I thought I knew a lot about feeding after five years of ongoing feeding therapy, four feeding therapists, having lived the experience of a child who vomited if food got on his lips to having him enjoy eating (even if it is a work in progress) and having heard other professionals lecture about feeding therapy.
Well, within moments of beginning a 2-day seminar with Dr. Suzanne Evans Morris on Feeding the Whole Child, A Mealtime Approach, my mind was blown. There were things I should have been doing, could have been doing to improve my son’s relationship with food. My thinking about mealtimes and children who are tube fed had been more focused more on the loss – the loss (or acknowledgement) that it is fundamental for a mother to want to feed their child and how emotionally devastating it can be when you can’t, the challenge of keeping a child who can’t eat occupied during a meal, what relatives may say at the holiday table, the separation of a child who is only able to eat a limited diet, etc. But, what I missed was what else a mealtime is really about and it is more than the food.
First, think about a nice dinner you have had – one with friends or family. When you remember the meal experience, it was likely more about the conversation, the enjoyment of a shared social experience, and maybe the food and drink. We watched videos of adult mealtimes and people talked and laughed, and they didn’t pay all that much attention to the food itself or how they were chewing and swallowing. The focus wasn’t on the volume consumed. It wasn’t stressful.
When we have mealtimes with our children with feeding issues, we focus almost exclusively on the mechanics of eating. It is all business. There is pressure to eat what is on the plate or in the bowl. We comment on chewing, swallowing, etc. We don’t enjoy the food or the company and we often don’t use the time to bond or talk with our child.
I found myself thinking back to the first few months of my son’s life. He had an NG, we didn’t have a diagnosis other than reflux, FTT and then delayed gastric emptying. I was gung ho on oral feeding. I didn’t understand oral aversions and how my shoving a spoon into his mouth and ignoring all his cues may make those worse. I figured it was just natural for him to eat orally, and I thought feeding therapy was kind of hokey. I remember waiting for him to vomit, because after a vomit he would eat so nicely. This all makes me cringe now. Who wants to eat after they vomit? I did realize soon after that I was likely doing more harm than good and I also noticed that my son began to refuse to eat with me. Of course, this makes a mother feel horrible. I was a ball of stress and I was putting a lot of pressure on him and eating, and he could feel that. It became medically clear that we were in it for the long-haul with tube feeding and my attitude shifted to getting the tube feeds right and increasing his tolerance of tube feeds. It wasn’t until we got to a GJ where, ironically, oral eating became more enjoyable for everyone and we were all less stressed about it.
What Dr. Evans Morris was talking about was a shift in thinking to supporting children with feeding issues at meal times to celebrate food and relationships. Giving kids reasons to want to eat, rather than having a child’s motivation to eat by an external force (like a reward, or pleasing others). A central part of this is creating a relaxing mealtime. One of the things we discussed was the impact of stress on gastric emptying. Wow, this hit home since so many of us have kids with motility issues. Kids can get into chronic stress patterns over eating. When the body is in flight or fight response, motility slows down. It is physiological, but doesn’t it make common sense? Also, if you think about when you are in that state of mind, do you learn anything? Well, no. You are focused on getting out of the situation; you aren’t going to learn how to eat better.
So, how do we create a relaxing, stress free mealtime? Dr. Evans Morris explained that we start by thinking of the mealtime as a partnership, where our child has an equal role. We, as parents (or our therapists), have to honor our child’s cues or what they are telling us. We have to build (or build back) trust. My big “a ha” moment was an exercise where we had to eat applesauce. First, we ate applesauce feeding ourselves with a spoon. Next, someone fed us applesauce. It was a completely different mouth feel. The spoon became really obvious, the applesauce and taste less obvious. Next, we fed our partner watching for their cues of when they were ready to accept food. This was really hard. I found myself focusing on the position of the spoon, how much was on the spoon and I missed looking at the eyes. I didn’t always wait for the other person to lean forward signaling they were ready for more. When I was being fed, I felt pressured to swallow and I found that I couldn’t manage to do that. I was overwhelmed by the volume in my mouth. I turned my head away. I didn’t look at my feeder. We then had to feed each other ignoring cues completely. WOW. My feeder was putting the spoon on my lip to make me open my mouth and I really didn’t like that. I cringed, she put more on the spoon. I wouldn’t have known if it was applesauce or another fruit. I was so focused on getting the food out of my mouth, I didn’t care. If it was more socially appropriate for me to have spit it out in the middle of a conference, I likely would have. Have I done this to my son? Looking back, absolutely. I have been guilty of pushing on the lip to open the mouth, putting more on the spoon and trying to feed faster when he was being accepting of food. I bet most parents are. You should definitely try this at home. You need to experience it for yourself. I don’t think I would have learned the lesson if someone just told me to put myself in my child’s place, because I already thought I was more empathetic to his situation than I really was.
I know that in thinking back I wasn’t as attentive to the cues my child sent me with oral eating and I was pretty motivated to ignore them, at times. In the end, we want our kids to have a positive relationship with food and a desire to eat. Pay attention to the subtle cues your child sends you, or what your child says if they are verbal. Notice that when you ignore those cues, they get bigger.
This may also require a change in perspective for some parents, but one of the great things about tube feeding is that it can take the pressure off of oral eating enough to allow children to develop good oral skills and a good relationship with food, so that they become better oral eaters.
One of the things I really loved about this approach is that is focuses on the enjoyment of eating as the end goal, not achieving a certain volume of food eaten. It is eating for pleasure, and the rest follows.