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Eating Styles Matter feeding & nourishing babies & toddlers who don’t follow typical eating progressions Linda Piette, RD, MS, LDN Author of JUST TWO MORE.

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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:

1 Eating Styles Matter feeding & nourishing babies & toddlers who don’t follow typical eating progressions Linda Piette, RD, MS, LDN Author of JUST TWO MORE BITES Producer of EATING LESSONS – Babies or Vermont Statewide Nutrition Workshop Waterbury Center October 31, 2012 © 2012 Eating Styles Matter by Linda Piette

2 “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

3 Malnutrition Risks - US Obesogenic Environment What disease will 3 out of 4 Americans have by 2020? PROCESSED FOODS ↑ calorie ↑ salt Kids like familiar foods…….

4 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

5 Pediatric News- Oct 2002 Incidence of Feeding Problems 25% of young children 50+% in children with autism 80% in children with developmental delays

6 Growth the most important developmental task of childhood….. keeping score Growth charts…. –Standard charts from –WHO (World Health Organization) on CDC website –Specialized charts for: Cerebral Palsy Down Syndrome Turner/ Williams Syndromes –Weight-age

7 Weekly Weight Gains Age (months) Weight (ounces) Height can ↑ 10 in in the 1 st year Source :JUST TWO MORE BITES

8 Growth How long does it take to gain a pound ? Infants: 3 weeks 1-year-old: 2 months 3-year-old: 31/2 months

9 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

10 Body Size (Weight-Age) WEIGHTWEIGHT-AGE (average for age) RANGE 8 lbsBirth6 – 9.5 lbs 13 lbs3 months lbs 17 lbs6 months14 – 20 lbs 22 lbs1 year19 – 26 lbs 27 lbs2 years lbs 31 lbs3 years27 – 36 lbs

11 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

12 Balancing Nutrition goals (short-term vs long-term) Maturity / readiness for food (digestive, motor & sensory)

13 Eating Styles happy, fussy, careful / fragile? Variations in growth, food variety (flavor & texture), skills & adaptability Balance short & long-term goals

14 Nutrition Goals for babies & toddlers PRIMARY Growth Food Variety (Good Nutrition= Adequate calories + food variety (texture?) SECONDARY Texture Progression Self-feeding Skills Healthy Food Habits

15 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

16 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

17 Fragile Eaters Poor Growth Poor Food Variety Not On Schedule….. Not Ready for Food Medical Risk Developmental Delay

18 Careful/ Rigid Eaters Good Growth ↓ Food Variety (flavors +/textures) –Sensitive to flavor, texture/ Temperature –Brand-specific preferences Self-feeding? Sensory? Behavior?

19 Careful/Rigid Eaters Ben 1-year-old Baby foods –purees Frosting only Force-feeding Adam Rigid eating (flavor + texture) Delayed progression

20 Tiny Eaters Poor Growth Good Food Variety –↑ Flavors –Volume…liquids...solids ? –Texture ? Motor delay? Food Aversions? Behavior ?

21 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

22 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

23 Monitoring Growth Degree of poor growth Pattern of growth fall off Calorie intake –Adequacy –Ratios (solids/ liquids)

24 Poor Growth Fragile Eaters –Medical/ developmental cause ? –Specialized growth chart ? –↑ calorie need ? Tiny Eaters –Oral aversion ? –Motor-delay ? –Timing/ off-schedule intro? –Can’t / won’t eat ? –Family food dynamics ?

25 Poor Growth MAKE EATING EASIER ……… increasing volume Fragile/ Tiny Eaters –Liquids Eating gear –Solids Gradual progressions Modify texture –Demos & reminders –Calorie concentration/ supplements

26 Breast/ Bottle Feeding Common Problems Poor latch –Adequate support? Poor Lip Closure/ –Leakage ? Poor Suck/ Swallow/ Breath Coordination –Rhythmic pattern?

27 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?

28 Breast/ Bottle Feeding Solutions Strategies: –Positioning –Oral Massage (promote tongue grooving & cupping) –Jaw Support –Nipple with wide base –Flow rate ?

29 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 +)

30 Special Bottles/ Nipples- Solutions Haberman-cleft palate Pigeon Nipple ½ firm ½ soft (Children’s Medical Ventures) Dr. Brown reduces air swallowing

31 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

32 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)

33 Cup drinking… new skill Which cup? Practice with open cup + thickened liquid Timing –Transition –Shaping preferences Maximize calories/ oral-motor skills?

34 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

35 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?

36 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

37 Poor FOOD Variety Fragile Eaters (poor growth, poor variety) –Delayed progression with textures –Timing & typical development can ↑ resistance Careful/ Rigid Eaters (good growth, poor variety) Typical (Flavors +/ texture Poor adaptability Self-feeding ?

38 Poor Food Variety MAKE EATING EASIER … increasing texture Solids Modify texture Gradual progressions –Demos & reminders Supplements ? Ratio of calories from liquids vs solids

39 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

40 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

41 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

42 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

43 Self-Weaning?? Started in England Skip purees/ spoon feeding Start with soft-solids (ie. Steamed veggies or soft fruit) Typically 8-10 months

44 Gradual Food Progression Make steps smaller Avoid mixed textures Aim for uniform size…. Food mills Graters Give dry crunchy BEFORE soft/wet solids

45 Oral Motor Programs Facial massage (use fingers or wash cloth) Nuk brush Infadent Vibration Blowing activities

46 Ready or not ….Eating is a Sensory Experience Taste Smell Sight Touch Hearing Careful & Fragile eaters are often NOT READY

47 Poor Variety MAKE EATING PREDICTABLE Prevention Repetition Routines/ structure Modulate sensory experience Redefine eating (expectations) Feeding Dynamics

48 Poor Food Variety MAKE EATING PREDICTABLE PREVENTION Avoid giving food from packages Pre-meal activity Food Jags vs downward spiral

49 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

50 MAKE EATING PREDICTABLE for rigid eaters ROUTINES/ STRUCTURE Schedules Rituals (stir, stir, lick) Songs/ rhymes (1,2,3, BITE)

51 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)

52 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

53 MAKE EATING PREDICTABLE for rigid eaters REDEFINE “eating” (expectations) tolerating/ looking smelling touching licking biting chewing swallowing

54 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

55 Food Fun Group Based on Kay Toomey SOS Program 12 weeks – 1.5 hour sessions Child group (with 10 foods) Parent group (discussion & support)

56 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

57 Age Related Problem 4-6 months = 19% 7-8 months = 25% 9-11 months = 29% months = 35% months = 46% 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)

58 Average Weekly Weight Gains Age (months) Weight (ounces) Source :JUST TWO MORE BITES by Linda Piette

59 Help Unhappy Eaters BALANCE Nutrition Goals (growth & eating habits) Child’s Maturity (digestive, motor & sensory)

60 Shape food attitudes… Set realistic goals and strategies…….. Consider eating style: Happy, Careful (rigid), Tiny or Fragile


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