The perspective on feeding therapy from a speech-language pathologist

When a child struggles with eating or eats differently than parents expect, it impacts the entire family. That’s because eating is about so much more than the variety and quantity of foods we consume. It’s about giving and receiving love, celebration, enjoyment, connection, learning, socialization, sensory experiences, fine motor skills and communication.

As clinicians who learn the technical aspects of eating, we sometimes view feeding through a medical lens. To better help families struggling with pediatric feeding disorder (PFD) though, we need to widen our perspective and consider a child’s eating in the context of their family and environment.

Of course, safety and nutrition are of primary importance. But to best serve families, we can’t evaluate and support feeding skills without also understanding how specific feeding challenges impact each family.

I recently worked with a client who was born prematurely at 24 weeks gestation. Prior to her birth, her mother spent four weeks in the hospital on bed rest. For this family, the stress and trauma related to their baby’s health began before she was even born.

After she was born, this little girl spent five months in the NICU and required surgeries, intubation, an NG tube and ultimately, a g-tube. The need for multiple medical interventions meant early experiences around feeding and bonding didn’t happen as expected for this family.

By the time I met them through Early Intervention (EI), feeding still felt very medicalized to her parents. Her parents adhered to a strict tube feeding schedule (as they were directed to do by her medical team) and desperately tried to find a formula that didn’t cause her to throw up after each feeding. There were few opportunities to learn her hunger cues, cuddle together while she ate or share love around mealtimes. Her parents felt powerless, confused and frustrated.

We began with conversations about what her family wanted their mealtimes to feel like. This helped them shift their lens to think about how to help their daughter feel comfortable and ready to learn. We talked about what she might enjoy. Of course, we continued to consider her complex medical needs, but together, we were also able to shift our focus to helping her feel safe, building trust between her and her parents, supporting her internal motivation to explore and learn and letting her explore at her own pace. Once she felt better, she became a very curious baby at mealtimes!

Her parents took time to learn that the goal of mealtime doesn’t have to be the specific number of ounces or calories. Instead, they began the journey to help their daughter discover what was right for her body. They were encouraged by small indicators of change, such as getting messy while exploring food and putting a spoon into her mouth independently.

Their focus became celebrating each learning experience.

Not every client I work with is so complex, but my approach to feeding therapy always remains the same: family-centered, responsive feeding.

Below are seven important tips for clinicians supporting children and families to keep in mind:

Eating develops in the context of relationships.
If you’ve spent time talking with families about how mealtimes feel and how hard they work to help their child eat, you know that the feeding experience is dependent on the participation and capacities of both a child and their caregiver(s).

In their book Pre-Feeding Skills, Suzanne Evans Morris and Marsha Dunn Klein describe this caregiver-child interaction at mealtimes as a dance. Families move, interact, and learn in response to each other. Considering that infants eat 8-12 times per day and toddlers eat 5-8 times per day, this makes eating the activity that families spend the most time doing together.

Relationships matter in feeding therapy, and supporting parents’ and children’s communication around mealtimes is key to facilitating trust.

Understanding a child’s communication is a gamechanger in feeding therapy.
PFD can co-occur with over 300 different diagnoses. That means many children with PFD also experience speech, language and hearing challenges that can further complicate feeding. When a child has difficulty clearly communicating with their caregiver, that caregiver may misinterpret mealtime behavior. Behavior is communication. Let’s work with parents to better understand what their children are telling us about how they feel about their experience. Are they communicating that something is not working? Do they need us to make a modification in order to help them feel more comfortable and ready for learning? When we seek to understand a child’s communication, we can also support parents in knowing how to respond appropriately.

Eating means more than consuming calories.
Central to supporting families of children with PFD is the realization that eating is much more than the physical act of consuming food. Love, connection, socialization, internal motivation, communication, sensory experiences and skill development are all important parts of eating.

As clinicians, we can inadvertently add to the stress and anxiety parents feel when we focus solely on quantity and volume goals.

The truth is that success is not always measured by the number of calories consumed. Instead, we can celebrate a child feeling comfortable enough to explore a new food or a caregiver who helps a child participate in family mealtimes in the way that’s right for them.

Acknowledge that it’s not our job to get a child to eat.
Although we need to carefully monitor a child’s nutritional status with the help of a child’s medical team, focusing on “getting” them to eat shouldn’t be the goal of feeding therapy. Instead, it’s our job to collaborate with caregivers and support a child’s autonomy, internal motivation and ability to learn. We can offer opportunities and then let a child show us what works for them at that moment.

Make asking about feeding part of your evaluation routine.
It would be an incredible service to so many families if we regularly asked about mealtime routines even when we meet a family with other primary concerns related to communication or other diagnoses that impact development. Because we know how prevalent pediatric feeding disorder is, we can facilitate earlier access to feeding support in early intervention and beyond.

When in doubt, check it out.
It’s not unusual to hear from families that another provider told them their child will grow out of a feeding concern. Parents know their children best. If a parent feels there is a problem, then there’s an issue to address –– even if it’s minor. Let’s give parents access to information and resources when they need it most. We know that for the children who are struggling, ignoring the issue can have a negative impact on family routines, interactions, and ultimately family life as a whole.

Families do best with a team approach to PFD
Many caregivers worry about whether their child with PFD is eating what they need in order to grow. Some parents may overestimate their child’s needs and underestimate their child’s intake.When we collaborate with pediatricians, registered dietitians and other professionals, we can gather specific data that helps us understand whether a child is consuming what they need to grow and thrive. This information helps us make informed decisions and often helps lower stress for parents, ultimately helping them feel more comfortable letting their child learn at their own pace. We can also collaborate with other professionals to help us explore the impact of medical conditions on eating and the psychosocial factors associated with family feeding experiences.

Feeding success looks different for every child, but with the right support, we can empower parents to be their child’s best teacher by supporting emotional connection and individualized earning.

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Stephanie Cohen is an experienced SLP and private practice owner in the Chicagoland area and co-founder and co-director of the Chicago Feeding Group, a nonprofit supporting children with pediatric feeding disorder and their families and providing responsive feeding-focused education for both families and professionals. Find her at www.learntotalkwithme.com.