foods with textures can be properly broken apart; 4)sensory skills, which allow the older infant and toddlerto tolerate the feel of foods in their mouth, to learnto like the taste of table foods, and to track where thefood is in the mouth at any given time; 5) hand-to-mouth skills, which allow the child to learn to self feed;and 6) parenting skills, which encourage the infant toenjoy a variety of foods and the feeding experiencethroughout the formative years.

Postural StabilityAs with the younger infant just learning to eat babycereal, the ability to sit upright independently is crit-ical for transitioning on to more difficult-to-managefoods. Once a child is able to sit independentlywithout falling over for approximately 10 minutes, itstime to make the transition from an infant feedingseat to a standard high chair. This usually takes placesomewhere between 8-9 months of age for most chil-dren. Todays new high chairs frequently have goodside and front supports, often with a saddle bar in thecenter to prevent the older infant from slidingforward out of the chair. If the family does not havethis type of high chair, a non-skid mat under the rearend and a foam insert called a High Chair Helpercan provide the same level of support and securesitting.

As the older infant grows into a toddler, parents willnotice their childs increased interest in sitting at thetable with the rest of the family, usually around 18months of age. Since this is also an age when childrenbecome very interested in imitating others, it is impor-tant to have meals at a family table where the childcan closely watch the family eating (Rozin, 1996).While keeping toddlers in high chairs may keep themcontained (somewhat), it also perpetuates physicalseparation from the family and doesnt allow them tosee well enough to learn by imitation. Ideally, thefamily will use a height-adjustable high-chair whichcan be pushed up tp the family table with the tray

removed. This will allow the inquisitive and activetoddler to remain in a stable seat, while still joiningthe family.

If the high chair is not adjustable, a booster seat, withvery high side arms and a stable back, should be used.The booster seat will need to be securely attached tothe front edge of the adult chair so that the toddlerslegs are in a 90 degree position with the feet aresupported by a foot rest. Sliding a booster seat to theback of an adults chair will cause the childs legs tostick out under the table at an odd angle, and doesnot permit stable seating. The lack of a stable seatingarrangement is the most common clinical reason fortoddlers to repeatedly get in and out of their chairsduring meals. Running away from the table duringmeals does not support good eating habits.

Oral-motor SkillsThe oral-motor skills needed for transitioning tofinger foods and table foods are different from thoseused for breast/bottle feeding and spoon-feeding.Breast/bottle feeding predominantly involvesforward/backward tongue movements. Spoon-feedingskills develop over time, however, from a normaltongue thrust for about the first month, to tonguewaves that transfer foods from front to back of themouth after about a month of practicing with thespoon. Between 7-9 months, the infant learns to cupthe tongue for the spoon, and close their lips aroundthe spoon to help draw the food into the mouth(Glass and Wolf, 1992).

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One of the common myths about eating is that it is easy and instinc-tive. Eating is actually the most complex physical task humansengage in. It is the only physical task that utilizes all of the bodysorgan systems: the brain and cranial nerves; the heart and vascular system;the respiratory, endocrine and metabolic systems, all the muscles of thebody, and the entire gastrointestinal tract. Just swallowing, for example,requires the coordination of 26 muscles and six cranial nerves. Eating isalso the only task which children do, that requires the simultaneous coor-dination of all of the sensory systems. The ability to manage this physicalcoordination begins instinctively, but only for the first month of life. Fromend of the first month to the end of the fifth or sixth month of life, theprimitive motor reflexes (rooting, sucking, swallowing) take over as theolder infant lays down pathways in the brain for the voluntary motor andsensory control over eating. After the fifth or sixth month of life, eating isactually a learned behavior.

Because eating involves the interplay of so many body systems and activities,it is important for parents to establish a feeding plan early on that will helptheir older infant and toddler master the incremental skills needed to transi-tion from pureed baby foods to textured table foods. The skills that need tobe achieved for successful eating include: 1) postural stability, which isaffected by the type of chair supporting the growing infant; 2) oral-motorskills, which need to progress from a sucking movement for purees to theside-to-side tongue movements needed for eating table foods; 3) jaw skills,which progress from a suck, to a munch, to a rotary chewing motion so that

Kay Toomey, PhDDirectorColorado Pediatric Therapy and Feeding Specialists, IncDenver, Colorado

Feeding Strategies for Older Infants and Toddlers

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Synopsis More than 50 million American children and adults suffer from allergic disease. In addi-tion to annoying symptoms, allergies may also contribute to asthma and, by causing sleep disorders, leadto fatigue and learning problems.

Of all the allergies, a sensitivity to pet allergens is the most challenging to manage and treat becausefamilies are usually quite emotionally attached to their pets. Cat allergen sensitivity is particularly chal-lenging because it is the most common pet allergy and the most difficult to completely eliminate fromthe environment. Sadly, often the best solution is to remove the beloved pet from the home particu-larly if the allergies are severe or trigger asthma in a family member. Many people, however, feel thattheir allergy symptoms are a small price to pay for the unconditional love, affection and companionshipthat they receive from their pet. In these instances physicians should attempt to educate, then focus on thetypes of treatment and avoidance that are most acceptable to the patient.

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In order to eventually manage thetransition to table foods, the olderinfant/toddler needs to learn howto move the tongue to the sides ofthe mouth and place a bite of foodonto the molar area of the gums.This movement pattern, known asa lateral tongue movement, is crit-ical for successfully transitioningfrom baby food purees to tablefoods. A controlled lateral tonguemovement pattern is learned indevelopmental stages that beginwith learning to tolerate the feel ofa long hard object in the mouth.Mouthing teething toys and avariety of developmentally appropriate objects ofdifferent textures helps infants and toddlers learn tomanage the feeling of objects in their mouth andteaches them how to move their tongue from side toside. Initially, the hands help move the foods aroundin the mouth. Over time and with practice, the lateraltongue reflex comes under voluntary control andfood is moved around without as much assistancefrom the hands (Morris and Klein, 1987). Typically,this skill develops around 8-9 months of age. Olderinfants who have mastered lateral tongue movementsare ready to try finger foods.

It is important to recognize that, in order to correctlymanage textured table food from an oral-motor stand-point, lateral tongue movements must be learned first.When older infants are given pureed baby foods thathave chunks of other foods in them before they learnhow to lateralize their tongue, the chunk of food maybecome stuck on the top of the tongue and cause thechild to gag. (You can find out just how uncomfort-able this feels, as well as come to a better under-standing of the oral mechanics of eating texturedfoods, by conducting the experiment on page 6.)Infants and toddlers who frequently gag on food learnthat eating is not a pleasant experience and, conse-quently, may avoid textured foods or avoid food alto-gether.

The oral-motor skills necessary for cup drinking arealso quite different from those used with breast andbottle feeding. Most importantly, the older infantneeds to learn how to hold a small amount of fluid in

the mouth, and to pull it into aball (or bolus) for swallowing(Morris and Klein, 1987). Cupswith no-spill valves perpetuate abottle/breast drinking oral patternin which the fluid is sucked backusing negative pressure with thetongue flat held underneath aspout (or nipple) and do notsupport the development of themore mature drinking skills. Anopen cup or sipper cup without ano-spill valve is a more appropriatefirst cup choice. Ideally, the cupwould have two handles and arecessed lid so the older infant can

easily hold and manipulate the cup, as well as avoidcompressing the nose against the lid

Jaw SkillsAs previously noted, breast/bottle-fed infants primarilyuse their tongue for feeding. While there is some jawmovement involved in both early fluid feeding(compression movements) and spoon feeding (openand close), the role of the jaw and chewing is smallcompared to that of the tongue (Glass and Wolf,1992). Between 9 and 10 months of age, the jawbecomes very active in eating as the child learns tobreak food apart by moving the jaw up and down withpressure on the food. An up and down jaw movementis referred to as a munch (Morris and Klein, 1987).

Rotary chewing emerges between 12 and 14 monthsof age as the toddler encounters more chewy texturedfoods (Glass and Wolfe, 1992). Appropriately sizedand shaped, soft table foods can be introduced once achild adds a small grind with the teeth on the food,along with a small side-to-side motion of the jaw(rotary chew).

Sensory SkillsEating requires the simultaneous integration of alleight of our sensory systems. These senses include thefive which are well known: seeing, hearing, tasting,touching and smelling, as well as the lesser-knownsenses of balance, awareness of body in space andinformation received from ones joints. The latterthree sensory systems are known as the vestibular,

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Even the typically developing childcan become a picky eater whenallowed to food jag. This isbecause if children are onlyexposed to the same few foodsevery day, they do not learn how tomanage the complex sensory infor-mation needed to eat difficultfoods, such as raw vegetables,hard-to-chew meats, or wet/slip-pery fruits. The infant who once ateall types of fruits and vegetables asa pureed baby food, doesnt learnhow to eat the table food versions.Or, the toddler who has becomeneophobic of every green food isno longer given the sensory prac-tice of eating peas because thechild is tantruming.

The key here is to back down thesensory progression of learningabout foods to a step the toddlercan tolerate. These sensory stepsare (in order of most basic to mostdifficult):

1) visually tolerating the food

2) interacting with the food withoutactually touching it (vestibular;kinesthetic and proprioceptivesystems)

3) smelling

4) touching

5) tasting and then, finally

6) eating

This means that a toddler mayneed to back down from actuallyeating peas to just squishing themfor a while to become reacquaintedwith their sensory qualities. Gradu-ally, the parent can move their childback up the sensory steps towardseating.

To move a child up the Steps toEating Hierarchy outlined above,the parent needs to create playwith a purpose, with the purposebeing to move the child up to thenext sensory step in the progres-sion. For example, for an olderinfant or toddler who does not wantto even look at the food, making it

wiggle in front of them can oftentimes attract their attention.Pretending the food is an animalcoming to talk to them is alsoengaging. Stirring, pouring anddumping from a spoon are all good(and fun) ways to encourage a childto interact with food. Having anolder child help with food prepara-tion is also an excellent way tomove up to interacting with thefoods while achieving the smellstep of the hierarchy. Breaking,pulling, waving and crushing thefoods are all excellent strategies forteaching a child about how thefood will move once it is in theirmouth, as well as moving them upto the touch step of the hierarchy.Blowing rockets into a cup orbetter yet into the trash is theeasiest way to get children to tastea food they otherwise would not gonear. Remember, playing with thefood is not the end goal of thisprocess. These are merely moremanageable steps along the way toactually eating the food.

Parent can prevent food jags in thefirst place by changing some phys-ical property about the preferredfood EVERY time it is presented.This means that the size, shape,color, texture, temperature or tastewill need to be different each timethe child is given their food jagfood. For example, for the childwho will only eat macaroni andcheese from a blue box, begin byputting the raw ingredients in aplain, sealed plastic bag or bowlfirst. Next, offer the child thepreferred noodle shape with thepieces cut in half, then change to adifferent shaped noodle for severalexposures. By this time the childshould be able to tolerate thedifferent flavor of the macaroni andcheese created by addingParmasean cheese to the mix.Finally, parents can offer the colormacaroni and cheese mixture in adifferent color by adding a small

amount of food coloring.

Many parents and professionalstreat food jags as a normal toddlerbehavior that can be tolerated.While the appearance of thepattern may be normal, maintainingit is not and will only serve to limita child's exposure to a variety ofother foods, reinforcing the child'spreference for a very limitednumber of foods.

Preventing and Treating Food Jags

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kinesthetic and proprioceptive systems respectively.Once an infant is sitting independently, these threesensory systems start to play a very large role infeeding.

Another one of the myths about feeding is that eatingis our bodys first priority, when actually it is only thethird. Breathing is the bodys number one priority andbalance is the second. As such, the vestibular/balancesystem becomes very important to the infant who is nolonger held by an adult who is providing theirbalance. In addition, every time humans move theirheads, the fluid in our inner ear shifts and thevestibular system must readjust our sense of balance.In order to spoon feed, the older infant needs tocome to midline and open their mouth; a task whichshifts the head in space and requires an adjustment inbalance. Chewing table foods is an even more difficulttask as humans do not naturally chew with their headsperfectly still. Young toddlers especially move theirhead with every chewing motion, and therefore haveto readjust their sense of balance with each munch orchew that they make.

With regard to kinesthesia, drinking from a nippledoes not require much body awareness since thenipple fills up much of the mouth. A puree coats the

inside of the mouth and is notdifficult to locate from a bodyawareness standpoint either.However, a small piece of tablefood can be easily lost in themouth if there is not good bodyawareness. Older infant andtoddlers need to be able totrack each piece of food in theirmouth so they do not acciden-tally bite their tongue or cheekinstead of the food. In addition,the food must be followedinside the mouth to know that ithas been placed correctly ontothe molars, and where it islocated when it is time toswallow. You have experienced akinesthetic awareness problem ifyou have ever eaten popcornand ended up with a popcornshell stuck in the back of your

throat. Your sensory system lost track of the location ofthat shell and it ended up in a place it did not belong.

During feeding, information received from the jawjoint via the proprioceptive system is also differentdepending on whether the infant is drinking a fluid,sucking back a puree, or chewing table foods.Remember, drinking is actually more of a tongue thana jaw movement, and spoon-feeding requires primarilyan open/close motion of the mouth. Chewing,however, is quite complex and gives a large amount ofshifting information as a food is broken apart for aswallow. (Think about how different the cracker youchewed in the above experiment felt from the firstchew to the last and what kind of jaw pressure differ-ences you registered).

Another very important developmental sensory eventthat occurs during this time is the change in functionof a toddlers taste buds (Mennella and Beauchamp,1996; Duffy and Bartoshuk, 1996). Prior to this age,the taste buds on the back of the tongue, soft palate,uvula and back of the throat were primarily used.Shortly after a childs first birthday, the taste buds onthe front of the tongue become predominant and theothers decrease in function and/or disappear. Assuch, the toddler begins to reject baby foods becausethe taste is no longer preferred. The toddler alsobecomes resistant to being spoon fed at this agebecause changes in cognitive and emotional develop-ment inspire them to test their independence.(Lieberman and Birch, 1985; Satter, 2000).

In order to eat textured table foods then, the toddlerneeds to be able to simultaneously integrate informa-tion from all 8 of his sensory systems with every singlechewing motion; the sight of the food changes as it is

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Do Try This at Home

Take large bite of a soda-type cracker. Chew thecracker 4-5 times, then place the pieces onto the centerof your tongue. Now, attempt to swallow the chewedcracker from here without lifting your tongue intoyour palate. This should be difficult and uncomfortable.

Next, close your eyes and take another bite of thecracker. As you chew and swallow normally, visualizehow and where you move the cracker in your mouth,where you chew it, and from where you swallow it. All ofthese skills must be in place for eating table foods well.

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Nobody knows the trouble Im inmight be the perfect lament of chil-dren with feeding disorders. Theyoften struggle along on minimalchoices from each food group. Theyaggravate their parents at every bite;while equally frustrated pediatricianstry to reassure parents that at leastyour child is growing along a normalcurve. No one may suspect thechild is in the early stages of abonafide feeding disorder, and fewerpeople know how to identify andcorrect them.

This occurs because our basictraining is excellent in the areas ofgeneral nutrition, gross and finemotor development, electrolytebalance, and the recognition ofvarious deficiency states, but isoften inadequate in understandingthe natural process of learning toeat. Eating is first and foremostexperiential, ultimately requiring theintegration of a childs sensory,gross, fine and oral-motor capaci-ties. The accompanying article byDr. Kay Toomey, details this elegantjourney of learned behavior. Sheprovides the rest of the story theydidnt tell us in medical school.

Its easy to appreciate the interde-pendency of these processes whenfaced with a disorganized preemie ora child who, for whatever reason,has been fed by a G-tube from anearly age. They have to learn orrelearn the process, and it is no easytask. At a more subtle level, thesame impediments to learning aretaking place with our problem eaters.

All of us can recognize a child withpoor weight gain, ongoing choking,gasping, coughing and vomiting, andthe child that arches and cries ateach meal. These symptoms promptearly and intense work ups, andusually demonstrate a suspectedmetabolic disorder, mechanical swal-lowing difficulty, or GE reflux.

But what about the otherwise normalchild who, due to a combination ofphysical and/or behavioral issues,wont eat, or will only eat a fewfoods? To the right are some redflags suggesting early signs of anemerging feeding disorder. The usualcause of each problem follows inparenthesis.

Simple and Effective Office InterventionsMany feeding difficulties can beprevented or treated with a littleguidance from you early on. Forexample:

Rethink your feeding recommenda-tions along developmental ratherthan nutritional lines. Success withthe early feeding of solids is bestattained when a child has learned tosit alone. Early on, an infant seat orswing works well. Later, a high chairwith a t-strap fastener (or a non-skidpad) and adequate back support isbest.

Suggest to parents that initially foodshould be explored by the sensesrather than eaten.

Encourage parents to demonstratehow to eat and explore new foodsbecause babies learn best throughimitation. Along those lines,encourage parents to smile whentheir baby grimaces at a new taste not imitate their babys frown.

Remind parents that it may take 10-20 exposures before a child acquiresa taste for a new food. Dont give uptoo early.

Instruct parents that the spoonshould just touch their childs lips.The child should be allowed toexplore and taste the food, ulti-mately taking the spoon into themouth by his own initiative.

Look carefully for signs of sensoryproblems, such as finger splaying,grimacing, extending legs, andclosing their eyes during feeding.

Aversion to loud noises, motion sick-ness, avoiding climbing stairs, orlack of interest in exploring anythingwith the mouth can also be signs offeeding problems.

Refer a picky eater sooner ratherthan later to a feeding specialistwith OT/ST support, so that the oral-motor sensory dynamics can be fullyevaluated and effectively treated.

In summary, dont be content withthe picky eater who consumes a fewitems from each food group, yetcontinues to grow at a normalvelocity on the curve. There isusually an underlying correctablereason that is worth pursuing.Persistence in your investigationand/or referral can make a world ofdifference early on in the lives ofyour patients and their families.

Putting Research Into Practice with Michael Frank, MD, FAAP

Dr. Michael Frank is a pediatrician inprivate practice in Denver specializing ineating disorders and ADHD; clinicalinstructor for TheUniversity ofColorado HealthScience Center,and MedicalDirector of theColorado PediatricTherapy andFeeding Special-ists, Inc.

Early Signs of a Feeding Disorder

1. Inability to transition to baby foodpurees by 10 months (oral-motor/sensory)

2. Inability to accept table foods by 12months. (oral-motor/sensory)

3. Inability to transition from breast/bottleby 16 months. (learned/lack of properexposure)

4. Inability to wean off baby foods by 16months. (oral-motor/sensory)

5. Avoidance of foods of specific texturesor food groups. (sensory)

6. Parents report that the child is difficultfor anyone to feed and meals are abattle zone. (any combination of theabove)

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chewed, how it feels changes, what it sounds like inthe mouth changes, the taste and the smell actuallychange, and adjustments need to be made in balance,location of the food, and pressure being exerted. Diffi-culties with the sensory system is the most commonclinical reason for children not being able to transi-tion from baby food purees to textured table foods.

Hand-to-Mouth SkillsFinger feeding begins when . and .. (A paragraphhere, please.)

While finger feeding should become noticeably effi-cient around 14-16 months, utensil use does notbecome efficient until after 24 months and should notbe the primary way of self-feeding until after the ageof 3 years. The best toddler utensil is one that is shortin length (not the long infant feeding spoon), with anenlarged handle covered in a textured surface. Thistype of utensil is ideally suited to allow for thetoddlers wider and less proficient grasp pattern. Ametal spoon bowl and metal blunted fork tines arepreferred by the toddler to assist with poking thefoods and because the rubber tipped infant feedingspoon has usually become a non-preferred item. Themetal makes the toddler utensils different from theinfant spoons and allows them to be more like theothers in their family using grown up utensils. Aheavy or weighted spoon is ideal as the slightlyincreased weight helps the toddler with their finemotor control.

The Parents RoleThe most important tasks for parents teaching theirolder infants and children how to eat are: focusing onthe mechanics of the task; choosing developmentallyappropriate foods; and making the experience enjoy-able. Pleasant, fun mealtimes help establish life-long,healthy relationship with food.

In order for parents to teach their children to begood eaters, they need to become aware of themessages that they may be sending their child aboutfood and/or about their own food preferences. If aparent is concerned that their older infant or toddlermay not be able to handle a particular food and thenlooks worried about it, the child will get the messagethat the food is not safe and should be rejected.

If the parent is concerned at all about their childsphysical capability of managing a food, they shouldinstead "show and tell" the child how to eat the food.This means literally talking their older infant andtoddler through the process of biting and chewing, aswell as showing the child in an over-exaggeratedfashion exactly how to move the food around in themouth. For example, a parent would want to explainin very simple language how they manage a bite of acracker by saying, Im going to bite with my frontteeth and move it back to my strong back teeth withmy tongue. Then I am going to chew, chew, chew.

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When children wont eat, parents and professionals areoften tempted to classify them in one of two categories:those who have organic or physical problems andthose who have behavioral problems. These kinds oflabels are not particularly helpful. First, because there isan implication of blame in this system, which is neithervery accurate nor useful when trying to help childrenwith feeding problems. Second, children with physicaldifficulties often develop behavioral problems after theirattempts to eat dont go well, and children with behav-ioral eating difficulties develop physical disorders afterhaving poor nutrition for a period of time. So there isnta clear-cut distinction between the two.

Rather than force children into categories where theydont belong, we need to think about children who wonteat as having had poor learning experiences with food.In other words, just as children learn to eat, they canalso be taught to not eat by the circumstances in theirlives.

Research shows that learning about food occurs in twomain ways. The first is when a connection is madebetween one stimulus (a natural event, behavior, orobject) and a second neutral stimulus. For example, weknow that feeling sick to your stomach causes the phys-ical reaction of appetite suppression. This is a naturalevent. If feeling nauseous is consistently paired with aspecific food (previously a neutral thing), eventually thefood itself will cause nausea. Another example would besomeone who is in pain or discomfort who would natu-rally try to escape or avoid the circumstance thatcauses the pain. If the pain is then paired over time withfood, the person will learn to avoid or escape from situ-ations that involve eating. Gastroesophageal reflux(GER) is a good example of this type of learning.

The second way that we learn is through reinforcementand punishment. Eating followed by praise or imitation(positive reinforcement) leads to more eating. Similarly,refusing food followed by lots of attention/interaction(also positive reinforcement) leads to more food refusal.

So, in addition to increasingdesired behaviors, positive rein-forcement can cause more ofan undesired behavior as well.

Punishment around foodis also very powerful.Booth showed that ifthe learned reaction to

food is negative, thephysical effect is

appetite suppression. That is, if the learning about foodis unpleasant, our bodies turn off our appetites. Wein-garten and Marten showed that if negative connectionsare made to the cues of eating (e.g., sitting down at thetable, the utensils used, the people present, the roomwhere meals are eaten), a child learns to avoid thefeeding situation completely.

The overall goal of all treatment with children who wonteat is to create a situation that positively reinforcesnormal, healthy eating patterns through:

Structure Have a routine to mealtimes, eating inthe same room, at the same table, with the sameutensils, which capitalizes on the need for repetitionin learning.

Social modeling Allow children to learn throughthe observation of good mealtime role models.Parents who are poor or picky eaters will have adifficult time helping their children.

Positive reinforcement Meals need to bepleasant and enjoyable, and any interaction withfood should be rewarded. Verbal praise, a smile, atouch, a cheer, and hand clapping are all greatoptions.

Manageable foods Foods need to be preparedin small, easily chewable bites, or in long, thin stripsthat a child can easily hold.

Learning about the physics of food The mouthand teeth will need to use hard pressure to breakapart a carrot stick. Wiggly, squishy string cheese ischewy in the mouth. Yogurt, which is cold, wet andsmooth, can just be sucked down.

By helping parents understand that eating is a learnedbehavior in which there is an interplay between thechilds physical capabilities and their experiences withfood, professionals can help them take on a positiveteaching role with their children rather than the negativeforcing or no-limits approaches to feeding. The teachingapproach clarifies for parents that there are things theycan do to make the feeding situation better, and it givesthem hope. It also teaches parents, as well as us profes-sionals, that there are also things that we can do whichmay make the situation worse and it reminds us how toavoid the pitfalls of working with children who wont eat.

Booth D: Learned role of tastes in eating motivation. In: Taste, Experienceand Feeding, E Capaldi and T Powley (eds), pgs 179-95. American Psycho-logical Association, Washington DC, 1990.

Weingarten HP: Learning, homeostasis, and the control of feeding behavior.In: Taste, Experience and Feeding, E Capaldi and T Powley (eds), pgs 45-61. American Psychological Association, Washington DC, 1990.

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cutters to make different shapes in the food andnatural food colorings to create foods that look inter-esting to eat. Describing the physical properties of thefoods (texture, temperature, consistency, pliability)facilitates exploration by teaching children thephysics of food and helps them understand how thefood will feel, break apart and move in their mouths.Allowing the older infant and toddler to get messyand play with their food, will be especially helpfulfor gaining and maintaining interest in food.

Play centered on food needs to be play-with-a-purpose; play which teaches the child something newabout the food. This type of play is different than playthat happens when a child is done eating. Play-with-a-purpose allows the older infant and toddler to explorefood as one more exciting and fun part of their world,as well as teach them how to manage food once it getsit into their mouths. Hopefully while using thesestrategies, parents will re-discover an enjoyment ineating for themselves, which they can then impart totheir children.

ConclusionWhen parents of typically developing children in pedi-atric practices are polled, up to 33% of them indicatethat they have problems getting their infant or toddlerto eat (OBrian, 1996; Crist and Napier-Phillips, 2001). Parental stress aroundfeeding can be greatly alleviated through guidance bya pediatric practioner who can educate parents aboutthe complexity of the process of learning to eat. Thiseducation empowers parents and helps them realizethat there are things they can do which will make thefeeding experience go better for their child and them-selves. This guidance can also give them hope for achild who will have a future healthy relationship withfood.

Dr. Kay Toomey is a Pediatric Psychologist specializing in theassessment and treatment of children with feeding difficul-ties. She has been working with children who wont eat forover ten years. Dr. Toomey co-founded the Oral FeedingClinic at The Childrens Hospital in Denver in 1990, andacted as Director of the Rose Medical Centers PediatricFeeding Center from 1995 to 2001. Currently, Dr. Toomey isin private practice as the Director of the Colorado PediatricTherapy & Feeding Specialists, Inc. She lectures nation-wideregarding her feeding treatment program, the SOS ApproachTo Feeding.

ReferencesBirch, L. (1990). Development of food acceptance patterns. Developmental

Psychology, 26, 515-519.

Birch, L. & Fisher, J. (1995). Appetite and eating behavior in children. In G. E.Gaull (Ed.), The Pediatric Clinics of North America: Pediatric Nutrition. (pp.931-953). Philadelphia, Pennsylvania: Saunders.

Birch, L. & Fisher, J. (1996). The role of experience in the development of chil-drens eating Behavior. In E. Capaldi (Ed.), Why we eat what we eat: Thepsychology of eating. (pp. 113-141). Washington D.C.: American Psycho-logical Association.

Birch, L. & Fisher, J. (1998). Development of eating behaviors among childrenand adolescents. Pediatrics, 101, 539-549.

Duffy, V.B. & Bartoshuk, L.M. (1996). Sensory factors in feeding. In E. Capaldi(Ed.), Why we eat what we eat: The psychology of eating. (pp. 145-171).Washington D.C.: American Psychological Association.

Crist, W., Napier-Phillips, A., McDonnell, P., Ledwidge, J. & Beck, M. (1998).Assessing restricted diet in young children. Childrens Health Care, 27(4),247-257.

Crist W, Napier-Phillips A. (2001). Mealtime behaviors of young children: Acomparison of normative and clinical data. Developmental and BehavioralPediatrics, 22(5), 279-286. OBrien, M. (1996). Journal of PediatricPsychology, 21(3), 433-446.

Glass, R. & Wolf, L. (1992). Feeding and Swallowing Disorders In Infancy.Tuscon, AZ: Therapy Skill Builders.Lieberman, A. & Birch, L. (1985). Inter-actional developmental approach. In D. Drotar (Ed.),

Failure To Thrive (pp. 259-277). New York: Plenum Press.

Mennella, J.A. & Beauchamp, G.K. (1996). The early development of humanflavor preferences. In E. Capaldi (Ed.), Why we eat what we eat: Thepsychology of eating. (pp. 83-112). Washington D.C.: American Psycho-logical Association.

Morris, S.E. & Klein, M.D. (1987). Pre-Feeding Skills. Tucson, AZ: Therapy SkillBuilders.

Nebling, L. (2002). Phytochemicals: The color of a healthy diet. PediatricBasics, 98, 2-9.

Rozin, P. (1996). Sociocultural influences on human food selection. In E.Capaldi (Ed.), Why we eat what we eat: The psychology of eating. (pp.233-263). Washington D.C.: American Psychological Association.

Satter, E. (2000). Child of Mine: Feeding With Love and Good Sense. PaloAlto, CA: Bull Publishing Company.

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Number 100 | Fall 2002 11PediatricBasics

The language needs to be paired with a large bitingmotion, with an open mouth to show how the tonguemoves and then with an up and down head movementto emphasize the chewing motion. Recall that chil-dren in this age range learn best by watching othersengage in an action. As such, parents need to be goodrole models for their infants and toddlers. This appliesnot only to role modeling the mechanics of eating,but also our food choices. If a parent makes a faceand complains that they dont like broccoli, it isdoubtful that their child will eat this food either.Recent research suggests that the likes and dislikes ofparents play a large role in whether or not their chil-dren learn to eat fruits and vegetables throughouttheir lives.

Parents also need to remember that it may take anaverage of ten exposures to a new food, paired withpositive reinforcement, before a child will consistentlyaccept the food (Birch 1990, 1995, 1996, 1998). If achild appears to dislike a food, the parent shouldmaintain their cheerful face, reassure the child thatthey are okay using a positive voice and then modeltaking another bite themselves. If the reaction is verylarge again, the parent can continue to reassure andpraise the child for taking the bite, but move on to adifferent food. The questionable food then needs tobe tried again on a different day.

The flip side of needing to try new foods several timesbefore prior to acceptance is not permitting a child tochoose to eat the same food over and over again tothe exclusion of any other foods. Known as a foodjag, this behavior is especially prevalent in oldertoddlers and thought to be related to their discomfortwith new foods, or neophobia (Rozin, 1996; Satter,2000). Food jagging is also believed to be a typicaltoddler feeding pattern and, therefore, is not viewedas a problem. However, a child allowed his food jags,eventually burns out on a particular food and refuseto eat it again, even after a month or more hiatus inchildren with feeding difficulties. As a result, the childloses more and more foods out of their food reper-toire as they jag and burn out on each successivefoods, until there may be only 5-10 foods that he willeat. This child then needs professional help in orderto assure a nutritionally adequate diet. For the typi-cally developing child, a break from the food forabout two weeks seems to be sufficient to allow thechild to become willing to eat the food again.

Lastly, parents should not forget that their olderinfant, and especially toddler, is becoming more inter-ested in exploring the world than eating. If meals andfoods are not made fun and an extension of thechilds exploration of the world, there will be littleincentive to come to the table to eat. Parents shouldfeel free to get creative with the food using cookie

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Table X: Picky Eaters Versus Problem Feeders

Picky Eaters Problem Feeders

Decreased range or variety of Restricted range or variety of foods, foods. Will eat 30 foods or more. usually less than 20 different foods.

Foods lost due to burn out because of a food Foods lost due to food jags are NOT jag are usually re-gained after a 2 week break. re-acquired.

Able to tolerate new foods on plate and usually Cries and falls apart when can touch or taste a new food (even if reluctantly). presented with new foods.

Eats at least one food from most all food Refuses entire categories of texture groups. food textures.

Will add new foods to repetoire in 15-25 steps Adds new foods in more than on Steps to Eating Hierarchy. 25 steps.

References

Start feeding your baby in aninfant seat

Move her to a high chairaround 8 months

Bring your toddler in closeto the family table

Number 100 | Fall 2002

PediatricBasicsFor a complimentary supply of this wall poster, call 1-800-595-0324

SENSORY SKILLS

HAND-TO-MOUTH SKILLS

Coordination of the eight senses: Seeing Hearing Tasting Touching Smelling Balance Body Awareness Joint Information

Is your toddler having a difficulttime shifting from purees totextured foods? Let him getacquainted with old and newflavors using all eight senses.

need text: Cup drinking Finger feeding Using utensils

Babies first learn to munch softfoods with their jaws up and down(9-10 months)

Chewing, comes second byadding a small grind with the teethand a side-to-side motion with thejaw (between 12-14 month)

Choose appropriate foods Show and tell your baby how to eat and enjoy

new foods Dont give in to food jags Dress up the flavor of foods to make

them more interesting cheese sauce onpeas, lemon sprinkled on cooked carrots

Repeatedexposure

during fun meal-times is the key tolearning to like a

good variety of foods.

Addsoft table

foods whenyour baby

startschewing.

Goodback and

side support is essential for goodeating.

Geta picture ofyour baby

wearing his food,because its just as

important toexplore food as it

is to eat it!

when youre very youngtheres more to food than just eating

Ratherthan just

spooning food in,gently touch the

spoon to yourbabys lips and let her come

for it.

Babiesneed to

explore toysand food with

their hands and mouths.

Talk with your doctor if your child: Eats only pureed foods at 10 months Wont eat table foods at 12 months Still takes a bottle at 16 months Eats only baby food at 16 months Avoids certain textures Avoids certain flavors Is difficult to feed

JAW SKILLS

POSTURNALSTABILITY

Babies need to learn to: First, move food around in their

mouths without gagging Then, move their tongues from side to side Finally, place food on the molar area of the

gums for chewing

ORAL SKILLS

PARENT SKILLS