How to help prevent an oral aversion from developing
- Newborns are born to suck. When a baby sucks, they strengthen their oral motor muscles, explore different sensations in their mouth and learn about tastes. When a newborn is unable to eat orally because of medical problems for an extended period of time, there is the risk of developing oral aversions. Even if your newborn can't eat and is on TPN and/or tube feeds, ask the doctor if you can encourage "non-nutritive sucking," or even "non-nutritive/comfort nursing" i.e. use a pacifier or your very clean finger, or pump/express all your milk (donate this to a milk bank) and then let the baby nurse. If baby doesn't have any interest, consider dipping the pacifier in sweet-ease (sugar water), water or formula. Your baby will likely need to "learn" to accept a pacifier, so expect that they will initially reject it, but keep trying. Don't force it - go slow at your babies pace. This can be critical in helping your baby to not lose the skill of sucking so they will accept a bottle or other food when they are ready.
- Newborns with SBS often have difficulty tolerating oral feeds without high outputs. Your newborn may need to start on very small amounts of formula (i.e. less than 5 ml. per bottle). Your doctor may suggest not giving bottles if outputs are high. But to preserve the sucking and feeding skills and to prevent an oral aversion from developing, ask if you can decrease volume, rather than eliminate them - even 1-2 ml. per bottle is much, much better than none at all. Comfort nursing, like the 1-2ml bottle (see above) promotes oral/motor development, as well as comfort for both mother and baby.
- Newborns who have spent any time in the NICU with a feeding tube or otherwise, have often had repeated, painful or uncomfortable touches around their face as tape is removed or reapplied, tubes are inserted or removed, etc. A parent's first reaction might be to not want to touch their baby's face since the baby might turn away,cry or otherwise reject touch to the face. However, just the opposite is necessary. A baby needs to learn that touch, in general, causes comfort and pleasure, not pain. So kiss, stroke and touch your baby's face frequently (many times a day), so your baby has many more positive than negative experiences around the face.
- During a normal day, a typically developing baby is exposed to many different types of sensations on their face as they are dressed, washed, fed, burped and spit up. These experiences help prepare a baby's sensory system to accept a variety of feelings on their face and in their mouth. These early skills help prepare a baby to accept a variety of flavors and textures in their mouth when as they grow. A medically ill baby many not have many of these experiences, again putting them at risk for feeding and sensory problems. As much as your baby can tolerate, again, expose them to different touches like a dry cloth, a wet cloth, a soft blanket, etc. Introduce soft touch, that are light on the skin (like a feather) and "deeper" touches, like the pressure of your cheek against your baby's face.
- Use whatever methods possible to help reduce pain, particularly around the face. For example, ask nurses to use adhesive remover, rather than just pulling tape off the face. Sweet-ease or sugar water, is known to reduce the experience of pain in babies 0-6 months (the effectiveness is lost after 6 months). In small amounts (1 or 2 dips on a pacifier or finger) it doesn't typically impact outputs. Request that this is used when your newborn is having an IV placed or another invasive procedure.
- It is true that a newborn or infant will not have "memories" of pain they experience in the manner that we have memories. However, there is body memory even at an early age; infants can learn to become defensive and avoidant of pain when they have repeated pain experiences. Repeated pain experiences, particularly around the face, combined with fewer than typical positive touch experiences will likely lead to an oral aversion.
An occupational therapist, speech therapist or a feeding disorders program can help your child successfully eat. Make sure the professional that you're working with is experienced with feeding treatment - bad treatment can make things worse, so do not use a therapist who is trying to force feed or make eating a very stressful and negative experience for your child. The earlier the intervention starts, the more effective it is in preventing and treating feeding problems, so don't delay getting help.
- Read the tips regarding newborns - many of the recommendations remain relevant.
- Even if your infant can't eat or can eat only a small amount, continue to develop their oral motor experiences.
- Ask your child's speech or occupational therapist about introducing a Nuk brush and "toweling" exercises. These techniques help de-sensitize the mouth and face and prevent oral aversions.
- Some babies naturally start to mouth toys and objects when they are a few months old. Children with oral sensitivities or who have a lack of experiences in an around their mouth may shy away from these new experiences, further promoting oral aversions. Help promote the mouthing of toys. This also readies the mouth for different textures of foods down the road. Do this by encouraging your baby to put toys and their fingers in their mouth. Don't force it. Consider again dipping toys or fingers in sweet-ease or water.
- Many children are willing to accept "smooth" foods such as baby cereal or stage 1 and 2 baby foods, pudding or yogurt, but struggle with the transition to more challenging lumpy foods. Here are some suggestions for moving up towards "chunky" and solid foods: introduce solid foods that melt easily in the mouth such as hulless popcorn, cheese curls or Gerber puffs; introduce "chunkier" forms of already preferred flavors of foods (i.e. stage 3 foods in the same flavors that your child accepts in stage 1 or 2 foods); expand variety by introducing different flavors of already accepted foods (ex. all the varieties and flavors of gold fish or Gerber puffs); Initially keep demands low - just 1 or 2 tastes of a non-preferred food; keep portions small - seeing a big amount of a non-preferred food can overwhelm children; at each meal, offer a favorite food (if there is one) and a less preferred food; when introduce new foods, pick similar foods in new flavors or similar textures (if your child likes dry crunchy foods like chips, expand to different brands and types of chips, rather than jumping to deviled eggs) use rewards (playing with a toys, bubbles, singing, etc) after eat bite of a non-preferred food; and pair a non-preferred and preferred foods together, gradually increasing the ratio of the non-preferred food (example, crumble graham crackers [non-preferred food] in rice cereal [preferred food] to introduce a new texture and flavor.
- Keep a consistent schedule and routine for snacks and meals.
- Use appropriate seating, such as a high chair or booster seat. Do not allow your child to wander around the house snacking - your child needs the structure and routine of sitting in one place for meals. Additionally, you then lose control of the meal and it's difficult to systematically introduce new foods.
- Make sure the seating you are using is appropriate for your child. An occupational therapist can assess seating.
- Avoid allowing your child to "graze" between meals or carry around a drink, this will actually decrease hunger and interest in food because the child never experiences a hunger or fullness cycle.
Toddler and Up
Children explore foods through all their senses. It's hard to address feeding problems, especially when children are beyond the toddler age, so make sure you have a knowledgeable therapist guiding you and your child. Some tips that may help:
- Build trust, go slow and be patient. You won't get anywhere by force feeding, trying to "trick" your child into eating a new or non-preferred food or forcing your child to interact with things that their sensory system isn't ready for. While you may set the goals for your child's eating, respect that your child gets to set the pace of working towards those goals. Remember that eating is naturally a pleasurable thing for many of us. However, eating is not actually instinctual - it is a skill that needs to be learned. There is a reason why your child doesn't want to eat. It might be due to a sensory issue, a history of medical issues, a bad experience with food (choking or recurring reflux), delayed oral motor skills or a developmental issue (Autistic children are often picky eaters). It's not because they are stubborn, lazy or spoiled. Ask a therapist (typically occupational or speech) to help you with some of these suggestions.
- Play with food. Allowing children to play with food, without the demand to eat it, is a great way for a child to explore how foods feel. Try finger painting with sugar-free vanilla and chocolate puddings. Try having gold fish crackers go "swimming" in apple sauce. Roll round foods (cheese puff) down their arms like a ski jump into a cup. Allowing children to be comfortable with food on their hands is the first step to allowing it near their mouth. Make it fun!
- Modeling is a great way to teach your child about eating. Make sure you child sits with you at family meals, even if they won't eat. They will be exposed to the sights and smells of various foods, while they watch you eating it. For older children, get them involved in mealtime by having them help with preparing food, cooking, serving food and passing food around the table. Avoid turning this great experience into a negative by making comments such as "Doesn't that look good? Aren't you going to try it?" or "All that work and now you won't even try it?"
- Mealtime isn't just about eating. It's about socializing and enjoying the company of the family. Lots of other skills can be learned during meals besides those associated with feed. Keep meals as stressless as possible (easier said than done). Try to avoid talking about food in a critical manner or pressuring your child to eat (comments such as "Why won't you eat?," "Your brother is such a good eater - can't you just take a bite?," etc). Talk about non-food or meal related topics instead.
- Do not discuss meal time later in the day with comments such as "If you'd eaten your dinner you wouldn't be hungry now." Once the meal is done, it's done. No discussions, comments or punishments.
- Keep your mindset positive. Monitor your body language. If you appear tense, anxious or overly excited when offering a new food to your child, they are going to pick up on that and be more likely to refuse. Remember that 90% of communication is non-verbal, so your child isn't listening to your words, they're listening to your body posture, tone of voice, facial expressions, etc.
- Make it fun. Allow your child to feed the family pet, so they realize this is an experience to enjoy.
- Use pretend play to have them feed their stuffed animal or doll.
- Get pretend/plastic food toys and pretend to make a meal and eat the pretend food.
- Some children may enjoy feeding you.
- Model trying new foods yourself. Tell your child you think it would be fun to try a new food and ask them to pick something at the supermarket for you to try. Make sure you model enjoying the new food!
- Talk about the qualities of food while you are eating. Many kids with feeding difficulties don't recognize (due to a lack of experience) that foods have different attributes such as color, bumpy, hard, soft, crunchy, smooth, cold, hot, mild, spicy, sweet, salty, etc.; they just see everything as "yucky."
- Try face painting. Face painting is another sensory experience on the face that is great to use for building confidence with new sensory experiences around the face.
- Have your child help you cook. Again, avoid the pressure for the child to eat it, just enjoy the experience of cooking.
- Go on a supermarket scavenger hunt to help your child learn about foods. Ask them to find a food that is a particular color, bumpy or smooth, small and large or wet (think the produce section).
- Have you child experience other sensory experiences such as touching tub foam soap or shaving cream (use it to give a favorite toy a bath or pretend it's snow), play with ice-cubes in warm water and notice the different temps. or play with dry materials (the easiest for the sensory system to tolerate) such as bins of rice, beans, noodles or bird seed.
- Expect that the child with feeding difficulties will initially refuse new foods. In fact, it takes 10-15 exposures/tastes of a new food before a child can truly determine if they like the food or not. If after 10-15 tastes, you child still doesn't like it, move on to another food don't continue to offer that food.
- Don't make family meals at dinner time a battle ground. Allow your child to have at least 1 preferred food at each meal, although non-preferred foods can be offered as well. Keep the real work of introducing non-preferred foods at a snack time. This can be called "food homework time" for preschool and school aged children. Keep the time limited (15 minutes) and the expectations clear (ex. to eat 1 chicken nugget - a non-preferred food). Make sure you are keeping the experience positive and using rewards - no intimidation, pressure, etc. should be used to get a child to eat.
- Remember that learning to eat non-preferred foods is a lot of work. Just like adults, kids need a "paycheck" for work. Use frequent reinforcement (playing with toys, singing and verbal praise), after each bite of a non-preferred food.
- Make sure you use planned ignoring to respond to negative behaviors such as crying, screaming, throwing food, etc.
- Gagging and vomiting is common with children with oral aversions. Have a speech therapist evaluate your child to ensure that they have adequate oral motor skills to eat the foods that are causing the gagging. If the gagging is clearly due to an oral sensitivity (rather than inadequate oral motor skills), then used verbal prompts to swallow and ignoring when gagging or vomiting occurs. Using a drink or a smooth food between bites of chunky food can help your child swallow without gagging. Never end a meal on a gag or vomit as this will reinforce the behavior. Rather, end on a positive note. So if your child gags or vomits, clean it up casually and then ask them to take one more bite or drink of a preferred food before ending the meal.
- You child may need you to prompt them and to model how to chew and move food around the mouth. To avoid gagging, food needs to be moved from the front of the mouth to the sides to chew smaller before the tongue moves it to the back of the mouth to swallow. Prompt your child, "chew, chew, chew" while making exaggerating chewing motions yourself. If you are feeding your child a solid food, try to place solid foods on the sides of the mouth to promote chewing. Your therapist can do some exercises to help your child become more aware of where their teeth are in their mouth and they can practice chewing on non-food objects (chewy tubes, etc).