Strategies for the Fussy Eater

Intervention approaches for oral motor and mealtime problems vary by profession and philosophical approach.

Occupational therapy intervention for these problems typically utilizes a sensory integration-based approach which includes the following guidelines:

• Based on a comprehensive assessment, the Occupational Therapist should identify which pattern or oral motor/mealtime dysfunction applies to the child and use a clinical reasoning approach to determine where to begin and how to progress intervention.
• The intervention should emphasize that the child’s comfort and feelings of safety and security, always come first.
• Family support and education, along with interdisciplinary collaboration, should occur throughout the process.
• Depending on the child’s needs, foundational skills such as sensory modulation, discrimination, posture and respiration should be addressed before progressing to direct interventions involving oral motor skill development or food interactions.
• A variety of activities and techniques is typically used throughout the intervention process.

Sensory Processing Disorder (SPD) can affect a child’s eating habits in different ways: 

Many children who are labelled “fussy eaters’ are actually struggling with sensory processing issues. When the brain does not adequately process the information that it receives from the senses, then the child may experience a disorder of sensory processing – also known as sensory integration disorder.

3 Subtypes of SPD
   

1. Sensory Modulation Disorder, which can present in different ways:
– Over responsive to sensory stimulation
– Under-responsive to sensory stimulation.
– Sensory seeking

Examples
• Oral defensiveness- the child who is over-sensitive to sensations in the mouth. The child may gag on solid or lumpy food and avoid strongly flavored food.
• Oversensitivity to the smells of food- the child who seeks out bland food.
• Sensory Seeking – the child who may dislike bland or soft food and only wants to eat food which is very crunchy, textured or highly flavored.

2. Sensory-Based Motor Disorder, which can present with difficulties such as:
– Poor postural control
– Poor bilateral integration skills (bilateral coordination)
– Poor motor planning skills (dyspraxia)

Examples
• The child who struggles with the skills needed to coordinate using use a spoon or knife and fork, and who may avoid food that takes too much effort to eat.
• The hypotonic child who has poorly developed oral motor coordination resulting in difficulty with chewing and swallowing, and may therefore prefer food which does not need to be chewed.

3. Sensory Discrimination Disorder, which presents as having difficulty in processing and understanding what the child sees, hears and feels. Sensory discrimination is the process of identifying specific qualities of sensory stimuli and attributing meaning to them.
These children have difficulties determining the characteristics of sensory stimuli.

Red Flags

•   Ongoing poor weight gain (dropping percentiles, or losing weight)
•   Frequent choking, gagging, or coughing during meals
•   Avoiding all foods of a specific texture (crunchy foods, soft foods, purees, etc.) or a nutrition group (meats, fruits, vegetables, etc.)
•   Eating less than 20 foods
•   Mealtimes are consistently a battle
•   Children who have difficulty transitioning to purees by 10 months, are not accepting table foods by 12 months, still eating only baby foods after 16 months, or haven’t transitioned to drinking something out of a cup by 16 months.

Recommended Progression of OT Intervention

Phase 1: Whole Body
The purpose of this phase is to address whole body sensory and motor needs. Intervention is based on traditional sensory integration treatment strategies which involve whole body activities. Children in this phase may spend most, if not all, of their treatment session engaged in gross motor activity.

Phase 2: Oral Sensory
The purpose of this phase is to decrease sensitivity of and/or improve sensory discrimination of oral structures (lips, tongue, cheeks). Activities in this phase will involve specific oral motor games to address the specific sensory modulation or discrimination problem of the child.

Phase 3: Oral Motor Skill

The purpose of this phase is to strengthen and promote increased control and use of oral structures (lips, tongue, cheeks). These skills facilitate the child’s ability to manipulate food in the mouth, bite, chew, and swallow food effectively.

Phase 4: Food Exploration– Non-Oral
The purpose of this phase is to increase tolerance of smells, tastes and textures of a variety of food as a precursor to putting foods in the mouth and consuming them for nutrition. Activities will typically involve food-based play, games and activities that require touching, looking at and smelling novel foods without bringing food to the mouth

Phase 5: Food Exploration– Oral & Consumption
The purpose of this phase is to increase tolerance for a wider repertoire of foods for increased consumption. Activities will typically involve food-based play in which child places novel foods in the mouth or eats food.

Phase 6: Eating in Functional Environments
The purpose of this phase it to promote eating meals in the community (restaurants, school) and at home. Emphasis is on functional carryover and transfer of skills developed in previous phases.

Tips to help improve a child’s eating habits at home

Remember that eating is a full body sensory motor experience. It involves body awareness, coordination, and motor planning just to get their hand to their mouth and they also have to be able to grade their movements, using appropriate force and timing to be able to feed themselves.

Preparation

Eat together, eat similar
It is not always practical, but if you can, try to shift your own meal times forward so you eat when your child is eating. Eating with the rest of the family helps younger children learn to eat the same healthy food as everyone else. It can encourage picky eaters to try new foods.

Model good eating
Children learn so much about the world from their caregivers and modelling eating the type of food you would like them to eat is an excellent start. It is also great if they are surrounded by other children eating different food types.

Utensils
The cups and utensils a child uses will affect the way they eat. Provide them with the tools they need to feel comfortable, in control and empowered. If your child struggles with fine motor skills or has poor coordination skills, invest in some eating aids to help with mealtimes.

Movement
If you know that the child just cannot seem to sit still for mealtime (rocking, bouncing, tipping back in the chair)– try some vestibular activities before meals.

Positioning
Make sure your child has a good, supported posture so that they can focus on eating.
– feet supported on the floor or on a bench so that their knees are at a 90-degree angle
– table at the right height
– adequate support at trunk and back

Stimulate the senses
Since eating is a full body sensory experience, oral sensory, olfactory, or tactile play can be used before mealtimes, to prepare the body for mealtime.

** Smell foods — The sense of smell helps to create the flavors that we taste in food. 

** Play with Food — Make an effort to play with food that your child may be resistant to. Being able to touch an unfamiliar or undesirable food is a big step in the right direction when the ultimate goal is to get that food into a child’s mouth.
– blow pieces of popcorn or roll peas across the table
– build with pretzel sticks
– play games
– make a mystery box for your child to reach into and feel different foods.

** Cook with Your Child — Getting in the kitchen with your child is the perfect way to provide interesting, playful experiences with food.

Presentation makes a difference, make food fun . Toddlers and small children are no different to adults. Food not only has to taste good, it has to look good, too. Toddlers are especially open to trying foods arranged in eye-catching, creative ways. Make foods look irresistible by arranging them in fun, colorful shapes kids can recognize. Kids this age also tend to enjoy any food involving a dip. 

Serve one meal for the whole family
Resist the urge to make another meal if your child tends to refuse what you’ve served. This only encourages picky eating. Try to include at least one food your child likes with each meal and continue to provide a balanced meal, whether the eat it or not.

Limit Visual and Auditory Distractions
This means turning off the TV, putting cell phones away, using lower lighting, if necessary.

Expectations

Take Baby Steps
A key concept in dealing with fussy eaters is to introduce one new food at a time, over a period of time, and to not ask your child to eat a plate full of new food. Start by encouraging your child to tolerate a non-desired food on their plate for a certain amount of time. Encourage the child to touch the food with their finger or lips, and to smell the food.

Offer the new food repeatedly: Your child will most likely have to see the food quite a few times before they will try it.

Have realistic expectations
Set small but achievable goals such as trying 1 bite of everything on the plate. It is better to put a small bit of new food alongside a larger amount of food that your child likes.
Make eating fun: By making eating healthy food fun, children are going to be more motivated to try some. Use food cutters to cut food into interesting shapes to make it more appealing.

Mealtimes

Make mealtimes happy & social

Try and make mealtimes an important time for the family to sit down together. Avoid distractions such as having the TV on. Try not to worry about anything that goes wrong during dinner (such as spilled drinks or food).

Introduce new foods in a fun setting
Such as a picnic, in a park or in another situation where your child is relaxed and happy.

Try and buffer the introduction of new and potentially scary foods with more familiar ones
Pair a new food with another food that your child enjoys eating. e.g. add peas or broccoli to mac and cheese

Pay Attention to Body Language
If a child is leaning away, has his hands up in front of his face, or is turning his head away from a food, respect the message that he is sending.

Give your child some say
Refusing food is often a response to wanting greater independence. You can give your child that independence in allowing them to choose their food from a range of healthy options.

Do not punish your child for being unable to eat something

Praise your child for trying
It is especially important to praise and give attention to your child when they try new foods. Once your child is emotionally mature enough for you to negotiate/reason with them (usually between the ages of 3-5 years), then you can start using incentives and introducing a new food to ‘try”. For some children, a reward chart may be appropriate.

Do not give attention to your child when they are refusing
Try and ignore the behavior as best as you can.

Modifying Foods Offered- This may include thickening liquids, decreasing the quantity of food on the plate, altering the density of food to allow for improved biting, minimizing mixed texture foods (e.g. soup), adding flavor via spices, reducing flavor by removing spicy food, being mindful of temperature, etc. You need to match the child’s food to their skills.

• If your child has a sensory aversion to a particular type of food due to its texture, find a healthy alternative which has a different texture.
• Keep in mind that when you heat foods, they smell stronger. If your child is sensitive to smells, serve food at room temperature.
• If your child cannot handle soft squishy food right now, then do not force it.
• If your child needs the food not to touch, then buy plates with compartments.
• If your child hates sauces, dish a portion up before you add the sauce to the pot.

There are many eating and feeding programs established to help children who are fussy eaters. Some programs are stand alone and may be used by disciplines other than occupational therapy. Some OT’s integrate strategies from several of these programs into their treatment approach.
Examples of common programs:
• The SOS Approach (Sequential Oral Sensory): Assesses and addresses feeding issues
• Beckman Oral Motor Protocol: Addresses oral motor skills
• Mealtime Notions with Marsha Dunn Klein: Targeting mealtime challenges
• Applied Behavior Analysis (ABA): Aims to change a child’s behavior through identifying antecedent,
behaviors and consequences.
• FOCUS Program: Unlike other programs, the FOCUS approach addresses foundational sensory processing and motor skills. Therapists using the FOCUS approach may draw on knowledge and strategies from other programs that they have training in while still following the phases of the FOCUS Program.

Resources:
https://thespiralfoundation.org/wp-content/uploads/2018/10/Parent_Guide_to_Mealtime_Success_6-11-18-edits.pdf
https://www.spdstar.org/node/1004
https://www.childwellbeingcentre.net.au/occupational-therapist-team/11-tips-for-helping-fussy-eaters/
https://www.ot-mom-learning-activities.com/dealing-with-picky-eaters.html
https://theinspiredtreehouse.com/15-tips-for-picky-eaters/