learn to not eat are many and varied.

Because learning is the key factor here, it is also critical to always be aware of what each feeding interaction may be teaching the child. By refusing to eat certain foods ourselves, are we teaching our children to avoid those foods? By never sitting down to a family meal are we preventing our child from having a rich learning experience about food, in addition to missing an important teaching opportunity? By giving a child a toy during a meal after they just refused to take a bite for us, haven’t we just reinforced noncompliance? By yelling or forcing are we teaching them that eating is unpleasant (and turning off their appetite)? Although difficult, it is often helpful to have someone else watch us feed our child so that they can help us pick up on these subtle negative teachings.

So, how do we teach children to eat? The overall goal of all treatment with children who won’t eat is to create a situation which positively reinforces normal, healthy eating patterns. There are five main categories of strategies:

Structure

– having a routine to meal times, eating in the same room, at the same table, with the same utensils are all things which capitalize on the need for repetition in learning. The more you can make things about the meal the same, the easier it will be for the child to learn. In addition, the routine itself can help get the child primed and ready to eat. It is especially important with G-tube fed children to have approximately the following routine: 1. help with food preparation, 2. sit in high chair or at table with same utensils, 3. offer food and drink first, 4. as the child is almost done with the meal, start their bolus feeding while still in the chair with food on the tray. Many G-tube fed children are fed lying on their back in their bed. This is not a normal way of eating. Children fed like this learn that when they are hungry food comes out of nowhere without their effort, or they learn that they eat from the pump without using their mouths. We want these children to learn to connect the sensation of their stomachs being filled with food in their mouth. Even infants on tubes should be fed in a normal bottle or breast feeding position, preferably with a bottle or pacifier with formula or breast milk on it in their mouth.

Social modeling

– one major way children learn to eat is through observation of others. Family meals are critical to providing children with multiple opportunities to learn about eating. This also means that we need to be very good role models. Overemphasizing chewing with our mouths open and swallowing helps children to understand about what to do with food. We need to be positive about our interactions with food. Because children love to imitate what we do, we need to not make faces or bad comments about food. If you are a poor eater, it may be difficult to help your child.

Positive reinforcement

– so many times when we see children who won’t eat, we find out that mealtimes have become an unhappy struggle for everybody. Meals need to be pleasant and enjoyable. Eat a normal family meal and wait to do any feeding programs until you are done with your food (but don’t forget to keep alittle so you can be a good role model during the program). During the meal, make sure that ANY interaction with the food is rewarded. Verbal praise is the best and most normal reinforcer. However, a smile, a touch, a cheer, clapping are all other options. The level of reward needs to be geared to each individual child. Also, remember that punishment can turn off a child’s appetite. Special feeding programs should be created only with the help of a qualified professional.

Making foods manageable

– a common problem we see is a child being offered foods they really can not manage to eat. Giving a 2 year old child with oral-motor problems a full hamburger, plus potatoe, plus vegetable on their tray is overwhelming, frustrating and defeating. Foods need to be in small, easily chewable bites or in long, thin strips that the child can easily hold. Also, the rule of thumb is to only present a child with a total of 3 foods on their plate at any one time. There should be 1 tablespoon per each year of your child’s age of each of these 3 foods. With new foods, make the food less “new” by first introducing it to the child on the table only. Then you can put it on their plate. Remember, new foods need to be presented repeatedly with positive reinforcement for any interaction .

Accessing cognitive skills

– because the skills for eating haven’t come easy to children with feeding problems, they need to use their intelligence (cognitive abilities) to help themselves better manage the foods. This means that we need to teach them about the physical properties of the foods so that they will know how to make the foods work in their mouths. For example, banging a carrot stick on the table and talking about how hard it is teaches that the mouth and teeth will need to use hard pressure to break that food apart. Versus, a piece of string cheese which wiggles and is squishy will be somewhat chewy in the mouth. Versus a food like yogurt which is cold, wet and smooth and therefore can be just sucked down. We refer to this process as teaching children the “physics of food”.

These recommendations are just a few of the many ways children can be helped to eat. Hopefully, this article will get you thinking about your child’s feeding interactions and how you can become a more positive feeding teacher.

[Anonymous]

Lisa

Thank you for this. I did find it pretty interesting (especially the part about blame… you don´t know how hard everything is until you hear from someone that you are responsible for your baby being on a tube).

I like all of the ideas — since we saw the psychologist, Matthew is not really eating much, but we have really started from the beginning with his feedings. (He does not eat yogurt anymore now, but on the otehr hand he has stopped throwing up and is not interested in doing it anymore, so i am glad overall).

I now have a routine for Matthew. Too bad nobody has taught me anything and i kind of had to do it all myself, but seems pretty much like your article describes. Maybe not so relevant for you because Matthew is on the tube, but Laura may want to hear what we are doing and i would love to hear what you are doing as well!

We have 4 meals a day — i talk to Matthew for 30 seconds, put on his bib, and sit him in the high chair (WITH SOME TOYS though). I feed him. The minute he gets fussy, i pick him up, calm him down…. i do this a maximum of 3 times or 40 min and then we are done with the feeding… sometimes it is a couple of ounces, sometimes NOTHING. Then i keep him in the seat while i syringe him the feedings (I try at least…).

I just keep talking ot him all of the time and i am really really patient now. Sometimes it takes 10min for him to open his mouth! But i just wait and smile at him…

I think we were kind of force feeding matthew before — there were so many distractions, and a couple of people feeding him that when he opened his mouth to breathe, he would find the food in there. Now, i just don´t do it anymore. Means a lot less eating… but i hope that we will get there some day.

Also, we used to feed him the same thing all of the time before. Now, i have just realised that we have a feeding tube (thank you Lauren for all your posts, if you are reading this) so we are experimenting a lot more! I give him a ton of flavors and don´t really care if he takes one spooful or 5…

Our main problems are that Matthew does not seem to have an appetite at all – he will open his mouth, but he is full with 5 bites; that and the fact that he is almost 8 months old and it is so hard to keep him sitting down for 40min on a high chair when all he wants to do is walk around.

Sorry for the long post — just wanted to post what we are doing and hear what other people are doing… we need all the help we can get!!

[Anonymous]

Wow – that’s an EXCELENT article…wish someone had given that to me 9 years ago! I have to say, though, that this was basically the program we followed with Andrew – the key elements being trying really hard not to stress about amounts or make the meals struggles. Easier said than done, I know, but once he was back on the charts and off his NG tube I had to really struggle with myself to accept that as long as he was healthy and growing – even slowly – that how much he ate HAD to be up to him. And he did SLOWLY creep up – to the 5th, then the 10th, then the 25th percentile, where he stayed for a long time, which was perfect for him. (Now he’s 9 and over the 90th!)

[Anonymous]

Thanks for the article Lisa! I printed off three copies- one for my ped (who tells me that he thinks the not eating is behavioural b/c most refluxers still eat), another for the psychiatrist (we’re going to fax it- who blamed us for the not eating), and the last one for the feeding doctor we saw (who also didn’t quite seem to get the correlation).

Thais, I know I’ve said this a billion times but I truly believe that Matthew’s eating issues stem from the reflux and most certainly have nothing to do with you. Hearing what you’re going through, I swear you are so patient. I hope that things improve soon. I noticed that you mentioned that you’re syringing feeds into his mouth- just wondering what you’re syringing? Is it formula?

Regarding the appetite issue, we have the same problem here. Hailey is just never hungry, and this is the case even if she refuses her am bottle. At lunchtime, after having gone for 12 hours without eating, she still is not hungry….totally refuses anything pureed, might have a puff or something, and then is done. It’s maddenning and bizzarre!!

Hope things get better for all of our non-eaters soon.

[Anonymous]

I understand the blame that you get when they find out your baby has a feeding tube. I have taken to “yes he is a preemie” because for some reason it is acceptable to be on a tube if they are early and nobody I have come across understands feeding difficulties in a normal baby…except for here of course. It is sad that I have to lie – but it is easier than trying to explain our situation to strangers.

Also, don’t you find it amazing that we as parents can find all this research and papers written on the feeding problems, when the peds and GI’s don’t seem to have a clue and Christians doctors don’t even want to read the research that I have found..they know best.

I think it is extremely important for Moms and Dads to realize that they are NOT to blame and that sometimes the feeding difficulties are far beyond our control and time and the positive reinforcment we as parents can give is the only thing that will help our children grow.

I am glad that your OT is providing you with helpful articles I hope that the physical guidance is also helping.

We to have established some routines to help with eating, same place, time, toys. Our dietician says even if it is only one or two bites – if they are pleasant then the association to eating will be pleasant. He will eat quantity at his own pace as long as he doesn’t feel threatened.

Thank you for posting this article.

[Anonymous]

Tricia – if i can ask — how long was Andrew on the NG tube… when was this?? I am trying to be positive and think that one day we will not have a tube… your story at least makes me realise we will get there one day!

Lori –Sorry — when i meant syringe i meant through the tube!! Sorry if that was confusing. How is Hailey doing?? Have you tried going to the other website? As for the blame, i know but it is so hard. Right now, i am exhausted again. Matthew is not sleeping at all and the psychologist said no to training (which we were doing great, with him crying for 5 min but then sleeping a long time). He is up 8 to 10 times a night again and sometimes, like last night, is up for one hour a couple of times. That and he is moving so much, he disconnects teh tube and takes it off (like last night). I am not putting it back on today. He can have a day off. I don´t care.

Laura — just curious. Does Christian take the first couple of bites ok? Matthew usually does that, unless he wants nothing to do with food. He opens his mouth and great… then the third one is a gamble… sometimes he does better. He now hates yogurt for some odd reason. He likes water, so i am putting in a little bit of formula into his water, and he is taking a little bit of it! But no more than 1 ounce of formula per 4 of water. I think it is a start, or so i tell myself!

[Anonymous]

Thais – Christian is finicky. I find that he will sometimes take the first 10 bites and refuse – or he will just start off with the first bite, after a bit of coaxing he will eat then. OR when we are out and distracted he can eat a whole jar before he realizes that he was actually eating.

Christian is also taking to the water/juice in the sippy cup. Right now I am just excited that he volunteers to drink something.

Keep your patience – that is what I keep reminding myself.

[Anonymous]

Thais,

I’m just curious is Matthew is on a strict feeding schedule? My OT told me the other day that its really important that I do my best to feed him at the same times every day, and not to give him any snacks in between. She said that his belly should get used to having food in it during those times. This is supposidly how he is supposed to get his appetite stimulated. Later, we are going to omit one or so of his feedings and see if he gets the connection with hunger and hopefully will begin to eat. I’m not sure if that will work for Noah, but I suppose its worth a try.

[Anonymous]

Lisa –

I live in Denver, Colorado & my dd actually sees Kay Toomey (the author of that article) for feeding therapy along with OT & speech therapists. This is a remarkable woman. She actually founded the feeding clinic at our Denver Children’s hospital & another hospital here. She travels all over the US about 2-3 times a month training therapists proper ways & helpful ways for feeding therapies. Kay Toomey is also a consultant to Gerber & helped then develop the “Lil Dipper”. These are the things that babies can use to help feed themselves when they can’t quite use silverware but want to feed themselves. I have to say that every week when we go, we get so much information & articles that I literally have a binder full of articles. Some are from her, some are from magazines & some are informational sheets that she has made up specifically for therapy. Ashtyn is in group therapy right now in a group with kids aged 18 months – 3 years. But the youngest is 22 months now & Ashtyn is the oldest at 29 months.

If you go to Google you can type in “Kay Toomey” & you can find more information for her. I think at one time I even came across a feeding pamphlet that Gerber put out a few years ago that had an article in it by her also.

[Anonymous]

Laura — thankyou. Yes sounds a bit like Matthew.

Lisa – Yes, Matthew is on tight schedule. We vary it by 20min at the most. Supposedly, babies who don´t eat do better, because part of learning to eat is the routine. What we are doing is 7.30am, 11.30am, 3.30pm and 7.30pm. (Matthew does not sleep much and will get up at 6am or so, but we wait because he is not hungry then).

Sometimes, we skip breakfast all together and wait until lunch time to feed him if he refuses the breakfast straight away. Then we feed him whatever he will take for lunch, afternoon and dinner and then make up at night for what we think he did not take.

Other times, we just change it and i supplement after every feeding to make his stomach used to food. (we are in this phase now).

This is all made up by me, so don´t know if it is right… but it makes sense to me!

How is Noah these days?

[Anonymous]

Thais, sorry for my ignorance about syringing through the tube. I wasn’t sure if that’s what you meant. Why did the psychologist say that you can’t sleep train anymore? Also, are you still seeing her regularly? Does she have anything more that she’s been able to offer?

Sherry, just wondering what the wait is like for Ashtyn’s feeding therapy program? Do you know if they have a program for babies? Also do you know if they have an inpatient program? Just thinking out loud really as my parents are in Denver and maybe I could go down although the cost out of pocket would probably kill us.

Lisa- no snacks at all? I’ve been putting some out on the tray of the stroller when we go out and hope that she’ll take something. She ususally just throws them all around but I still offer. Is it okay to offer water in between?

[Anonymous]

Lori — she does not want me to let him cry right now, until his eating is a little bit better… i am in for some sleepless nights! We saw her again — matthew had already eaten at home and she just asked me how it was going. I said fine and she said — ok, just make sure you do not overstimulate your baby — he seems extremely sensitive and shy (when people look at him he just throws himself into my arms although just to hide face… isn´t that just normal baby…??). She thinks he needs much calmer days. We are not seeing her again as will be back in NY after Easter!

On the calmer days…. she really does not know Matthew… the only thing he does is walk around everywhere — my back is killing me — not even walking, but running… he thinks he can do it on his own and he is standing ALL DAY LONG. I wish she would keep him for one day and see what it is like. The little man is SO ACTIVE.

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