Hi TalkTools,
What would you recommend for a 12 month old who is talking and lateralizes many of her sounds? Currently, she is drinking from cups, not sippy cups, she does nurse 1 time a day and is eating solids. She is using straw #1, and the lateralizations decreased, but when she moved to straw #2 they increased. She is also using the maroon spoon for the spoon feeding exercise. She is not on the horns or bubbles at this point.
Thank you,
Sandi

READ LIZ'S ANSWER

Dear Lori,

I attended the Sensory Feeding Course in England in June, and would like to thank you for a full two days of professional input.  Before I left Manchester, I had already thought of how I was going to utilize some of the techniques in my therapy sessions.

You had mentioned that you would not mind answering questions, so I hope you do not mind me taking advantage of the very generous offer.

I have my first appointment to see a 4 month old boy with feeding problems next week.  Mom reports that he breast fed nicely (after an initial period of latching difficulty, and the need to suck using a nipple shield). After 1 week, baby got floppy, stopped feeding, and was taken to hospital, where he stayed for a few weeks. He is currently being fed through a nasal feed tube.  Although he is reported to have a strong suck, he does not suck on breast for long. Bottle feeding has the same results.  This child has had extensive genetic testing, endoscopy (up to larynx), videofluroscopy, and EMG--all without any abnormal findings. He is scheduled for an endoscopy to investigate the esophagus.  He has reflux, and I was told that milk came through the nose.  The ENT did not find any sub-cutaneous cleft, nor velo-pharyngeal insufficiency.  He will also have an MRI.  The current medical opinion seems to indicate problems with swallowing.   All this information was received by phone. I have not seen any reports, as yet.

My goal for the session (aside from meeting and assessing the child), is to show mom the oral and sensory-motor stimulation techniques and massages (as well as hand, foot and body massages).  I also would like to introduce some pre-feeding activities, to try to prevent, or, at least minimize oral sensitivity and aversion to food taken orally.

Question: With a dry spoon (Beckman E-Z feeder), shall I introduce spoon feeding with a front feed, or side feed technique? I am inclined to do both, as they involve different oral motor movements.  However, I do not want to instill incorrect feeding behaviors.  (This is the first time that I am working with an infant).

I would like to thank you in advance for your input.

Best regards,

Dear Lori,

I just completed your "Feeding Therapy: A Sensory-Motor Approach" DVD. What an amazing course! It certainly gave me a great deal of confidence in working with children with feeding disorders. While it was extremely thorough and informative, I do have several questions for you. I would love your input!

1. When would you typically recommend an OT evaluation?  Or perhaps I should say,  in which cases would you not refer a child (with an apparent feeding disorder) to an OT?  ***Great question! I look at the whole child and ask a lot of questions about how the child moves through life. In my case history form I ask questions like: does your child get upset easily, does your child have difficulty calming, does your child have difficulty in new situations, transitions, separation etc, does your child have complicated routines for bed, bath, daily living activities, etc... During the evaluation I watch how the child responds to input in the environment. If I observe underlying sensory concerns (sometimes parents just think their child is challenging, or high maintenance and do not realize the behaviors they observe are secondary to sensory issues) I immediately refer to an OT. If the child seems to be able to self regulate, modulate incoming information (for everything but feeding) ....I would not necessarily refer to an OT immediately. I might start an oral sensory motor pre-feeding program and see how the child progresses.***

2. You spoke a bit about breastfeeding, and I was wondering, what role would a lactation consultant play in breastfeeding support if you are working with a nursing mother?  Would our job be the same as a lactation consultant's or would you ever refer the family to one?***I work with great lactation consultants. They are often the first ones to see the baby. They call me in when they observe oral sensory motor issues which are not related to the mothers milk production, bonding, positioning etc. If it is a mom issue...it is definitely the lactation consultants role to consult. If the baby has oral sensory motor issues....that is our role.***

I would also like to order some tools from your website for my practice.  I want to add the Mickey Mouse attachment, but I am not sure if I should buy the hard or soft one.  ***It depends on your child's sensory system...but overall I prefer the soft mouse*** When would you use one vs the other? ***If a child needs more input I would recommend the hard one*** And what about the cat?  I don't think you talked about it in the video, but I am curious to know when it should be used. ***I use the cat ears to get tongue tip pointing. For example, I may present the cat ear at the lateral incisor for chewing hierarchy level #3, and then alternate lateral incisors!!!!***

I really wish I was able to physically attend your course and get to meet you in person!  You are such an inspiration to me!!  Thank you for all of your incredible work. ***Thank you for taking the class on video, and I hope one day we will meet in person. I am doing a one-hour seminar at ASHA this year!!!! If you are there, please come and introduce yourself!!!!

My very best,

Lori***

I am treating a beautiful, 4 month old baby born at 29 weeks gestation. Meyer was immediately intubated and sent to NICU where he experienced bouts of apnea. Meyer was given feeds on 2/3 for 5 days with good suck and intake, but subsequently required surgery for Necrotizing Enterocolitis (NEC - a gastrointestinal disease, that involves infection, inflammation and destruction of some/all of the bowel). Successful surgery was completed. While on PO feeds at hospital Meyer had uncoordinated swallow/suck with sputtering and bradycardia (i.e. bradys). An oral pharyngeal motility study (OPMS) demonstrated aspiration on both thin and thickened liquids. Discharge report indicated NPO status. Meyer's discharge recommendation: 5CCs of thin liquid each day orally and remainder of nutrition via naso-gastric tube. He currently receives 85% daily feeds via an NG tube, but when we attempt to increase his oral feeds he shows bradycardia. After trials with a medium flow Playtex nurser, he was very successful with the Haberman feeder using thickened breast milk for a couple of weeks with no Bradys, mom paced him from fast to medium flow as he got organized with the feed. We are thickening the breast milk with rice cereal (pediatrician and I felt giving a preemie rice cereal early was the lesser evil to aspirating on thin liquids). He saw a renowned, pediatric ENT at Emory University due to stridor and was diagnosed with fairly benign laryngomalacia – she feels it will disappear and is not impacting his swallow -- she scoped him, looked at his swallow without liquid and said it looked "fine.”

In the past week it has changed – he has increased Bradys. Pediatrician and mom think it is due to increased GERD. Last week, he went from 40 CCs via the Haberman (we limited amounts to work him up to accept it without Bradys) 3 times per day, to less than 20CCs at each feeding and he "falls asleep" during feeds. I think he is becoming cognitively aware of the GERD and refusing to suck. His mom did a trial feeding on the breast yesterday and he sucked well. I'm thinking maybe he has not learned that the breast causes pain from GERD. He does have some decreased oral motor skills with his jaw and cheek, but he is able to suck a pacifier well. We are doing O-M exercises daily. My thought is to maintain the O-M exercises and treat the GERD in the hopes we can get it under control and get him to eat more. Would love any thoughts you might have – poor baby has lots going on.

Thanks, Jennifer

Hello Jennifer. He does sound like a complicated little guy, and you have done a good job with him. I understand that sometimes you have to make a decision about using rice cereal as the lesser of two evils...but I am always concerned about motility (and allergies) when thickening premies' feeds. Have they explored possible allergies? Is the baby being bottle fed with the NG tube in? This MAY account for increased reflux. Is mom working with a lactation consultant? There MAY be less reflux with breast feeding than bottle feeding. Have they tried a lactaid? If the baby is sucking well on the breast...this may be an idea. In what position are you recommending feeding him? Feel free to run the pre-feeding exercises by me if you want another set of "eyes.”

Lori Overland