1. The Feeding Relationship

2. The feeding relationship Nourishing and nurturing Supports developmental tasks

3. Development of Feeding Behaviors AgeReflexesFeeding Behavior B-3 monthsRoot, suck- swallow-breathe Suckling pattern of feeding 4-6 monthsFading root/bite reflex Mature suck, brings objects to mouth, munching pattern 7-9 monthsNormal gag develops Munching, rotary chewing, sits alone, holds bottle alone 10-12 months Bites, brings food to mouth, drinks from cup, spoon feed

4. Stages of Development Homeostasis Attachment Separation and individuation

5. Stages AgeInfant Development 1-3 monthshomeostasisstate regulation neurophysiologic stability 2-6 monthsattachment“falling in love” affective engagement and interaction 6-36 monthsseparation and individualization differentiation behavioral organization and control

6. The Feeding Relationship The Relationship –Parent –Child Tasks –Parent –Child

7. Tasks Infant –time –how much –speed –preferences Parent –food choices –support –nurturing –structure and limits –safety

8. Homeostasis Infant cycles through physical states Parent provides a safe and comfortable environment Reflex feeding transforms to self regulation of hunger

9. Attachment Emotional/social interactions Parent reciprocates/engages Infant’s emotional and physical needs reinforced

10. Separation Struggle for autonomy Parent supports autonomy and guides daily structure Emotional needs distinguished from physical needs

11. Children do best with feeding when they have both control and support

12. Feeding “is a reciprocal process that depends on the abilities and characteristics of both the parent and the child…Once feeding starts, the parent and child work on the process with more or less flexibility and skill” Satter J Pediatr 117(2) 1990

14. Problems established early in feeding persist into later life and generalize into other areas Ainsworth and Bell –feeding interactions in early months were replicated in play interactions after 1st year

15. Healthy Feeding Cycle Child associates hunger with need to eat Child communicates need Parent reads cues and provides Child communicates satiety Parent responds Positive experience gained Parent anticipates physical needs

16. Feeding Difficulties Related to maturity, medical and neurodevelopmental status State control endurance suck-swallow-breath coordination sleep-wake cycles cues and demand behavior temperament patterns of oral-motor development

17. Feeding Delays in feeding skills feeding intolerance behavioral medical/physiological limitations other

18. Factors to consider Medical Developmental Temperament Psychosocial Nutritional Environmental

19. Factors Medical respiratory, cardiac, GI Developmental immature feeding skills, temperament, sensory integration, oral/motor

20. Factors Nutritional –Frequency, density, appropriate, balance, other Psychosocial –Anxiety, depression, stress, unmet social.emotional needs, disarray –Self regulation, attachment, separation

21. The Complexity of feeding problems in 700 infants and young children Presenting to a Tertiary Care Institution Rommel et al: J Ped Gastro and Nutrition, July 2003 Multidisciplinary Assessment catagorized feeding problems: –86.1% medical –61% oropharangeal dysfunction –18.1% behavioral

22. Rommel et al Single identified problem –26.7% medical –5.2 % oral/motor –5.4% behavioral

23. Rommel et al Multifactorial –48.5% oral/medical –1.5% oral/behavioral –5.2% medical behavioral

24. Rommel et al Medical/oral-motor –occurred more often <2 years of age Behavioral –occurred more often >2 years of age

25. Focus Group Parent Response from Gaining and Growing Website “ I wasn’t afraid to bring home a baby that weighed only 3 pounds, but I was afraid to bring home a baby that wouldn’t eat”

26. Parent Response Survey of Parents of Premature Group “ I felt I had to choose between growth and force feeding” “At 9 months, height/weight is proportionate, but we are still having to force feed” “I’ll have concerns until she is at 5% for everything” “even though my son had no difficulties with the mechanics of eating and no food issues, we had lots of questions, much anxiety, and too much stress…”

27. Jamie Born prematurely at 25 weeks GA Birthweight 800 grams Current age: 1 month corrected age Problems: –BPD –Feeding difficulties –Growth concerns: poor weight gain

28. Jackson Born at 32 weeks gestation Birth weight 1100 grams, small for gestational age Currently 15 months corrected age Problems: –growth concerns: weight and length <5th % –Speech and developmental delays –Feeding Problems: gagging, food refusals, difficulty transitioning to solids