1. Please Take a Bite!! Decreasing Challenges during Mealtimes April 4, 2014 Presented By: Amanda Beamer OTR/L Pinnacle Health Infant Development Program Kera Fringer, M.S. CCC-SLP Pinnacle Health Infant Development Program Joanne Kliss, M. Ed.,OTR/L Capital Area Intermediate Unit Kristen Owen, D.PT Pinnacle Health Infant Development Program

2. Please Take A Bite! A Review of Feeding Milestones And Strategies for Successful Mealtimes Amanda Beamer OTR/L abeamer@pinnaclehealth.org

3. Nutrition Formula Feeding Guidelines AgeAvg. # of Feedings per day Avg. Amount per Feeding Birth-1 wk6-102-3 oz. 1 wk-1 month 7-82-4 oz. 1-3 months5-64-5 oz. 3-6 months4-56-7 oz. 6-9 months3-47-8 oz. 9-12 months 37-8 oz.

5. Milestones for 0-4 Month Olds  Feed only breast milk or Formula by bottle or breast  Feeding occurs at breast, cradled in caregivers’ arms, side lying, or facing feeder  Recognizes nipple or bottle by sight and turns his head toward the nipple  Brings hands to mouth and sucks on fingers  Coordinates suck, swallow breathe at 2-3 sucks before swallowing

6. 0-4 Month Old Strategies  Create a calm and quiet environment  Never prop a bottle; encourage baby to hold the bottle by guiding their hands to the bottle; feeding time is a great time to bond with your infant  As your infant gets older try to keep them awake during their feedings and do not put them to bed with their bottle  6 wet diapers per day is a good sign that your infant is getting adequate amounts of formula/breast milk  If changing formulas you may try titrating the new formula into the old formula; discuss all formula changes with your doctor  Provide stimulation around your child’s mouth by introducing textures on your fingers and massaging around their mouth  If your infant is showing leakage during feedings alternate his position  Bottle feedings should not last more than 20 minutes

7. 4-6 Month Milestones  Iron fortified rice cereals begin to be introduced if your child is able to sit with support  Begins to accept mild fruits and veggies in puree form  Continues breast/bottle feedings  Spoon is introduced  Chewing patterns begin to emerge  Begins to pat bottle with one or both hands  Opens mouth when spoon is presented **Always check with your pediatrician before offering new foods

8. 4-6 Month Old Strategies  When beginning infant cereals start with a thinner consistency and work up to a thicker consistency  Allow your child to begin closing their mouth on the spoon to remove the food  Explore a variety of spoons that are smaller than an adult sized spoon, shallow spoons work well  Apply slight pressure to the back of the tongue to prevent tongue thrust  Face your child when feeding them and show excitement when he accepts a bite  Allow your infant to explore new foods with their hands, by placing some on his tray before mealtime  Add a spoonful of pureed fruit/veggies to your infant cereal to begin to change taste  Alternate between a consistent taste and new taste when introducing a new taste

9. Allergies  When beginning to introduce foods from a spoon, it is time to start looking for signs of allergic reactions  It is best to begin with rice cereals because there are less allergens  Introduce a new food and wait three days before introducing the next new food  Signs of Allergies Rash Diarrhea Runny nose Vomiting **Speak with your child’s pediatrician about any allergy concerns; every child is different

10. 6-9 Month Old Milestones  Primary nutrition continues to be from formula/breast milk  Begins to accept finely chopped, soft fruits and veggies when your infant has teeth  Able to sit in a highchair with some assistance  Begins to accept a cup held by an adult  Chews using a side to side tongue movement  Clears food from a spoon  At 9 months begins to swallow with lips closed  Begins to feed himself dissolvable solids using fingers

11. 6-9 Month Old Strategies  Gradually add lumps and fork mashed fruits and veggies to purees  Don’t give up when your child refuses a food; continue to offer it.  Make mealtimes happy and use positive praise  Portions are small. May want to offer smaller meals/snacks more frequently.  Open cups can be introduced to assist in lip closure. Can try in the bath tub to prevent spilling and use of a small medicine cup  Offer hand over hand help to help child bring dissolvable solids to their mouth  Remove valve from sippy cups

12. 9-12 Month Old Milestones  Whole cow’s milk can be introduced at 12 months (discuss with your child’s pediatrician)  Able to sit in a high chair  Takes teething biscuits, dissolvable solids, ground/mashed foods  At 9 months swallows with mouth closed  Improved ability with cups  Reaches for spoon and will bang spoon when grasping  Finger feeds many soft foods  Begins to hold cup/sippy cup

13. 9-12 Month Old Strategies  Add fork mashed fruits and veggies to puree, slowly decrease puree that is added  Alternate between textured bite and non-textured bites  Make slow changes to textures if your child is hesitant with new foods  If your child is resistant to the spoon, you may need to take a break from the spoon. Use other foods as a spoon.  If your child is not showing interest in accepting foods by spoon; promote the feeling of hunger by limiting drinks before mealtimes. Offer liquids after the meal.  Try to avoid stage three foods; ground and fork mashed soft foods provide more nutrients and help to avoid surprise textures.

14. 12-18 Month Milestones  May begin to reject the bottle/breast  Improved use of the cup  Accepting soft table foods  Feeds self with fingers  Begins to self-feed using a spoon  Use upper lip and front teeth to clear food from spoon  Bites through soft foods  Drinks from a straw  Picky eater concerns may develop

15. 12-18 Month Old Strategies  Begin to offer straws; juice boxes; self-priming straws  Help your child scoop food and guide to his mouth using hand over hand help and by positioning yourself behind your child so your child can see their hand holding the spoon  Place food on their fork and allow them to bring to their mouth  Use spoons and forks in play  Create a calm environment  Keep objects familiar and a consistent routine  Keep your child’s tray simple and serve small portions so your child does not become overwhelmed  Embrace the mess, encourage touch and play in new foods. Use fun and positive words to describe the foods they are touching.  Always include a food that is consistent.

16. 12-18 Month Olds Mealtimes should be limited to 20-30 minutes An egg timer can be introduced to end the meal Snack times are a good time to work on new food introduction, so that the mealtime is not disrupted

17. Bottle Weaning  Toddlers between the ages of 15-18 months are more likely to become attached to objects  Around 9 months offer bottles after meals and snacks, except in the morning and at bedtime  Around 11 months remove one bottle and offer a snack instead  Around 12 months the bottle should primarily be in the morning and at bedtime  First bottle to eliminate should be the lunch bottle; offer your child’s milk in a cup instead  At breakfast begin to wean the morning bottle and offer a breakfast of table foods with in 30 minutes of waking

18. Bottle Weaning Continued  If your child is over the age of 2 ½ you may want to try having the “bottle fairy” visit your home  Prevent your child from walking around your home with the bottle or falling asleep with the bottle; this may harm their teeth  Do not offer juices or flavored milks from bottles; limit these liquids to sippy, open or straw cups  Always offer sippy, straw and open cups at meals beginning at 9 months  After your child is weaned; remove all bottles  Redirect your child to an exciting activity when they request the bottle  If your child is older begin to warn your child that it is about time to be a “big boy” and give up his bottle  Make night time bottles less inviting by adding water to milk

19. 18-24 Month Old Milestones  May give up bottle  Efficient with cup  Takes harder and chewy table foods  May sit in a booster seat or child sized table  Efficient rotary chew  Bites through a variety of foods  Brings spoon to mouth with palm up

20. 18-24 Month Old Strategies  Allow your child to help choose foods at the grocery store  Allow your child to help in the kitchen; give them their own bowl to mix  Use positive reinforcement and first, then statements  Eat meals as a family so your child can have positive role models  Offer foods on fun divided plates or in muffin tins  Offer dipping sauces  Have a consistent meal routine

21. 24+ Month Milestones  Mature chewing pattern  Drinking and swallowing skills are complete  Uses cup efficiently  Eats regular table foods  Use a fork and spoon efficiently

22. Calorie Boosters  Butter/Vegetable Oil (35-40 calories/tsp)  Wheat Germ (25 calories/tbsp)  Powdered Milk (25 calories/tbsp)  Powdered Cheese  Cream Cheese (50 calories tbsp)  Heavy Whipping Cream (50 calories/tbsp)  Avocado (75 calories per ¼ avocado)  Pediasure (speak with pediatrician)  Carnation Instant Breakfast

23. Resources and References  www.sleeplady.com www.sleeplady.com  www.gerber.com www.gerber.com  www.similac.com www.similac.com  Klein, Marsha Dunn and Delaney, Tracy. Feeding and Nutrition for the Child with Special Needs.  www.Amazon.com www.Amazon.com Benders Spoons by Boon Munchkin Trainer spoons Learn and Turn Adjustable Spoon and Fork Beaba Rotating Spoon Suction Bowls