Presentation on theme: "Eating Styles Matter feeding & nourishing babies & toddlers who don’t follow typical eating progressions Linda Piette, RD, MS, LDN Author of JUST TWO MORE."— Presentation transcript:
“Eat what you like and let the food fight it out inside.” Mark Twain SCIENTIFIC BREAK THROUGHS Digestion/ nutrition Immune Function Gene Expression NEW ENVIRONMENT food touches every part of life
Malnutrition Risks - US Obesogenic Environment What disease will 3 out of 4 Americans have by 2020? PROCESSED FOODS ↑ calorie ↑ salt Kids like familiar foods…….
Flavor Exposure Starts early Breast milk/ formula flavor impact Table foods by 1 st birthday. Foods introduced after age 4 more likely to be disliked.* Nov 2002, 5-yr study J American Dietetic Assoc
Pediatric News- Oct 2002 Incidence of Feeding Problems 25% of young children 50+% in children with autism 80% in children with developmental delays
Growth the most important developmental task of childhood….. keeping score Growth charts…. –Standard charts from www.cdc.gov –WHO (World Health Organization) on CDC website –Specialized charts for: Cerebral Palsy Down Syndrome Turner/ Williams Syndromes –Weight-age
Weekly Weight Gains Age (months) Weight (ounces) 1-65-6 6-123-5 12-15 2 15-361.5 36-481.2 Height can ↑ 10 in in the 1 st year Source :JUST TWO MORE BITES
Growth How long does it take to gain a pound ? Infants: 3 weeks 1-year-old: 2 months 3-year-old: 31/2 months
No eating….no growth Eating Connections….. Physical/ Motor –Motor Skills & Eating (mechanics) –Body Size & Motor Skills (weight-age) Readiness –Digestive –Neurological Social/ Cultural –Family Food Traditions/ Dynamics –Health Risks –Economic
Eating Milestones SOLIDS Closes lips around spoon (6-9 months) Uses tongue to move food from side to side (8-11 months) Table foods by 1 year LIQUIDS Drinking from a cup by 16 months Able to drink 6 oz within 10 minutes or less Able to drink thin liquids without gagging
Balancing Nutrition goals (short-term vs long-term) Maturity / readiness for food (digestive, motor & sensory)
Eating Styles variations in growth & variety HAPPY Good growth Good food variety CAREUL/ RIGID Good growth Poor food variety TINY Poor growth Good food variety FRAGILE Poor growth Poor food variety
Happy Eaters Focus on Long-term Nutrition Goals: Trust baby’s ability to self-regulate calories ↓ sugary foods Off baby foods early Avoid restrictions Introduce healthy table foods early (off baby foods early) Off bottle at 1 year ↓ milk to ↑ solids
Fragile Eaters Poor Growth Poor Food Variety Not On Schedule….. Not Ready for Food Medical Risk Developmental Delay
Careful/ Rigid Eaters Good Growth ↓ Food Variety (flavors +/textures) –Sensitive to flavor, texture/ Temperature –Brand-specific preferences Self-feeding? Sensory? Behavior?
Careful/Rigid Eaters Ben 1-year-old Baby foods –purees Frosting only Force-feeding Adam Rigid eating (flavor + texture) Delayed progression
Tiny Eaters Poor Growth Good Food Variety –↑ Flavors –Volume…liquids...solids ? –Texture ? Motor delay? Food Aversions? Behavior ?
Tiny Eaters Connor Reflux Delayed texture progression ↓ fluid volume Poor Growth (FTT) George 1-year-old Eating Table Foods Poor Cup Drinking Growth Rate Drop
Strategies….. Balance long and short-term nutrition goals - growth or oral motor skills? -↑ sugar/ fat foods? -↑ liquids to ↑ calories Feeding dynamics - use distractions? - food as reward/punishment? - feed while sleeping AVOID - force feeding ? NEVER As short-term feeding problems resolve shift to long-term goals
Monitoring Growth Degree of poor growth Pattern of growth fall off Calorie intake –Adequacy –Ratios (solids/ liquids)
POOR GROWTH ….LIQUIDS ? How much is enough? Formula –Term baby …approx 2 oz of formula/ pound body wt (note: ↑muscle tone, cardiac/pulmonary/ digestive problems ↑ calorie needs) Breast…. –5/6 wet diapers/day Delay transition to cup?
Breast/ Bottle Feeding Solutions Strategies: –Positioning –Oral Massage (promote tongue grooving & cupping) –Jaw Support –Nipple with wide base –Flow rate ?
Nipples Latex/ silicone –↑thinness ↑risk of collapse Shape –(wide/ narrow base) –(orthodontic/ angled/rounded) Flow rate (+ pause) –Slow to med to fast Pliability (soft/hard) –Preemie/Newborn/older Size (length of shank) No flow during pause –Gerber Silicone Slow –Gerber silicone Fast Flow Standard –Avent Naturally Feeding Bottle Flow during pause (continuous) –Gerber Silicone Medium Flow Standard –Gerber 3-hole –Parents Choice (0+ and 6-mo +)
Special Bottles/ Nipples- Solutions Haberman-cleft palate Pigeon Nipple ½ firm ½ soft (Children’s Medical Ventures) Dr. Brown reduces air swallowing
Miguelina Fragile baby HISTORY –GI issues –Delayed/ abnormal oral- motor skills INTERVENTIONS –Facial massage –Positioning/ feeding gear, etc –Formula change & concentration –Liquids to solids ratio –G-tube –Keeping oral alive POOR GROWTH –stabilized with g-tube
Sandy fragile newborn & toddler POOR GROWTH –Began at birth –Stabilized after 2 nd birthday HISTORY Cardiac problems –Weak suck –↑ Calorie needs Down Syndrome –↓ muscle tone INTERVENTION –OT (massage, nipple change, texture progression) –RD (formula concentration, growth chart, fiber & medication review)
Cup drinking… new skill Which cup? Practice with open cup + thickened liquid Timing –Transition –Shaping preferences Maximize calories/ oral-motor skills?
George tiny toddler POOR GROWTH Started at 1-year After transition to cup Resolved after intervention HISTORY Delayed texture progression Mild torticolis INTERVENTION Thickened milk ↑ calorie drink
Cup drinking… CUP DETAILS Height & handles Spouts –Hard/soft –Rate of Fluid Flow –Dot/slit opening –Spill proof LIQUIDS Formula/ supplement Texture + flavor Cost Shaping habits Delay transition to cup?
Connor tiny infant & toddler POOR GROWTH –Through infancy –Resolved after food group HISTORY –Reflux –Delayed texture progression –Oral aversion? INTERVENTION –Medication –Thickened formula –Supplements –Food group
Poor Food Variety MAKE EATING EASIER … increasing texture Solids Modify texture Gradual progressions –Demos & reminders Supplements ? Ratio of calories from liquids vs solids
TRANSITIONS Solids (Purees)→Textures Calorie Implications Liquids - ↑cal (milk or standard formula 20 cal/oz) Solids - ↓ cal (fruit/veg 10 cal/oz) Exceptions: baby yogurt (30 cal/oz), heavy cream (51 cal/ TB, oil/ butter (100 cal/TB), avocado, hummus
Eating Milestones SOLIDS Closes lips around spoon (7-9 months) Uses tongue to move food from side to side (8-11 months) Table foods by 1 year LIQUIDS Drinking from a cup by 16 months Able to drink 6 oz within 10 minutes or less Able to drink thin liquids without gagging
Steps to Eating Oral-Motor Skills Biting (Jaw) Chewing - munching - rotary Tongue - side-to-side - tongue tip -food propulsionLips -active for food removal and closure -active for food removal and closureCheeks -keep food contained -keep food containedSwallowing - oral phase - oral phase - pharyngeal phase - pharyngeal phase - esophageal phase - esophageal phase
TRANSITION to SOLIDS Signs of readiness Sitting up Closing lip around spoon Tongue lateralization Up + down munching Has doubled birth weight and is 13 lbs. Her head and back is straight in supported sitting and she can reach out for a toy. Puts hands and toys into mouth easily and frequently Shows positive mealtime communication cues Shows good oral motor coordination to accept and swallow food
Self-Weaning?? Started in England Skip purees/ spoon feeding Start with soft-solids (ie. Steamed veggies or soft fruit) Typically 8-10 months
Gradual Food Progression Make steps smaller Avoid mixed textures Aim for uniform size…. Food mills Graters Give dry crunchy BEFORE soft/wet solids
Oral Motor Programs Facial massage (use fingers or wash cloth) Nuk brush Infadent Vibration Blowing activities
Ready or not ….Eating is a Sensory Experience Taste Smell Sight Touch Hearing Careful & Fragile eaters are often NOT READY
Poor Food Variety MAKE EATING PREDICTABLE PREVENTION Avoid giving food from packages Pre-meal activity Food Jags vs downward spiral
Poor Food Variety MAKE EATING PREDICTABLE REPETITION Toddlers “neophobic” Need to see a food 16-50X Build bridges … Gradually change ….flavor texture color OR shape
MAKE EATING PREDICTABLE for rigid eaters ROUTINES/ STRUCTURE Schedules Rituals (stir, stir, lick) Songs/ rhymes (1,2,3, BITE)
Poor Food Variety MAKE EATING PREDICTABLE MODULATE SENSORY EXPERIENCE Sensory seeker/ avoider ? –“Big” food flavors –Dry foods before soft solids Distance food contact –Squish food in baggie –Cut up straws as holders –Dry finger foods “Comfortable” environment –(lights, mirrors, noise, etc)
Connor Sensory seeker Over stuffs & pockets food in cheeks Grinds teeth Swallows food whole or barely chewed Messy eater; not aware of food on hands or lips Difficulty with manipulating food with hands or utensils Prefers big food flavors
MAKE EATING PREDICTABLE for rigid eaters REDEFINE “eating” (expectations) tolerating/ looking smelling touching licking biting chewing swallowing
MAKE EATING PREDICTABLE for rigid eaters FEEDING DYNAMICS Division of responsibility: Adults (what, when & where), Child (if & how much) Ellen Satter Force/ permission Dance Force Distractions (tv, toys, computers,cars, etc) Bribes
Food Fun Group Based on Kay Toomey SOS Program 12 weeks – 1.5 hour sessions Child group (with 10 foods) Parent group (discussion & support)
Picky Eaters vs. Problem Feeders Adapted from Kay Toomey “Picky Eaters vs. Problem Feeders” PICKY EATERS Decreased number of acceptable foods (30 or less) Food jags – burn out foods regained after 2 weeks Tolerates new foods on plate (may touch/taste) Eats a variety of food textures Family dynamics may intensify PROBLEM FEEDERS Extremely limited range of acceptable foods (20 or less) Brand-specific food preferences Downward spiral – no regaining of burn out foods Cries/falls apart with new foods Feeding skills are often delayed
Age Related Problem 4-6 months = 19% 7-8 months = 25% 9-11 months = 29% 12-14 months = 35% 15-18 months = 46% 19-24 months = 50% Carruth, et al. “Prevalence of picky eaters among infants and toddlers and their caregiver’s decisions about offering a new food,” J of the American Dietetic Assoc. supp.1 Vol 104 (2004)
Average Weekly Weight Gains Age (months) Weight (ounces) 1-65-6 6-123-5 12-15 2 15-361.5 36-481.2 Source :JUST TWO MORE BITES by Linda Piette
Help Unhappy Eaters BALANCE Nutrition Goals (growth & eating habits) Child’s Maturity (digestive, motor & sensory)
Shape food attitudes… Set realistic goals and strategies…….. Consider eating style: Happy, Careful (rigid), Tiny or Fragile