the feeding relationship. the feeding relationship nourishing and nurturing supports developmental...

The Feeding Relationship

The feeding relationship

• Nourishing and nurturing

• Supports developmental tasks

Development of Feeding Behaviors

Age Reflexes Feeding Behavior

B-3 months Root, suck-swallow-breathe

Suckling pattern of feeding

4-6 months Fading root/bite reflex

Mature suck, brings objects to mouth, munching pattern

7-9 months Normal gag develops

Munching, rotary chewing, sits alone, holds bottle alone

10-12 months

Bites, brings food to mouth, drinks from cup, spoon feed

Stages of Development

• Homeostasis

• Attachment

• Separation and individuation

Stages

Age Infant Development

1-3 months homeostasis state regulation

neurophysiologic stability

2-6 months attachment “falling in love”

affective engagement and interaction

6-36 months separation and individualization

differentiation

behavioral organization and control

The Feeding Relationship

• The Relationship– Parent– Child

• Tasks– Parent– Child

Tasks

• Infant– time

– how much

– speed

– preferences

• Parent– food choices

– support

– nurturing

– structure and limits

– safety

Homeostasis

• Infant cycles through physical states

• Parent provides a safe and comfortable environment

• Reflex feeding transforms to self regulation of hunger

Attachment

• Emotional/social interactions

• Parent reciprocates/engages

• Infant’s emotional and physical needs reinforced

Separation

• Struggle for autonomy

• Parent supports autonomy and guides daily structure

• Emotional needs distinguished from physical needs

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

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

• 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

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

Feeding DifficultiesRelated 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

Feeding

• Delays in feeding skills

• feeding intolerance

• behavioral

• medical/physiological limitations

• other

Factors to consider

• Medical

• Developmental

• Temperament

• Psychosocial

• Nutritional Environmental

Factors

Medical

respiratory, cardiac, GI

Developmental

immature feeding skills, temperament, sensory integration, oral/motor

Factors

• Nutritional– Frequency, density, appropriate, balance, other

• Psychosocial– Anxiety, depression, stress, unmet

social.emotional needs, disarray– Self regulation, attachment, separation

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

Rommel et al

• Single identified problem

– 26.7% medical– 5.2 % oral/motor– 5.4% behavioral

Rommel et al

• Multifactorial– 48.5% oral/medical– 1.5% oral/behavioral– 5.2% medical behavioral

Rommel et al

• Medical/oral-motor – occurred more often <2 years of age

• Behavioral– occurred more often >2 years of age

Focus Group Parent Responsefrom 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”

Parent ResponseSurvey 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…”

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

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