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Feeding avoidance is when an uncomfortable situation occurs related to food. The situation can be either painful, frightening, or scary since there was too much pressure, and the control was taken away from the child. This experience with the food may lead the child to remember the specific situation as something negative. The child typically becomes extremely selective and picky with what they want to eat. The negative experiences then become a memory for the next mealtime, leading the child to have a feeding aversion. A feeding aversion is where the child associates feeding as negative and will avoid it altogether. Food avoidance leads to feeding aversion! Causes of Feeding Aversion: The digestive function is not working properly Medication tastes gross or creates abdominal pain Cardiorespiratory issues Tube feedings Lack of oral experiences Inappropriate responses to child's cues Oral Hypersensitivity Tip for Children with Feeding Aversions: Provide opportunities for non-related food sucking Offer a soother (e.g., chewy toys) Encourage mouthing of fingers and toys Encourage participation with mealtime routines even if the child does not eat the food Provide proper positioning with the right support Limit distractions during mealtimes Have a regular feeding schedule (3 meals a day with a snack in-between) Make gradual changes Food chain Give the child control Give the child an opportunity to spit Provide repeated exposures to food even if the child shows disinterest References Cammarata, C. M. (Ed.). (2023, April). Avoidant/restrictive food intake disorder (ARFID) (for parents) - nemours kidshealth. KidsHealth. https://kidshealth.org/en/parents/arfid.html Marcus, S., & Breton, S. (Eds.). (2022). Infant and child feeding and swallowing: Occupational therapy assessment and intervention (2nd ed.) AOTA Press.

FIRST! eating is not the top priority for the body - ensure the first two steps are addressed before addressing eating! 1. Breathing 2. Postural stability 3. Eating For eating, feeding, and swallowing difficulties, “a collaborative team approach is essential for assessment and ongoing management of feeding difficulties" (McComish et al., 2016). Roles Speech Language Pathologist: SLPs focus mainly on the oral structure and swallowing problems. SLPs can conduct a swallow barium study and endoscopic assessment to determine where the food is going and how the child’s swallow looks internally. Occupational Therapist: Occupational therapists focus on maximizing the child’s engagement in therapeutic activities in daily living, such as eating, feeding, and swallowing. OTs help the child develop the fine motor skills needed to hold utensils or to bring food to the mouth, develop social skills of what food they like and do not like (how to ask for more, expressing feelings of hunger/stomach ache/fullness), address seating and positioning at the table, and regain/adapt functions to have successful eating habits (Blayden et al., 2021). Children with feeding problems often have sensory challenges that impact their participation in eating; therefore, an occupational therapist is important to address these sensory sensitivities (Gettier, 2022). OTs are responsible for creating a positive feeding experience while expanding oral motor development for children with inadequate oral skills to increase their confidence in food exploration (Petrozelle & Moll, 2020). Physical Therapist: Physical therapists address the postural tone and movement of the child's body. Postural control comes first when it comes to eating and feeding oneself; if it is not strong, eating becomes an undesired experience. Specific postural components the physical therapist will work on are head control, trunk control, and specializing the seating arrangements for feeding if needed. Nutritionists/Dieticians: Nutritionists and dieticians are the food and nutrition experts. This discipline “evaluates the growth parameters and growth potential and assesses caloric and nutrient need and tolerance. Teach parents food and formula preparation and provide information on nutritional needs. Dieticians recommend specialized formulas chosen for caloric and nutrient properties and for tolerance” (McComish et al., 2016). “They work with families toward a balanced healthy diet using food from all food groups as well as normalizing feeding schedules” (McComish et al., 2016). Lactation Consultant: A lactation consultant assesses "the maternal lactation status in conjunction with the infant's breastfeeding ability and supports the mother to achieve her breastfeeding goals" (Marcus & Breton, 2022). Lactation consultants are crucial in the NICU setting and ensuring breastfeeding is smooth. Gastroenterologist: A gastroenterologist will evaluate any pain or diarrhea experienced, poor weight gain, reflux, and constipation (Haiao, 2014). Behavioral Psychologist: When a child's behavior, such as shaky hands, phobic reactions to foods, or appearing "out of control" during mealtimes and is affecting their nutritional status, a behavioral psychologist is here to help. A behavioral psychologist can administer as many tests and measure a young person’s intellectual health to determine a child’s psychological health if the medical factors are ruled out and feeding/swallowing activities are still impacted. Allergists/Immunologists: Allergists and immunologists determine allergies and food intolerances that may be causing the child internal discomfort or pain in the GI tract. Internal discomfort or pain leads to children not wanting to eat, having irregular bowel movements, difficulty with digestion, and frequent vomiting. When experiencing these symptoms, no one would want to explore foods. Cardiologist: Children with cardiac issues tend to fatigue quicker, and eating takes energy; therefore, the child may not receive the proper nutrition. Cardiologists can determine underlying factors and solutions to increase energy in a child’s daily life. Dentist: The dentist can determine if any cavities or pain are causing the child to refuse to eat or be defensive about their mouth when eating or brushing their teeth. Endocrinologists: An imbalance in hormones can cause the child to be malnourished due to the body’s inability to process certain nutrients. Endocrinologists can help control the child’s metabolism, nutrition, growth, and energy. Nurse: “Neonatal nurses are the frontline practitioners who judge preterm infants’ risk for aspiration during oral feeding and determine readiness for oral feeding. They use their clinical judgment to determine when preterm infants are physiologically stable, ready to initiate oral feeding, and feeding adequately” (Ferguson & Estis, 2018). Teacher: The teacher of the child has an important role since they are in the child's everyday life during the school week. The teacher will be able to observe the child's behaviors and tolerance regarding eating in a noisy and busy environment: the cafeteria. Teachers can help advocate for the child's eating by informing parents or other therapists on how they are eating, what they are eating, and how they are interacting with their environment during lunch or snack time. Other Important Roles to Consider The Child: The child is the most important person to listen to and observe when addressing their eating difficulties. There is a reason why they are having difficulties eating in the first place! The Parent: The parent(s) are the primary feeders for the child. Parents are very aware of how their child behaves/interacts with foods during all meal intakes. Parents are key; therefore, it is important to listen to their concerns about what has been working, what has not been working, their relationship with their child, and their culture/beliefs regarding eating. References Blayden, C. M., Holland, K., Hughes, S., & Nicol, J. (2021). Feeding difficulties in children: A guide for allied health professionals an evaluation report. Internet Journal of Allied Health Sciences & Practice, 19(3), 1–8. Feeding matters. (n.d.). Feeding skill. https://www.feedingmatters.org/what-is-pfd/feeding- skill/ Ferguson, N. F., & Estis, J. M. (2018). Training students to evaluate preterm infant feeding safety using a video-recorded patient simulation approach. American Journal of Speech-Language Pathology, 27(2), 566–573. https://doi.org/10.1044/2017_AJSLP- 16-0107 Fraker, C., Fishbein, M., Cox, S., Walbert, L. (2007, November 2). Food chaining: The proven 6-step plan to stop picky eating, solve feeding problems, and expand your child’s diet. Hachette Books. Gettier, M. (2022, June 1). Children with problematic feeding, selective restrictive eating: A pilot program. Aota.org. https://www.aota.org/publications/ot-practice/ot-practice-issues /2022/problematic-feeding-selective-restrictive-eating Haiao, E. Y. (2014). Gastrointestinal issues in autism spectrum disorder. Harvard Review of Psychiatry., 22(2), 104–111. doi:10.1097/HRP.0000000000000029 Marcus, S., & Breton, S. (Eds.). (2022). Infant and child feeding and swallowing: Occupational therapy assessment and intervention (2nd ed.) AOTA Press. McComish, C., Brackett, K., Kelly, M., Hall, C., Wallace, S., & Powell, V. (2016). Interdisciplinary feeding team: A medical, motor, behavioral approach to complex pediatric feeding problems. MCN. The American Journal of Maternal Child Nursing, 41(4), 230–236. https://doi.org/10.1097/NMC.0000000000000252 Morris, S. M., & Klein M. D. (2000, January 1). Pre-feeding skills: A comprehensive resource for mealtime development. Pro-ed International Publisher. Petrozelle, D., & Moll C. M. (2020). Sibling-supported feeding intervention: Sibling participation leads to growth in food repertoire and generalization of positive habits to home. OT Practice, 25(2), 10–13.

The first feeding session should be solely focused on the child! The therapist’s primary goal in the first session is to build a positive and healthy relationship with the child. A new environment and new people can be a stressful experience; therefore, the food comes second. The food is introduced to see what the child can and can not tolerate. It is also a time when the food may not be touched. During the first session, the parent(s) may or may not be in the room. This will be a decision that is made both by the therapist and parent(s). It will also be based on the parent’s preference, and the presence of the parent(s) may change as the child progresses with feeding therapy. What should you bring to feeding therapy? A hungry child! Food! The therapist will typically recommend bringing two preferred foods and two non-preferred foods. What role does the caregiver play in feeding therapy? Interacting in feeding therapy if the therapist instructs the parent to Participating in caregiver training Implement the therapist’s recommended home program at home

Halloween candy, it's always hard to navigate how much or how little a child should be given. Should they be allowed to eat everything, or should the candy intake be limited? For parents and caregivers, the suggestion is to use your best judgment based on your child's needs. For example, if your child tends to overeat, give them the opportunity to overeat so they can learn what it may feel like to have too much candy. If your child tends to undereat or is a picky eater, suggest offering a highly preferred candy throughout the week. If your child tends to be dysregulated, such as bouncy up and down, fidgeting their fingers, or cannot sit still, suggest removing any candy with Red 40 in it as it can enhance the dysregulation (Darby, n.d.). Halloween happens once a year which presents a learning opportunity for all children (Satter, 2000)! When a child goes trick-or-treating, it is so exciting to collect all their favorite candies that they normally can't have. They look forward to getting home and spreading the candy they've collected. Halloween gives an opportunity to provide responsibility to the child the first two days on how they want to get the candy, possibly eating as much as they want or trading for chocolate only! This responsibility comes with a consequence, sometimes a stomach age or headache due to overeating candy. However, this will allow the child to learn how their body feels when they overate, giving the opportunity to talk about possible solutions for next time. This lesson also allows the child to learn more about their internal cues (e.g., headaches, stomachache, not full), and the parents can come in to talk about why he/she may be feeling the way they are. Parents can interfere when they feel their child may be at harm or they feel spacing out the candy is their preference. Tips for Halloween Day (Cronan, 2021): Have a good healthy meal before trick-or-treating Talk about candy expectations at home before Halloween Store and keep candy in the kitchen to distinguish what room is for what (for example the bedroom is for sleeping and relaxing, the kitchen is for cooking and eating) Role model how you want your eats to eat candy (in moderation) Role model that it does not have to be candy (for example our house hands out toys, cereal, snacks, bubbles) Important Note: Halloween only happens once a year! It will not ruin the year's progress you have made with your child References Cronan, K. M. (Ed.). (2021, October). Halloween candy hints (for parents). Nemours KidsHealth. https://kidshealth.org/en/parents/candy-hints.html Darby, J. (n.d.). Nutrition management for patients with ADHD - Summit professional education. Summit Education. from https://summit-education.com/online-course /2304877 Satter, E. (2000). Child of mine: Feeding with love and good sense. Bull Publishing Company.

Oral feeding in infants is a highly complex process involving multiple nerves and muscles working together to control the incoming liquid without choking or gagging (Marcus & Breton, 2022). The complex process also includes being able to coordinate the suck, swallow, and breathe all at once. If the infant does not have suck-swallow-breathing coordination, breathing is the primary focus, and feeding is no longer of interest and becomes a dangerous thing. If your baby is fussy, coughing, or gagging during bottle feedings, this can be a sign of a feeding problem (Fraker et al., 2007). The first step is to try one different formula, but if the new formula does not work, address the problem to your pediatrician. Signs of poor suck-swallow-breathe coordination (Marcus & Breton, 2022): Unable to breathe during a sucking burst Pulls away from the nipple Appears panicked or frightened Loses liquids at the corners of the mouth Has disorganized tongue movements Shows signs of breathing distress Uses short sucking bursts with frequent pauses Refuses to eat after a few feeds Tips to improve bottle feeds Establish consistency with how you feed your infant Read your infant cues, such as stop feeding when showing signs of distress Provide lots of rest breaks throughout Decrease the liquid flow (there are multiple bottle systems in the market that does this) Feed infant in a side-lying position, helping them breathe easier References Fraker, C., Fishbein, M., Cox, S., Walbert, L. (2007, November 2). Food chaining: The proven 6-step plan to stop picky eating, solve feeding problems, and expand your child’s diet. Hachette Books. Marcus, S., & Breton, S. (Eds.). (2022). Infant and child feeding and swallowing: Occupational therapy assessment and intervention (2nd ed.) AOTA Press.