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FEEDING- Introducing Solids

 

     

 

 

 

 

 

 

 

 

 

 

 

Conditions that may lead to feeding and swallowing disorders

Being born prematurely or having a low birth weight
• Reflux
• Breathing difficulties such as asthma
• Cleft lip or palate
• Hypotonia- affecting oral-motor skills
• Medicines that reduce appetite or make the baby drowsy
• Sensory issues
• Diagnoses- CP, Cystic Fibrosis, Down’s Syndrome, ASD

 

 

During the early stages of introducing solids, the goals are to improve oral motor skills, establish safety, maintain positive associations with eating and to develop a diet with a wide variety of foods.

 

4 Phases of Swallowing
1. Anticipatory Phase: This is the “getting ready” phase
2. Oral Phase: Oral Preparatory and Oral Voluntary- This is where the food or liquid is manipulated in the mouth into a bolus and propelled backwards to exit the oral cavity.
3. Pharyngeal Phase: This phase begins with the initiation of the swallow reflex.
4. Esophageal Phase: This moves the bolus through the esophagus into the stomach.
** The Pharyngeal and Esophageal Phases are involuntary.

 

Introducing new textures
Before introducing new textures, first look for signs of readiness:
• Good head control- Baby can hold their head up and sit up straight while supported in a high chair
• Baby opens their mouth when the spoon approaches and can clear the spoon with their lips
• Baby has mastered thin purees – can swallow thin purees without gagging or choking, or tongue thrusting
• Baby shows interest in what parents or other children are eating
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3 Stages of baby food — from purees to finger foods
Stage 1: Thin Purees (4 to 6 months).
Stage 2: Thicker consistency (6 to 9 months).
Stage 3: Soft, chewable chunks (10 to 12 months).

 

Texture Progression

Stages Typically introduced  Example
Stage 1: Liquid

 

 Birth – 4/6 months Breastmilk or formula.
Stage 2: Thin purees

 

4-6 months

• Shows interest in food & opens mouth when spoon approaches

Infant cereals, thin pureed fruits and vegetables. Beginning with single ingredient, then combined ingredients.
Stage 3: Thick purees 6-7 months

 

Gradually thicken familiar thin purees by adding less water, or adding baby cereal to thicken it. Homemade applesauce, yogurt, meats pureed in a blender, pureed soups, mashed veggies and fruit.
** With fork-mashed soft fruits and veggies initially make sure the consistency is uniform. At 8 months start to introduce lumps in food.
Stage 4: Meltable/Dissolvable solids. 9 months Dissolvable or meltable solids are finger foods that completely dissolve in saliva with no or minimal pressure from the tongue, palate or teeth. Therefore, they do not require the oral-motor skills that other lumpy or hard solid foods require. E.g. Gerber Puffs, Cheerios, Graham Crackers, Mum Mums.
Stage 5: Soft cubes 10 months Soft exterior but maintains its shape, needs munching pressure to break it apart. E.g. Ripe fruits, overcooked vegetables, avocado, peaches, sweet potatoes, banana, cut into small cubes for finger feeding.
Stage 6: Soft solid single texture 11 months

 

Pasta without sauce, scrambled eggs.
Stage 7: Soft solid mixed texture

Mixed textures are challenging because infants learn to eat purees with a sucking motion.

12 months Macaroni and cheese, lasagna, fish sticks.
Stage 8: Hard solid single texture

 

13 -14 months Raw fruit and vegetables, dried fruit, bite sized pieces of meat- always with supervision.
Stage 9: Hard solid mixed texture 15-18 months Offer whatever the family is eating as long as it is safe for the toddler.

 

NOTE: Pureed food feels safe for parents who worry about babies choking on whole foods. It is however important to introduce new textures and lumpy foods before a child is 9 months of age because studies have shown that delayed introduction of lumpy textures can lead to feeding difficulties and can affect a child’s food acceptance at a later age. 

 

Development of chewing

Hard Munchables
Typically introduced at 8 months.These are hard textured foods for oral exploration only- NOT FOR CONSUMPTION. Examples: carrot stick, lollipop, hard dried fruit sticks, celery sticks, bell pepper strips. Once a child can move their tongue around the hard munchable, they are ready to transition to textured table food. Moving hard solid food around their mouth helps to increase sensory awareness of the mouth and further develop their tongue movement.

Development of tongue movements
• Soft Mechanical – soft texture (soft exterior but maintains its shape), needs munching/grinding pressure to break it apart.
• Hard Mechanicals- harder textured exterior food, requires grinding/rotary chewing (circular chewing pattern) to break apart.

Chewing foods
Chewing requires a combination of lip, tongue and jaw movement. After the introduction of lumpy solids, infants can coordinate all of their mouth movements; sucking, biting, and up and down munching.  Chewing efficiency develops in response to different textured foods being offered. 

 

 

Tips for introducing new foods and new textures 
• Introduce one new food every 3-4 days to help detect potential food allergies. Wait approximately one month before proceeding to the next stage of solids.
• Let the child get messy.
• Tactile play with food between meals can increase comfort with new textures.
• Eat with the child, family meals create a positive mealtime relationship, allows the parents to model good mealtime behavior, and promotes language development.

 

Tips for picky eaters
• Present food in a variety of ways. Try new containers, cups, utensils, toothpicks or even a muffin tin with several choices.
• Offer healthy foods with something fun to dip it in to encourage a variety of colors, textures and flavors. Some dip ideas are ranch salad dressing, hummus, nut butters or chocolate hazelnut spread.
• Cut food in shapes, use cookie cutters or arrange food in a shape.
• Let your child feed themselves. It will be messy!
• Encourage positive interactions with food using the five senses: seeing, feeling, smelling, tasting and even hearing the sound of crunchier foods can help them enjoy eating.
• Offer targeted, healthy choices: do you want your sandwich cut in squares or triangles? Do you want sweet potatoes or peas?

 

Advantages of using a fresh food feeder to introduce solids

• You can introduce baby to new flavors, with a significantly reduced risk of choking.
• It provides opportunities for babies to explore sensory input all around the mouth, rather than just the front of the mouth like most teething toys. This is so important for oral development.
• It can teach babies to move their tongue side-to-side (lateralization) as the feeder moves from one side of the mouth to the other while they chomp with their whole jaw.
• You can use it to introduce foods to toddlers who are picky eaters, so they can try the flavor without having to deal with the texture or actually touch the food.

 

 

 

Sensory processing 

Adequate sensory processing
• Child is not averse to having food on face or hands during meals.
• Child eats a wide variety of tastes and textures.
• Child engages in messy play activities without distress.

 

Behaviors which typically reflect sensory processing difficulties

 

 Signs/Symptoms

Sensory Modulation Hypersensitivity (over-reactive)
– gagging, increased head extension, lip retraction, tongue thrusting, jaw thrusting, and bite reflex.Hyposensitivity (under-reactive)
– deceased coughing, over-stuffing and pocketing, drooling, decreased awareness of food residuals, inability to safely detect hot/cold
Tactile

 

• Limited repertoire of food textures

• Extremes (very mushy – very crunchy)

• Difficulty transitioning with textures

• May spit out lumps in food

• Foods chosen in a pattern

Over-responsive
• Dislikes “messy” play
• Bothered by certain textures of clothing
• Prefers a specific temperature of food
• Avoids mixed textures

Under-responsive
• Unaware of touch unless very intense
• Unaware of food left on face or in mouth
• May swallow a large bolus with no reaction
• “disconnected” from their hands
• Seeks “messy” play
• Seeks strong flavors (food or drink)
• Mouths objects to gain information

Proprioception • May have difficulty adjusting/grading amount of jaw opening needed to take bites of foods

• May hold and use eating utensils with too much/little force

• May bite lip/cheek without noticing

• May not know how much pressure to exert when using a cup/spoon (spilling frequently)

• Poor body awareness (in relation to objects/people – spilling or dropping frequently

• May over-stuff mouth

Gustatory Increased taste sensitivity: over-responsive
• Objects to certain textures (mashed, lumpy)
• Objects to certain temperatures (hot, cold, room temperature)
• Often gags when eating.Decreased taste sensitivity: under-responsive
• Mouths inedible objects (playdough, toys)
• Prefers intense flavors (spicy, sour, salty)
• Prefers intense temperature (hot or cold)
Praxis Major difficulties between coordination and execution of oral movements

 

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Rources:
https://www.ncbi.nlm.nih.gov/pubmed/19161546
https://occupationaltherapy.com.au/building-skills-positive-eating-sos-approach-feeding
https://intermountainhealthcare.org/blogs/topics/pediatrics/2018/07/when-your-babys-not-eating-well
https://www.feedinglittles.com/blog/five-spoon-feeding-mistakes-most-parents-make
https://butterflytherapy.com/feeding-your-child-introducing-textures-sheryl-jean-occupational-therapist

 

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