Comprehensive Guide to Pediatric Feeding, Eating, Sleep, and Rest Interventions

Feeding

Setting up and bringing food to mouth.

Eating

Manipulating the food or fluid in the mouth and swallowing.

Pediatric Feeding Disorder

Impaired oral intake that is not age-appropriate and is associated with medical, nutritional, feeding skill, and/or psychosocial dysfunction.

Common Challenges Associated with Feeding and Eating

Gastroesophageal reflux disease (GERD), food allergies, poor oral motor function, difficulties with tongue function, drooling, and challenging behaviors such as gagging and sensory-related responses.

Collaboration in OT Practitioners

Collaboration with child, family and caregivers, psychology, nutrition, medicine, and speech language pathology.

Multidisciplinary Approaches

Can lead to successful weaning from tube feedings, increased oral intake, improved mealtime behaviors, and reducing parenting stress.

Holistic Approach to Interventions

Focus on safety, universal precautions, and recognizing signs of distress.

Adaptive Equipment

Includes Dycem, scoop dish, suction cup dishes, light-weight utensils, built-up handle, universal cuff, utensils with shorter or curved handles, cups with handle or wide base or lid, long straw used in cup with cup holder, adapted seating with stable tray, and stabilizing elbow on table/tray to reduce physical demands.

Promote Grasp & Release & AROM

Utilizes biomechanical and developmental approach, motor learning techniques, ROM, strengthening, endurance, and coordination.

Phases of Eating and Swallowing

Includes oral preparatory (container to oral manipulation = food bolus), oral propulsive (moves bolus posteriorly), pharyngeal (swallow is triggered), and esophageal (food moves through the esophagus towards stomach).

Positioning: Oral Prep Phase for Infants

Midline positioning with full support of head and body and gently flexed posture is ideal for infants who are breast and body feeding.

Positioning: Oral Prep Phase for Older Children

Aim for >90/90/feet flat on the surface; slight flexion in trunk and neck facilitates swallowing.

Choking Hazard Position

Supine poses choking hazard.

Recommended Positioning for Suck-Swallow-Breathing Coordination

Side-lying on incline may be recommended.

Upright Position Recommendation

4-6 months = more upright position recommended.

High-Chair Adaptation

High-chairs can be adapted with small towels to maximize lateral support, stability, alignment, and improve oral motor skills for oral intake.

Lips and cheeks

Adequate lip closure and lip seal are needed for sucking and oral control (prevent spillage and drooling).

Structural differences

Such as a cleft > adaptive equipment, positioning.

Abnormal tightness

Requires AROM/PROM.

Weakness

Requires strengthening.

Tongue

Activities include silly faces in the mirror, licking lollipops, frosting, and whipped cream.

Dissociation from jaw

Refers to the ability to move the tongue independently from the jaw.

Lateralization

Beneficial for children with a tongue thrust; present spoon or food to the side of the mouth instead of midline.

Jaw

Issues include open mouthed posture, drooling, food/liquid loss during feeding/drinking.

Non-nutritive chewing

Repetitive chewing on a resistive device (p & q).

Adaptive bottle systems

May benefit infants with weak suck, limited endurance, and/or anatomic differences.

Introduction to straws

Best with a smaller straw, which requires less suction and delivers smaller amounts of liquid.

Sippy cups

Available in different spout varieties and non-spill valves.

U-Shaped cut out cups

Helps maintain a neutral head position for children with extensor tone or poor head control.

Thickened liquids

Considered for improving swallowing safety.

Aspiration

Food in airway before, during, or after a swallow, which can lead to lung disease, pneumonia, and other medical problems.

Signs of aspiration

Refer to Box 11.4.

VFSS

Videofluoroscopic swallow study.

FEES

Fiberoptic evaluation of swallowing.

Non-oral feeding methods

Such as tube feeding may be required.

Chin tuck

Reduces laryngeal opening; may be contraindicated for infants with softening of the cartilage of the larynx or trachea.

Natural chin tuck

Promoted via straw or straw style sports bottle.

Empty spoon technique

Offering an empty spoon in the same way as a bite of food may stimulate oral movements to prompt a second swallow.

Pace of oral feeding

Recommendations should allow the child sufficient time to swallow between bites.

Modification to food consistency

Thin liquids offered from an open cup are most difficult to control during swallowing.

Thickened liquid examples

Simply thick, Gelmix, Purathick.

Blenderized foods

Regular fruits and vegetables, baby foods, yogurt, and pudding may be blenderized to make thickened smoothies or shakes for older children.

Behavioral interventions

Create new positive interactions and child associations around feeding activities and mealtimes.

Positive reinforcement

Use positive reinforcement and ignore or redirect inappropriate behaviors.

Systematic Desensitization

A therapeutic approach used to reduce anxiety by gradually exposing a person to the feared object or context.

Cognitive Behavioral Therapy

A type of psychotherapy that helps individuals understand the thoughts and feelings that influence behaviors.

Regular Exposure to Non-Preferred Foods

Evidence suggests that it takes multiple presentations of a food before a child feels comfortable with it.

Structuring Mealtimes

Helps promote hunger cues and less access to less nutritious foods.

Environmental Adaptations

Changes made to the environment to promote better eating habits and safety.

Consistent Meal-Times

Promotes routine and stability in eating habits.

Self-Feeding Effort

The effort involved in self-feeding impacts oral motor skills, swallowing safety, and overall length of meal.

Ideal Meal Periods

Meal periods of 15-30 minutes are considered ideal.

GI Disorders and Neuromuscular Challenges

These conditions benefit from shorter, more frequent meal-times.

Limit Distractors

Reducing distractions helps promote independence and safety during meals.

Oral-Motor Challenges

May benefit from tough textures presented first during meals.

Hypersensitivity

Characterized by gagging with advanced consistencies or a lack of flexibility in food tolerance.

Hyposensitivity

Frequently seeks input by mouthing toys, decreased awareness of drooling, and/or overstuffing while eating.

Deep Pressure

Applied from distal to proximal to provide sensory input.

Oral Exploration through Play

Involves using teethers, vibrating toys, and self-directed touch in a child-controlled motivating context.

Food Chaining

A method that begins with a preferred food and gradually introduces new foods that are similar in texture.

Sleep

A reversible state where one is perceptually disengaged from and unresponsive to the environment.

Circadian Rhythm

A biological clock that operates in 24-hour cycles, influenced by light, mealtimes, temperature, bedtime routines, and physical activity.

Melatonin Release

The clock alerts the body and brain to release melatonin after dusk when it gets dark.

Sleep Problems

Can disrupt family dynamics and lead to cognitive and behavioral issues in children.

Consequences of Sleep Deprivation

May result in stress, irritability, reduced concentration, sleepiness, and impaired sleep quality.

Sufficient sleep

Associated with rest and overall well-being.

Rest

Quiet and effortless actions that interrupt physical and mental energy.

Rest time activities

Should be different from regular activities to promote relaxation.

SUIDS or SIDS

Sudden unexplained infant death syndrome, a broad spectrum of explained and unexpected deaths of previously healthy infants under a year.

Unsafe sleeping environments

Environments with soft surfaces or objects that can block an airway, shared sleeping with another person or pet, or infant's position leading to airway blockage or entrapment.

Factors negatively influencing sleep

Using technology before bedtime, light from technology sources, high-intensity social activities, school policies, low socioeconomic backgrounds, using child's sleeping space as punishment, and validating irrational fears.

Factors positively influencing sleep

Environmental modifications, soothing sounds, comfortable temperature, predictable caring relationships, calming bedtime routines, and use of favorite items.

Lifestyle Modifications

Consistent bedtime and wake-up time, dark and quiet bedroom, avoidance of excessive fluids, caffeine, vigorous activity, and limiting screen time.

OT Interventions

Cognitive behavioral training for insomnia, promoting positive self-talk, journaling, guided imagery, and educating parents about sleep benefits.

Cognitive behavioral training for insomnia

CBT-I, a method to improve sleep through cognitive and behavioral strategies.

Mindfulness

A practice that involves being present and fully engaging with the moment.

Yoga

A physical and mental practice that combines postures, breathing exercises, and meditation.

Progressive Muscle Relaxation

A technique to reduce muscle tension and promote relaxation.

Calming sounds

Sounds such as white noise that help soothe children to sleep.

Soothing aromas

Scents like lavender, cinnamon, and baby powder that promote relaxation.

Comfortable temperature

An optimal sleeping environment that is neither too hot nor too cold.

Predictable caring relationships

Relationships that provide emotional support and care to children.

Calming and supportive bedtime routines

Routines that help children wind down and prepare for sleep.

Bed-time routine

A series of activities performed before sleep, such as a bath close to bedtime.

External noise

Sounds from outside the bedroom that can disrupt sleep.

Excessive fluids before bedtime

Consumption of drinks that may lead to nighttime awakenings for bathroom use.

Caffeine before bedtime

Intake of stimulants that can interfere with the ability to fall asleep.

Vigorous activity before bedtime

Engagement in high-energy activities that may hinder the ability to relax and sleep.