 This is a 3 part inservice. The first will address feeding skills development and dietary needs, the second will address red flags and when to refer to SP or OT, and the 3 rd will discuss bottle nipples, utensils, and feeding tools.

Objectives  Provide information on feeding skill development in the birth to 3 population.  Provide information on the nutritional needs of the birth to 3 population as supported by Primary Children’s Feeding Clinics.

Birth to 3 Months Breast feeding  Bottle Feeding

 BREAST FEEDING  Every 2-3 hours  15 – 30 minutes  Amount the child is taking is unknown  Weight monitored closely  Children with cleft palate will not be able to breast feed  Much more difficult than bottle feeding BOTTLE FEEDING Every 3 hours 15 to 20 minutes 3-4 ounces at this time of formula. Typical formula is usually attempted first (similac/enfamil) Specialty formulas will be tried by pediatrician if baby is vomiting, irritable, seems to be in pain (soy based, elemental formulas) Some mothers may choose to bottle feed pumped breast milk

Newborn Feeding Skills  The newborn infant is physiologically set up to drink well and safely from the breast.  Rooting reflex  Sucking reflex  Cheek pads  Physiologic flexion  Gag Reflex Spontaneous suckling occurs with cupped tongue, jaw depression and rhythmic sucking while breathing after sucking bursts Sucking a pacifier occurs at twice the rate as nutritive sucking

 The newborn to 3 month old infant can eat in a reclined position because their oral structures are set up to protect them from aspirating.  At 2- 3 months the infant has a period of lower muscle tone and the physiologic flexion starts to diminish. At this time the infant’s suckling patterns may seem less efficient and more liquid may be lost at corners of mouth.  Reflux typically increases at this time in all infants.

Gastro-Esophageal Reflux Disease (GERD)

Treatment for GERD-  Zantac or Prevacid to decrease the acidity of stomach contents.  The child may still vomit but the stomach content will not burn their esophagus.  Avoid too much handling after meals  Avoid positions that encourage too much hip flexion after meals

3-5 months  Sucking pattern is emerging at 3 months as the predominant pattern of getting liquid from the bottle or breast by 6 months.  By 3 months the child has a long sequence of suck/swallow/ breath -20 sucks in a row.  The child is now eating 6-8 ounces of breast milk or formula per feed, every 3 hours and can sleep through the night.  The control and strength the infant is gaining through their neck and trunk are the base of support for improved oral motor skills.  Infants need to be breast fed and bottle fed in more upright positions.

 The infant is bringing objects and their hands to their mouth more which helps move the gag reflex back in their throat.  Jaw strength and stability increase, lips and cheeks are becoming more active, and tongue is developing more variability in movement.

6 months  As the infant develops the ability to sit independently (though they still may use their own hands for support)they are able to eat from a spoon while seated in supportive high chair.

Beginning spoon feeding Infant sucks and suckles food from spoon. Tongue movements are forward and back so some food may be lost. Gagging can occur with new tastes and textures up to 10 months of age. Breast fed infants should start with rice cereal as they need the iron supplement. Begin 1 st or 2 nd food fruits or vegetables 2x per day. SPOON FEEDING IS FOR THE PURPOSE OF TEACHING THE CHILD TO EAT FROM A SPOON AND DOES NOT PROVIDE ANY NUTRITIONAL VALUE.

7- 9 Months  The infant has developed the ability to sit without hand support and plays freely in sitting.  Spoon feeding should occur 3 times per day.  Provide a cup of breast milk or formula at meals. They can take 1-2 sips from a non spouted cup at this time.

7-9 months  Finger foods can be offered at this time. Start with something the child can hold onto and place in their mouth like Biter Biscuits or Zwiebac crackers.  Meltable solids that can be held while the child explores their mouth with this item (towne crackers, graham crackers).

10-11 months  The baby now has improved grasp and release patterns so they can pick up smaller objects to place in their mouth.  They can move tongue from side to side in their mouth to place and retrieve foods  Soft cubed foods can be provided: gerber fruits or veggies, bits of muffins or nutragrain bars, cubed sized avacado, overcooked squash, banana

10 months  Bottle or breast feeding every 3 hours  4 meals per day  Meal time should include smooth pureed food or baby food (not 3 rd ’s), some type of finger food and a cup of breast milk or formula.  They can begin eating foods with milk in them (if they do not have a milk allergy) but should not be drinking milk as it does not provide the same nutritional value as formula or breast milk.

12 months  The babies lips actively close around spoon with eating.  They can take 4-5 swallows from a cup at one time.  Jaw pressure is controlled on soft foods.  They are eating soft table foods 4-5 times per day.  They should move to a formula that is appropriate for children 12+months if they do not have a lot of variety in their diet  Whole milk can be used as a primary source of nutrition if they have variety in their food choices and their weight is appropriate for height and age. (They should have tripled their birth weight by 12 months)

Things to Remember  No honey, karo syrup or molasis before 12 months due to the risk of botulism poisoning  No eggs (except cooked into things) prior to 1 year and then start with egg whites and then move to yoke.  No peanut butter before 2 years of age (unless the child’s allergist has already tested them for peanut allergy). Some doctors are recommending no peanut butter before 5.

When can a baby transition from a breast or bottle to a cup?  When their parents want them to.  When they can drink their necessary amounts from a cup.

13+ months  TODDLER DIET  5 Scheduled meals per day, offered every 3 hours.  At each meal the toddler should be offered 1 tablespoon of protein, starch and fruit or vegetable for each year of age they are.  4-6 ounces of milk or toddler formula at each meal and snack (The child receives the majority of their nutritional needs from milk or formula through 24 months of age) Toddler foods are still very soft and can be eaten without many teeth.

 As the child matures we want to add more variety of foods to their diet.  We would like children to have at least 10 different protein, starch and fruit or vegetables that are consistently part of their diet.  Advancing a child’s diet in taste and texture too quickly can contribute to difficulties eating/accepting foods.  Foods provided to a child should match their existing oral motor skills.

 As children get older their foods should be selected based on their feeding skills, the foods nutritional value, and the child’s taste preference.  1 tablespoon of each protein, starch and fruit or vegetable for each year of age they are.  ounces of whole milk until 2 and then 2% (unless milk allergy where they should be on a toddler formula).

Scheduling Meals and Establishing Mealtime Routines:  Children who graze will eat less.  Children learn optimally within a routine  Promotes appetite  Decrease Anxiety with predictability

 This is essential to good nutrition and good eating habits.  No in between meal snacks and drinks.  Children who graze will not take tastes of new foods because they are not hungry

Medical Diagnoses that Impact Feeding  Prematurity  Poor state control  Oral structure differences  Overall weakness  Environmental impacts  RespiratoryConditions  Cardiopulmonary Problems

Craniofacial Abnormalities  Cleft Lip  Cleft Palate

Syndrome Related Craniofacial Disorders  Pierre Robin Sequence  CHARGE association  DiGeorge Syndrome  Mobius Syndrome  Beckwith Weideman Syndrome  Goldenhars Syndrome  Kabuki Syndrome  Crouzon’s Syndrome

Gastrointestinal Issues  Constipation  Breast fed infants may stool every 3-6 days before being considered constipated  Bottle Fed infants stool every day to every 3 days before being considered constipated  Toddler s should stool daily most of the time  If this is not the case families encourage families to contact their pediatrician about a dosage of miralax  GERD  Esophageal Dysmotility

 Short Gut/Necrotizing Enterocolitis (NEC)  Bowel Obstruction  Liver Disease  Food Allergies/EE/EoE  TEF

Dysphagia  Diets need to be modified based on the results of a swallow study.  Some of these children will not be allowed to eat orally until dysphagia is resolved (typically by time)  Oral stimulation will need to continue until ready to eat.

Extended Periods of Tube Feeding

Why do infants/children get tubes?  They cannot get their nutritional needs orally due to:  Dysphagia  Oral Motor Skills or strength that do not support eating enough  Ex: children with cerebral palsy, very young children with down syndrome  Physiologic or structural issues (stomach, esophagus,oral) that do not support eating enough or allow a child to eat a large amount at any one time.

Specific Diagnoses where feeding skills are impacted  Cerebral Palsy  Down Syndrome  Seizure Disorder

Specific Diagnoses where nutritional needs are impacted:  Autism Spectrum Disorder  Their feeding problems emerge from sensory issues  They limit their diet to create a routine that is consistent and safe.  Their food restrictions do lead to oral motor delays-they do not have the same variety to encourage acquisition of improved skills