The Feeding Relationship

The feeding relationship Nourishing and nurturing Supports developmental tasks

Development of Feeding Behaviors AgeReflexesFeeding Behavior B-3 monthsRoot, suck- swallow-breathe Suckling pattern of feeding 4-6 monthsFading root/bite reflex Mature suck, brings objects to mouth, munching pattern 7-9 monthsNormal gag develops Munching, rotary chewing, sits alone, holds bottle alone months Bites, brings food to mouth, drinks from cup, spoon feed

Stages of Development Homeostasis Attachment Separation and individuation

Stages AgeInfant Development 1-3 monthshomeostasisstate regulation neurophysiologic stability 2-6 monthsattachment“falling in love” affective engagement and interaction 6-36 monthsseparation and individualization differentiation behavioral organization and control

The Feeding Relationship The Relationship –Parent –Child Tasks –Parent –Child

Tasks Infant –time –how much –speed –preferences Parent –food choices –support –nurturing –structure and limits –safety

Homeostasis Infant cycles through physical states Parent provides a safe and comfortable environment Reflex feeding transforms to self regulation of hunger

Attachment Emotional/social interactions Parent reciprocates/engages Infant’s emotional and physical needs reinforced

Separation Struggle for autonomy Parent supports autonomy and guides daily structure Emotional needs distinguished from physical needs

Children do best with feeding when they have both control and support

Feeding “is a reciprocal process that depends on the abilities and characteristics of both the parent and the child…Once feeding starts, the parent and child work on the process with more or less flexibility and skill” Satter J Pediatr 117(2) 1990

Problems established early in feeding persist into later life and generalize into other areas Ainsworth and Bell –feeding interactions in early months were replicated in play interactions after 1st year

Healthy Feeding Cycle Child associates hunger with need to eat Child communicates need Parent reads cues and provides Child communicates satiety Parent responds Positive experience gained Parent anticipates physical needs

Feeding Difficulties Related to maturity, medical and neurodevelopmental status State control endurance suck-swallow-breath coordination sleep-wake cycles cues and demand behavior temperament patterns of oral-motor development

Feeding Delays in feeding skills feeding intolerance behavioral medical/physiological limitations other

Factors to consider Medical Developmental Temperament Psychosocial Nutritional Environmental

Factors Medical respiratory, cardiac, GI Developmental immature feeding skills, temperament, sensory integration, oral/motor

Factors Nutritional –Frequency, density, appropriate, balance, other Psychosocial –Anxiety, depression, stress, unmet social.emotional needs, disarray –Self regulation, attachment, separation

The Complexity of feeding problems in 700 infants and young children Presenting to a Tertiary Care Institution Rommel et al: J Ped Gastro and Nutrition, July 2003 Multidisciplinary Assessment catagorized feeding problems: –86.1% medical –61% oropharangeal dysfunction –18.1% behavioral

Rommel et al Single identified problem –26.7% medical –5.2 % oral/motor –5.4% behavioral

Rommel et al Multifactorial –48.5% oral/medical –1.5% oral/behavioral –5.2% medical behavioral

Rommel et al Medical/oral-motor –occurred more often <2 years of age Behavioral –occurred more often >2 years of age

Focus Group Parent Response from Gaining and Growing Website “ I wasn’t afraid to bring home a baby that weighed only 3 pounds, but I was afraid to bring home a baby that wouldn’t eat”

Parent Response Survey of Parents of Premature Group “ I felt I had to choose between growth and force feeding” “At 9 months, height/weight is proportionate, but we are still having to force feed” “I’ll have concerns until she is at 5% for everything” “even though my son had no difficulties with the mechanics of eating and no food issues, we had lots of questions, much anxiety, and too much stress…”

Jamie Born prematurely at 25 weeks GA Birthweight 800 grams Current age: 1 month corrected age Problems: –BPD –Feeding difficulties –Growth concerns: poor weight gain

Jackson Born at 32 weeks gestation Birth weight 1100 grams, small for gestational age Currently 15 months corrected age Problems: –growth concerns: weight and length <5th % –Speech and developmental delays –Feeding Problems: gagging, food refusals, difficulty transitioning to solids