Key Elements of Picky Eaters: Feeding Assessment

I have been a speech therapist for over 11 years with a real love for feeding and swallowing. In the past couple years, the buzzword in our community, not just in our speech therapy community, is “picky eating”. What's normal, what's typical? What's just not pushing our children? Picky eating has really evolved and become very well known.

I actually have my own picky eater. I think one thing I left out of my bio is that I am a mother of three. Twin boys are my youngest and one of them is a very picky eater.  So, I have worked on this professionally and personally, and some nights at dinner I just want to quit.

This course will focus on the assessment of picky eaters.  I will review some common causes of picky eating, how to complete a comprehensive assessment, and then review some case studies.

Understanding Feeding Disorders

The first thing we're going to look at is understanding feeding disorders. You have to understand the “why” behind something to understand how to fix it.  That goes for everything in life, but especially with feeding disorders.

Feeding starts reflexively. However, it does not stay reflexive. It becomes a learned behavior. Initially a healthy baby without challenges, is going to come out of the womb and suck on a nipple; whether it be a pacifier, a bottle, a breast, et cetera. It's reflexive. Over time, they learn if they like that or if they did not like that? Did that work, did that not work? Did that go into my lungs? Nope, I'm okay. Or yeah, it did, I don't like that. So, feeding becomes a learned behavior fairly quickly, not too long after birth.

In addition to that, feeding skills are tied to gross and fine motor skills. Being able to determine where they are with their gross and fine motor skills is really going to help with where they should be with eating. Not necessary where they are, because sometimes external factors have either pushed them further than they should be or held them back more than they should. But they are tied together and we need to remember that.

Typical Oral Motor Development

Looking at typical oral motor development, below are the approximate age ranges of when certain oral motor skills begin.

• Suckle (emerges 28-40 weeks gestation)
• Suck (develops 6-9 months)
• Chewing Pattern
  • Munch (7-8 months)
  • Vertical or Lateral Chew (9-12 months)
  • Rotary Chew (12-36 months)

If you have a four-month old, you're not going to be working on chewing. It's kind of easy from the beginning to know. A suckle develops in utero between 28 and 40 weeks gestation.  Sucking develops between six and nine months.  Suck and suckle tend to get used interchangeably, but there is a slight difference between the two.  A chewing pattern has some layers to it.  Babies don’t just go from sucking to chewing.  There are various layers to chewing.  Infants need jaw stability to move from that sucking pattern to the first level of chewing, which is a munching pattern.  (Developing the entire chewing pattern actually takes years.  A rotary chew is not developing until 12-36 months. It takes that full two-year range to fully develop and mature.) But munching is seen around seven to eight months.  A munching pattern is the tongue and jaw moving up and down together. It's less reflexive.  The tongue is flattening out.  It doesn’t have that complete cupping shape, like it does for sucking.

A vertical or lateral chew usual emerges around 9-12 months.  The tongue starts moving laterally in conjunction with the jaw moving up and down.  The last level with chewing is the rotary chew, emerging about 12-36 months.  With a rotary chew, the jaw is moving in a semicircular motion with the tongue moving laterally as well.  It's like a side to side, up and down, and all around.  A rotary chew is very mature and it's what our typical developing 1-3 year olds are doing.

We need to understand typical oral motor development because many of the children on our caseload don’t have it.  However, we need to know it so that when they come to us, and they're stuck in one of these patterns, we know what's next. We know what we need to be working on to move next with them.

Oral Motor Compared to Gross Motor

Again, oral motor is tied to gross and fine motor. So, what are these gross motor skills? Between the ages of 0-6 months, babies have a suckle. In gross motor development, at 0-6 months, babies are also working on head control and propping themselves up. They're not sitting by themselves yet, but they are propping up.  At 6-9 months, the suck comes in for oral motor development and infants are also starting to do a little bit of rolling and sitting. Their core is getting stronger which is really needed for success with their oral motor as well. Then, at 7-8 months, a munching pattern starts to happen. Remember, munching is not a full chew. It is just the beginning of chewing. For gross motor, at 7-8 months, infants are starting to crawl. They're alternating their right and their left. They are also doing this up-and-down motion with their mouth.  At 8-12 months, they're doing a vertical chew. At the same time, they're starting another gross motor skill of standing and cruising. Then from 12-36 months, the rotary chew develops as well as walking.

Again, these are typically developing children. Some of our children are not quite this straight across the board. But knowing what is typical helps you know what to do next with a child on your caseload.

Diet with Oral Motor Pattern

Now that we know how oral motors skills are tied to gross motor skills, let's look at what diet goes with each oral motor pattern.  Diet needs to be consistent with the oral motor pattern that the child is currently demonstrating, not their age.  For example, a baby might be 12 months old, but if he is just learning to sit, then he should not be eating something like toast.  However, the mom might be giving toast to the baby because he doesn’t mind the texture.  He is on your caseload though because he is struggling with it.  It’s important go back and look at what is his oral motor pattern? What are his gross motor skills? What's their appropriate diet?

There are several types of diet:

• Liquid
• Puree
• Mashed Solids
• Soft Meltables – yogurt melts, etc.
• Chopped Table Foods
• Regular Diet

Liquid

An example of a liquid diet is breastfeeding, formula in a bottle or breast milk may be in a bottle. Babies who are 0-6 months old are on a liquid diet.  The oral motor pattern that goes with that is a suckle.  The gross motor skill that we should be seeing is the beginnings of head control and working on propping up. All of this is, again, typical development. But even with infants who are not showing typical development, oral motor and gross motor skills are tied together.  A suckle with head control and propping, and a liquid diet is what's appropriate for them.

Purees

Purees consist of Stage 1 and Stage 2 baby foods with a spoon, such as pre-made or homemade purees in a blender.  These are usually fed to infants who are 4-7 months old who are able to suck.  These infants are typically sitting at this age as well.  Their core is getting stronger, which is the foundation for spoon feeding. When the core is strong, they are starting to sit and are ready for spoon feeding.

If you have a child with Down syndrome, they are going to hit all these milestones. But they might be a month or two later compare to typically developing babies.  Remember, we need to do spoon feeding when their core is ready and they're starting to sit. The age of 4-7 months is just typical developing children. It's not a requirement that they are doing spoon feeding of purees by this age.

Mashed Solids

Mashed solids are foods such as mashed up bananas, mashed potatoes, Gerber mac and cheese (not what is served at a restaurant). Usually infants around 8-10 months old are eating mashed solids. 

At 8-10 months old, the oral motor pattern is munching into a vertical chew. They're starting to migrate up a level. With gross motor skills, infants are starting to pull up, they're standing near a table or a couch, and cruising along.  They are not walking independently. They're in that transition stage of beginning to walking.

Soft Meltables

The next stage is soft meltables like yogurt melts, puffs, and wafers. etc.   These are pretty safe foods because if they got in the airway, they're likely to dissolve before really blocking the airway.

This stage is usually around 9-11 months.  The oral motor pattern is a vertical chew; that up and down motion with the tongue going a little bit to the sides. Gross motor skills at this stage include walking, although a bit unstable.  They are standing with a wide-gait. Their hands might be out for balance.  They are probably not running across the room yet, but they are getting there.

Chopped Table Foods

At 12 to 24 months, children are eating chopped table food like ground beef, some strawberries, cheese, chicken nuggets, etc.  Their oral motor pattern is a vertical chew and they're working on a rotary chew.  Remember that a rotary chew takes about 2 – 2 ½ years to fully develop. But in this time, they're continuing to practice that skill.

Gross motor abilities include walking and running. They may be going up and down stairs, too. But their walk is really stable.  There is a phrase, “You walk like you chew or you chew like you walk.”  If a child walks very unsteady, then they probably don’t have a rotary chew developed yet.  If a child walks into my office and I see that their gait is a little off, my first thought is to check their chewing abilities. How is their oral motor for chewing? It’s really important to know what they're doing gross motor-wise because it is going to correlate to what they're doing with their oral motor skills.

Regular Diet

At 24-36 months, children are starting to eat a regular diet.  A rotary chew will continue to develop and gross motor skills definitely include walking and running.

Learned Behavior

As I stated earlier, feeding starts reflexively and becomes a learned behavior over time. Each of these steps is a learned behavior.  Therefore, any interference with learning these skills is going to cause a change in behavior. Negative behaviors can start to develop at this time. Examples of interference include aspiration of the food going to the lungs, GI issues (e.g., reflux, constipation), any motility issues and illness.  For example, I had a child with severe RSV.  He was hospitalized and feeding had an interference during that time.  Some children bounce back without difficulties, while others do not. 

Peggy Eicher said it best: “Refusing to eat as a result of interference is the child's appropriate response to our inappropriate demands.” That's really important to share with our families.  They often say to, “What did I do wrong? I did something wrong, I messed up.” We responded to our child and maybe it wasn't the most appropriate response, but we did our best.” It is our job to then teach them some other appropriate responses to their reactions.

Each behavior is a response to a prior stimulus.  Whether that behavior is repeated or not will depend on the consequence following that behavior.  Some examples: 

Let’s say a child drinks milk, has reflux and it becomes very painful.  It doesn’t just happen once but repeatedly.  As a result, the child starts to drink less milk (often stopping at the two ounce mark).  I am not sure why this occurs, but I do see it often that an infant who is bottle-fed will stop at two ounces and it’s often tied to reflux.  They are limiting the volume to make their stomach not hurt so much.  They learn over time that if they stop there, it doesn’t hurt so bad.  It's a learned behavior.

Another example is a child is presented with a solid food. The child finds chewing really hard and, therefore, doesn't enjoy it.  Often, a big chunk of food is swallowed and that hurts a bit.  The child learns to not eat that food anymore.  They change their behavior based on the feedback they receive. 

Cause and Effect

We have to go back to the “why”. Why is all of this happening for this child? What causes the feeding difficulty and what maintains the feeding difficulty may or may not be the same thing.  For example, reflux caused the difficulty as a baby. Then they became this picky eater. The reflux might be gone now, but they still don't like any of those other foods, and they never learned to like those other foods. Even though the reflux is gone, that could still be happening. But if that reflux is still happening, they're going to have that same response.

You don't necessarily know if what caused the reflux is still happening or not. But working with the family in therapy will help you determine if it is.  The longer the issue goes on, the harder it is to actually find the cause. What started all of this, and what is maintaining it? Again, the cause and what's maintaining it may or may not be the same thing.

There is a study called “The Complexity of Feeding Problems in 700 Infants and Young Children Presenting to a Tertiary Care Institution”. It's listed in the references. The study found that gastroesophageal reflux disorder (GERD) is the most frequently identified underlying medical condition for patients with feeding problems.  I think Primary Care Doctors (PCPs), in my area always wonder why I go right to reflux as the issues.  But it is just that common.  If you can’t figure out what is going on with your patient, be sure you have looked into reflux as the cause OR possibly what is maintaining their problem.

Assessment

Without a good assessment, therapy is going to get off to a rocky start.   A really good assessment that looks at why the issue is happening, what is causing it and what is perpetuating it, really gives you a good place to start in your treatment. The assessment includes:

• Case History
• Physical exam
• Current diet – what are they eating, what does it look like day-to-day
• Eating observation – watch them eat
• Home exercise program
• Report

Case History

The first thing that I look at is birth history.  Someone once asked me why I cared about birth history when seeing a six-year-old.  Even if you know that the child had a normal birth with no complications, you need to know that they went home from the hospital without issues. Were they born full time or early? How much did they weigh? Were they small for gestational age? Were there any complications with delivery? Did they go straight to the breast? Did they have trouble nursing? Did they go home on formula and why? That is important information for later.