Many Facets of Feeding Part 2

In the last post, I had emphasized on why it is important for a young child to self-feed. Eating independently provides ample opportunities for touching, feeling, and exploring various food textures. Consequently, tactile sensory input is received, processed in the nervous system, and leads to learning about the texture and other characteristics of the food.

Self-feeding is important for development of hand-mouth coordination in the first 2 years of life. When a child touches food with their fingers, they also look at it. There forms the foundation of neural connections between the hand, eyes, and mouth; which is so much needed throughout life. In India, we are used to eating with our fingers. We are adept at breaking pieces of roti or dosa using only one hand, and picking up morsels of mushy foods like daal-chawal and khichdi without making a mess. But all of this requires ample practice in early childhood.

Some guidelines that will lead to improvements in your child’s feeding habits. 

Everyone understands the importance of eating meals as a family. This seems difficult in our busy life where parents are working and multitasking. There is a need to sit together as a family and eat, which can be done at least on weekends.

Dinner is a time when everyone is at home. However, the key to dinner time is around sunset which is quite early for urban families. Plan dinner for children around 700 pm. Early dinner will also lead to better sleep patterns. 

Instead of showing a screen during meal times, talk animatedly or narrate a story to your child, as young as when they first start solid foods. Perceive this as an opportunity to form an emotional connection with your child. 

Allow children to feed themselves in early childhood, as soon as they start on solid foods and then progress to table foods.  If you do so at home, they will not have difficulty with eating independently later in preschool. 

A young child will be messy during meals, it is acceptable, and will lead to many benefits such as tactile learning, development of hand-eye-mouth coordination, and more importantly satisfaction (as my grandmother used to say). It is hard for parents to clean up after every meal where a child is messy. However, look at it as a good trade-off. You spend time and effort in cleaning, but gain many benefits when your child eats independently, leading to learning about foods in near future. 

Watch the following video --

  https://www.youtube.com/watch?v=LfJVDbG6AxY

A preschooler who self-feeds will quickly learn the names of vegetables, fruit, and various dishes that we consume as a part of our daily meals. Have you ever thought as to why children know the names of junk foods so well?  Not only these are heavily advertised; children being fond of pizza, burger, namkeen, know their names because they pick up these items to self-feed.

As they grow, involve the child in small kitchen jobs such as peeling boiled potatoes, mashing boiled potatoes, plucking on leaves of mint, and shelling peas. There are many tasks in the kitchen where children as young as 3 to 4 years can participate. This becomes a way of spending time together with your child in addition to what your child is learning.

Take your child to the Indian market or street bazaar. Looking at heaps of vegetables, fruit, and flowers is a visual treat. There are sarees and fabric hanging in front of the stores, steel utensils visible in the store window, and the smell of fried items sold on the curb side. This is a sensory rich environment. It can be chaotic, but a child needs this experience. Learning is all about experiences. Provide a shoulder bag to your child and let them carry light loads with which they can walk home with you. Indian markets are in close proximity to many of us. Hence walk, buy the needed items, and return with comfortable loads. Such experiences not only provide learning in the short -term, but also prepare the child for lifelong skills.

Children are highly likely to choose and eat healthy foods if they are involved in food preparation. This includes food shopping too. 

Children with special needs

When it comes to children with special needs, foods and feeding pose certain challenges. Children with autism and other diagnosis commonly present with oral sensitivities, as well as difficulties with chewing and swallowing. Picky eating is another challenge that many children demonstrate. Tactile issues become a barrier in touching, feeling, and exploring food textures with use of fingers. Hence a child with sensory difficulties must play and mess with material that is similar to foods. Many children with autism demonstrate touch aversion to mushy foods.

When it comes to self-feeding, most parents of children with special needs report that their child picks up and feeds on pieces of biscuit, chips, namkeen, and papad. To me as a mother and a therapist, these are not ‘real’ foods and hence do not matter. I want to know whether the child is touching, picking up, and feeding on table foods that are a part of our daily meals while providing appropriate nutrition.

Chewing and swallowing difficulties with certain food textures are highly likely in children with special needs. Be careful in trying out new foods so that the child does not gag or choke.

1.         Communicate with the occupational therapist, or sensory integration therapist, or speech therapist, about feeding habits or issues that you are facing with your child.
2.       . Professionals will help you with ‘what’ and ‘how’ to introduce new foods to your child. Your child may also require stimulation of the oral area or special interventions such as oral placement therapy.
3.       To improve processing ability in the oral area, activities / exercises that address the trunk are crucial. Also important is the role of the ‘movement’ system or the ‘vestibular’ system. There is a scientific rationale for the same, which is beyond the scope of this post.
4.        Provide opportunities for tactile exploration with a wide range of material in the form of play. This material can be finger paint, edible items such as curd, or rough textures such as raw beans or rice.
5.        Let your child sort raw vegetables and fruit that every kitchen seems to have – potatoes, onions, tomatoes, brinjal, garlic. This kind of sorting activity will not only lead to improved tactile processing, but becomes a cognitive task as well.
6.        One way to introduce touching a new texture is to expose the child to the same. For example, if a child is averse to touching mushy food, it is fine to let them use a spoon.
7.       . Make small balls of rice-daal or rice-ghee. Initially it will just be a visual exposure. After days or weeks, it is likely that the child will start touching these rice balls.
8.      .  Tangy and sharp foods stimulate the oral receptors. These can range from soup, rasam, sucking on citrus fruit, and small gratings of vegetables such as radish, cucumber, carrot.

In summary, feeding is neither a single system or approach, nor is only accomplished with fingers. There are many facets to feeding that need to occur as a part of the child’s developmental journey.  

Many Facets of Feeding

 

Every parent is concerned with providing the right nutrition to their child. This becomes particularly important when the child first starts solid food and then progresses to complex foods as growth occurs. Parents generally worry about their child’s food intake because they want to ensure that the child is growing well physically. There is much more to foods and feeding than just providing nutrition and caring about growth.

It is generally recognized that a baby can be given solid foods when they are able to sit. Every culture has its own set of rules about how and what babies are fed. But broadly, the rules remain similar: starting with soft or pureed foods and gradually progressing to regular table foods. Whether you eat with fingers or use a spoon right from the start is also a cultural trait.

In India, a regular meal consists of varying food textures that are solid, soupy, mushy, and crispy. At home, many of us eat mushy foods such as khichdi, dal-chawal, and sambar-rice using fingers and without much spilling.

Tactile Input or Touch

Young children, as early as 6-7 months, start touching food when offered to them. Besides touching, they also play with food by pressing, crushing, squeezing, and transferring food from one container to another. Some children roll food into small balls using the palmar grasp. Around 9-10 months, they can pick up bits of food using a pincer grasp. These are attempts to learn about different food textures before bringing it to the mouth.

More than 4 decades ago, I would often hear my grandmother tell young mothers in the family or in the neighbourhood to let the child feed themselves. She would say that when offered food, whether rice or pieces of roti, the child will spill or waste half the quantity while self-feeding. And that is normal. She would emphatically opine that a young child feels better satisfied when they gradually learn to feed themselves. I think that my grandmother, and many other grandmothers of that time, already knew the importance of a child eating on their own. What they described as satisfaction or learning to self-feed......translates to feeling the various food textures, developing finger dexterity while picking up foods, and practicing hand-to-mouth coordination. Didn’t they have that wisdom which possibly was passed on along generations of mothers?

In my clinic at Activ Kaarya, besides children with special needs, I also see grade school children who have issues such as fine motor skills and handwriting. I often ask children what they ate for breakfast or lunch. Very few children even come up with a response. In most cases, it is “I forgot”. Over the years, I presumed that many of these children are fed at home by a mom or nanny. Therefore, they are not into the habit of eating on their own at school. Moms do complain to me that their child’s lunchbox is barely half finished or the child stays hungry at school. These children do not have autism or special needs, have at least average cognition, can follow instructions, and have good speech and language. And yet, they have not learned to eat a meal independently. When I dive deeper into reasons (trying to find out any oral-motor issues), moms have given me an array of reasons such as – in the morning there is a rush to leave for school, so I feed breakfast… she takes a long time to finish lunch, so I feed… we have a very loving nanny who likes to feed my child. The last one being an exasperating reason to me; how can you expect a child to finish their lunch box in school when they do not eat independently at home?

At a personal front, I am a mother, a woman who has frequently taken care of many cousins in my teenage years, and watched many children grow up in the neighbourhood. I have witnessed many children feed themselves. And therefore, I feel that every child should be provided opportunities to engage in self-feeding. Children who are developing in the neurotypical range and have no oral-motor issues should be encouraged to feed themselves right since their early days of eating solid foods (following my grandmother’s advice). They should be permitted to use their fingers and mess with food while eating. As they grow, they should be allowed to experiment with holding a spoon.

While at home, we use our fingers to finish a whole Indian meal. We are adept at breaking a roti or a dosa or a chilla using fingers of one hand, we are skillful at using fingers to pick up morsels of mushy foods like daal-chawal and khichdi and bring it to our mouth without spilling. This has been a result of years of practicing to eat independently. Years ago, as a young therapist in USA, I found myself arguing with an OT friend as to how eating with fingers could also be a fine motor skill.

When using fingers, we learn so much about the temperature and texture; and just feeling the food with fingers makes it interesting to eat. (Outside of home, we use the spoon or fork, mostly for etiquette and reasons of hygiene. And therefore, it's important to learn to use a spoon and fork early on in life).

When a child learns to eat independently, mealtimes are opportunities to learn about the names of vegetables, fruit, daal, and different dishes. There are times when we can bring in conversations about whether the food is spicy, salty, or sour, and how it feels in the mouth.

Challenges of Chewing-Swallowing and Oral Sensitivities

Many children do present with feeding challenges early on. These can range from being a picky eater, to gagging, to avoidance of certain or many foods. The child may have chewing difficulties and hence may just swallow the mushy food without feeling or chewing it. The child may just not accept certain food textures.

It is highly likely for children with autism to demonstrate feeding difficulties. At the same time, there are many children with feeding issues in the absence of signs and symptoms of autism or any other diagnosis. They may display oral sensitivities or a sensory processing difference when it comes to foods.

As a clinician looking into sensory-motor issues, I have several questions for parents regarding their child’s feeding habits and the variety of foods that the child consumes. This information is important for detecting oral-motor issues. Besides providing nutrition, our gut health also depends on the variety of foods that we consume.

Most parents report that their child with autism will self-feed finger foods such as chips, papad, bhujia, and biscuits; and may also verbally express or reach out for these foods through nonverbal gestures. (well, these are not ‘real’ foods because they have poor nutritive value and do not form a part of our daily regular meals).

I would like to know whether the child is not eating mushy textures at all. Or foods such as rice or poha that are grains separate from each other, are being rejected due to oral sensitivities. So many children with autism do not eat raw salads, fruit, and dry-fruit. Is the child consuming at least a reasonable number of foods, are they being fed, do they use a spoon, or do they touch mushy food with their fingers? All this information provides me with an idea about their tactile processing through hands and mouth.

Wait for my next post on strategies of feeding your child!

Extend therapy Beyond the therapy room

Therapy should not be limited only to the therapy room, but should always extend in the world outside of the therapy center. The motor learning principle postulates that in order for the brain to learn anything,

•           it requires many repetitions of the task.
•          and the same task performed in various ways.

The required repetition and the variation necessitates that therapeutic tasks should be incorporated as a part of daily life and in the real world. For children, work is play. Every child deserves to have fun. At the same time, every child needs to learn many daily functions of life as a preparation for participating in the world. Hence play, fun, and function, all need to be included in therapy. When a task is learnt through play, it requires less repetitions to learn. Therefore, the point is to learn tasks through play at home and elsewhere in the external world. This is known as carryover of therapy in the world of physiotherapy and occupational therapy.

Tasks or activities will heavily depend on the age and capacity of the child. There are various activities that can be incorporated into the daily / weekly routine that would provide the necessary meaningful movement and sensory input. Additional benefits would be a sense of accomplishment, increased confidence, and self-esteem.

 

Do activities that are suitable for your child.

Ensure SAFETY and SUPERVISION to prevent

•         mouthing or swallowing small objects
•        prevent falls that can lead to serious accidents such as fracture or head injury.

 

Do remember to watch the YouTube videos on

https://www.youtube.com/watch?v=TfljcTYjfeo&t  So many therapeutic activities are possible in the form of play to enhance a child's sensory-motor capacities. These are not a replacement for therapy administered by a professional therapist. Based on Dr. Ushma's clinical activities and suggestions, they have been performed at home by parents who avail therapy for their child at Activ Kaarya.

https://www.youtube.com/watch?v=EyjHNmxGRoY&t=45s  A variety of material such as bubble wrap, brown paper, rice flour, can be used to have fun. Work on the smaller muscles of the hand by using the pipe-cleaner and single-hole puncher.

https://www.youtube.com/watch?v=dy1Iro0GmCI&t=73s  Simple rubber band activity for young children.

https://www.youtube.com/watch?v=Tbr0da596-w  this is a video on making playdough at home. You can make it in larger quantity, it is less crumbly, and children can roll, poke, squeeze, and press – great muscle work for hands and fingers.  

 

Functional activities that provide therapeutic value and instill a sense of responsibility

Use the Indian ingenuity, also known as ‘jugaad’ to find items in your own home so that your child is occupied in meaningful tasks and is receiving sensory input at the same time.

1.     My favorite task for children is removing wet clothes from the washing machine. Wet clothes are heavy, sometimes tangled, and need to be pulled with two hands. There you are working on bilateral coordination, tactile, and proprioception. Not to mention balancing task whether the child is standing on the floor or standing on the stool and bending over a top load machine. Once all the wet clothes are removed and placed in a bucket, pushing the bucket to the dryer stand is another proprioceptive task that also provides visual-spatial awareness.  

2.      Push the bucket containing wet clothes towards the balcony or drying rack.

3.      Dry clothes on a rack.

4.      Park all your groceries at the main door of the home. Let your child carry each item from the main door to the kitchen. It could be small bags of grains, fruit, vegetables.

5.     Teach them to drag the 3 kg or 5 kg atta bag while walking backwards.

6.    Have your child play in plant soil, dig, and pick up soil with hands. Working with soil / gardening serves as an anti-depressant. Micro-organisms found in plant soil, compost, and leaf mold can help release serotonin which is a feel-good neurotransmitter.

7.      Use a spray bottle filled with water to squirt on plants and bathroom walls.

8.      Scrub bathroom walls using scrubbers – rotating in various forms such as plastic, coir, utensil green scrubber.

9.      Wipe tables after a meal using a small wet towel.

10.  Wring / squeeze towels with both hands.

11.  Pour water on self while using a mug during bath time.

12.  Give them a coir loofa to scrub themselves during bath time.

13.  Give 3-4 size containers such as small medicine cup, plastic glass, squeeze bottle to pour water from one container to another.

14.  Do not hold the banana for the child. Have them hold a banana with 1 hand, peel it with another hand, eat, and then throw the peel into the dustbin. Speak to them about the different actions and you end up teaching them a whole task.

15.  Teach them peeling oranges too.

16.  Use a small pestle-mortar to pound peanuts.

17.  Churn buttermilk using a wooden tool.

18.  Pour half kg to 1 kg of rice-dal packets into a jar.

19.  Place a beach ball into a pillow cover, tie it up into a potli, and suspend it from the ceiling.  Tap the ball back and forth using 2 hands.

20.  Similarly, place a tennis ball in a sock, tie it up, suspend it from the ceiling. Let your child hit it with a plastic bat.

 

Pre-writing Activities

1.     Scoop grains like rice, dal, and beans using 2 hands, small cups, and pour the same in another container.

2.      Tear paper and crush pieces of paper into a ball prior to throwing in the garbage.

3.      Finger painting and Vegetable printing.

4.      Sort vegetables such as potatoes, onions, lemons, tomatoes etc either using tongs or hands.

5.      Use at least 2 different sized tongs to pick up objects. You can buy them at a local store.

6.      Peel boiled potatoes, mash them if needed.

7.      Let your child pick up large pieces of watermelon with fingers. Let them use fingers to pick up pieces of fruit, salad vegetables, dosa, paratha.

8.      If your child can handle a fork, let them poke into pieces of fruit with a fork.

9.      Cut boiled or firmly boiled vegetables such as carrot, pumpkin, sweet potato----use a plastic knife.

10.  Use plastic tools such as knife and spatula to manipulate/ cut/ lift playdough.

11.  Hide small treasures such as coins, beads, bottle caps etc. into playdough or therapy putty and let your child find it.

12.  Use an eye-dropper to drip colored water.

13.  Pick up tooth-picks and insert them into a salt-pepper shaker. Make sure that the child is holding the shaker with 1 hand while using the other hand to insert toothpicks into the holes.

14.  Pull and fix rubber bands around a steel glass or cardboard cylinder.

15.  Fix clothespins on a chart paper.

16.  Have your child write large letters in shaving cream, flour, sand.

17.  Writing/drawing/painting on a vertical surface—stick a large chart paper on the wall a little above eye level. This helps stability of shoulder and wrist.

18.  Place a large chart paper on the floor and let the child color in crawling position.

19.  Write/ color on a slate, or blackboard, or driveway with chalk.

20.  Focus on drawing shapes such as circle, square, cross, diamond, etc. prior to writing letters.

21.  Trace a letter on your child’s back and have them identify it.

 

Cycling

Many parents purchase a bicycle with training wheels / side wheels, only to find that their child is having difficulty with peddling. Peddling and balancing when the bicycle moves is not as easy as we think.

At home, you can place old shoes under the side wheels. Now you have converted this into a static bicycle. Your child can sit on it and practice peddling, but the bicycle will not move.

At Activ Kaarya, we use the peddler to practice peddling. Please read the following blogpost.

https://sensoryintegrationbangalore.blogspot.com/2016/03/peddler-in-pediatric-therapy.html

Learning to cycle may take a few weeks or months. In some cases, children have learnt to ride a bicycle with side wheels within a few sessions.

 

Outdoor Activities

1.    Go to the park 4-5 times a week, sometimes to indoor play areas that offer so many opportunities for climbing, jumping, crawling, and balancing.

 

2.    Go for frequent walks with your child, have them carry a weighted backpack which is 10% of their body weight.

 

3.      While travelling, let your child pull the wheelie bag as and wherever possible.

 

4.   Take your child to the street market / desi market with you. Let them experience the colorful atmosphere of the market, look at the sarees hanging in the stores, the heaps of colorful fruit and vegetables, the smell of food being fried in small shops, and much more. Carry a bag or a bag pack to fill up and walk back home. 

 

5.      Push a heavy cart in the super market.

 

6.      Carrying weighted bags home from the market.

 

7.    Go for walking in natural enviroments. Bangalore is gifted with natural sites around the city – Nandi hills, LalBagh, Cubbon park, Banerghatta zoo, that offer walking and climbing. 

 

8.      A day can be spent on a farm where the child can play in mud, splash in water, and much more.

 

9.    Swimming can be learnt gradually. But first let the child just float in water wearing the safety gear. A parent can also get into the pool with the child.

 

10. If you are planning a vacation, go the beach. The beach offers a natural sensory environment – the different textures of the sand on various parts of the beach, the sound of the waves, making a sand castle that involves scooping, digging, pouring, and pressing.

 

https://www.youtube.com/watch?v=yZT5nfhnOjA home as well as open gym exercises can be done by children 5 years and older.

https://www.youtube.com/watch?v=X-u1W7cOCp8  simple activity with balls and cups to enhance reaction time, attention, cognition.

https://www.youtube.com/watch?v=n55pNvYiQw0 rubber band activity for children 5 -6 years and up, for finger strength. You can do them during travels also.

https://www.youtube.com/watch?v=nprmd3l8Nmc&t  to improve single-leg balancing, timing & sequencing to an auditory beat, figure-of-8 walking. Please watch and follow 16:00 onwards on this video.

 

Have Fun with your child! Include Play & Language in all the activities that you do. Connect with child. Give up the screen and be present with your child in the moment!