Mealtime Partners, Inc.

Specializing in Assistive Dining and Drinking Equipment

April 2016 Independent Eating and Drinking Newsletter

	April Topics: Positioning for Eating Eating Versus Being Fed
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Introduction

Mealtime Partners newsletter is published once a month, and the topics that are covered relate to eating and drinking safely, and independently. Some basic topics are extremely important to safe eating and drinking for those who have difficulties feeding themselves or taking a drink without help. Because of the fundamental importance of these subjects we are going to revisited some of them. In the next few months our newsletter will reexamine some issues that were covered several years ago. This month we are going to discuss seating and positioning during eating. The same information should be considered when someone is taking a drink, however, because we hope that everyone is drinking throughout their day, not just at mealtimes, it is sometimes more difficult to adhere to the same positioning practices used during meals. It should always be remembered that the head should be level or tipped a little bit forward while drinking.

Positioning for Eating

Everybody performs numerous tasks every day and for each task the body is positioned and adjusted for ease of task performance. Eating is one of the tasks that we perform several times a day and able-bodied people unconsciously adjust the position of their body to prepare for eating, and make ongoing adjustments throughout the meal for optimal positioning for eating. Not only do we move our bodies forward and back for each bite of food but we also change the position of our feet many times during each meal to stabilize our trunk. These movements fine-tune our body posture for us to eat comfortably and safely. For many individuals who are unable to feed themselves, adjusting their position for eating is either very difficult or impossible, and they must depend upon their caregiver to position them.  

The correct seating and positioning of the body during eating is very important because it improves both the safety and the enjoyment of the meal and facilitates better digestion. A good position for eating requires the trunk to be very stable. To enable the trunk to be stable, the feet must have firm support so that they can bear weight as the person eating, moves throughout the meal. Additionally, the thighs and buttocks should bear weight. When the feet, thighs and buttocks bear weight, the body becomes more stable and the shoulders, arms, and head are able to maintain a more constant, steady position. This will promote better control of not just the head and neck, but all of the muscles in the jaw, tongue and mouth. The overall result is that the person will eat more safely and gain better control over eating.

Even people who sit on a regular chair with no type of restraint at mealtimes, should have their stability evaluated. It is also important that their feet can rest firmly on the floor or a foot support. Unsupported feet will lead to instability in positioning during a meal (which is a common occurrence with children in booster seats). For some people it is easier to stabilize themselves if they stagger their feet, rather than having them side-by-side on the floor in front of them. One foot can be moved backwards under their thigh. This will cause a slight toe flex. A staggered foot position helps increase the weight bearing on their thighs and buttocks and, in turn, allows the trunk and upper body to be better controlled. If a person is sitting on a normal upright chair, their knees should be under the table far enough that their hands and forearms can rest on the table if they would like to do so. This, in turn, provides greater stability. If eating at a table, the individual should lean forward towards the table and round their shoulders slightly. This position encourages them to hold their head in a chin-tuck position, which promotes safe chewing and swallowing. (See Promoting a Chin Tuck for Safer Eating in the June 2009 Newsletter for additional information about this topic.)

Many people with disabilities sit in wheelchairs to eat and are unable to freely position themselves. Many of these individuals remain in the same position while conducting all tasks. Commonly, this position is specifically designed for safely transporting the individual, not for task performance. If you are sitting in a wheelchair during a meal, the wheelchair should be as up-right as possible. Foot positioning is normally dictated by the wheelchair foot-rests, and, therefore, it is important to make sure that the footrests support the feet adequately and allow the thighs to bear weight. If the individual has shoulder straps that restrain their upper body, slightly loosening the shoulder straps should be considered to allow a small forward movement of the shoulders. First try loosening one shoulder strap to see if this freedom of movement is enough to encourage the head to move forward and down. Placing a small wedge or rolled-up hand towel behind the individual’s shoulders can encourage this position.

If the person has poor muscle tone and is pulled forward by gravity when they lean forward past the upright, 90 degree, position, producing a chin tuck can be more difficult. However, a chin tuck can be produced while the person is sitting in a slightly reclined position (to avoid the impact of gravity) by supporting the shoulders in a forward, or rolled, position and also supporting the head. A neck pillow can provide support for the head and placing rolled hand towels or small pillows under the shoulders can help shoulder positioning. In this way the pull of gravity is overcome and yet a chin tuck is produced. (This is similar to the position that you would be in if you wanted to watch television while lying in bed.)

It should be noted that while achieving a shoulder roll (i.e., pulling the shoulder forward and down slightly) you do not want the individual to collapse their trunk because it will put pressure on the stomach and increase the occurrence of reflux during and after eating. You must locate the position that allows a chin tuck but does not cause the trunk to collapse.

A laptray on a wheelchair is often a benefit for individuals who have difficulty maintaining their trunk stability. Their forearms can rest on the laptray while eating and can bear the weight of the shoulders. This position will bring the individuals shoulders forward and produce a chin tuck. If the individual leans too far forward on the laptray, pressure will be put on their stomach, either from the laptray physically pushing on their stomach, or because their ribcage is resting on their stomach because they have collapsed their trunk; both are unhealthy for eating and digestion.

Finally, here is a tip for those who feed someone. You too need to be in a specific sitting position to meet the feeding needs of your dining partner. If you stand up while feeding someone, their head will automatically tilt upward to accommodate the position of your arm. This head position puts them at an unnecessary risk of aspiration because their airway protective mechanisms are less effective with their head raised. It is better, when feeding someone, to sit directly in front of them, facing them, and to present the food to them at the level of their lower lip when their head has an adequate chin tuck. Sitting to the side of the individual, tends to induce the person to turn their head towards the utensil and they are no longer in an ideal position to receive food into their mouths.

Conclusion: The overall objective of good positioning for eating is to provide the body enough stability that the muscles involved in eating can perform at their best. With a stable body, people are able to better control their muscles and therefore they are able to chew more productively, manipulate the food in their mouth with greater ease and swallow safely. Eating in the right position over an extended time can result in improved muscle tone and thus better overall oral motor control.

 

The Mealtime Partner Dining System
For individuals who are unable to feed themselves because of limited or no hand and/or arm function, the Mealtime Partner provides them a way to eat independently. This lets them experience an enjoyable mealtime that is totally under their control. They can choose what they eat for each bite and pace their eating to suit their own needs and desires.
The Mealtime Partner Dining System can be positioned to meet the specific needs of each user. The user does not have to adjust their position to eat using the device because the Partner’s flexible mounting systems permit positioning to fit the user's needs, making mealtimes a comfortable, relaxed experience, with the user positioned safely for eating. The Mealtime Partner empowers its user to eat what they want, when they want it. The Mealtime Partner Dining System is quick and easy to learn and has no complicated programming requirements. Each Dining System comes with a complete training video on DVD so new users and caregivers can learn to use it in just a few minutes. There are no other assistive dining systems that meet the needs of the users, like the Mealtime Partner. For more information about this device, click on this link. To talk to a representative call: 800-996-8607, or email us at: info@mealtimepartners.com and we will be happy to assist you in selecting the best system to meet your needs.

Eating Versus Being Fed

Recently the question was raised, how do you stop feeding someone who has been fed for years, and allow them to actively eat at mealtimes? First, the difference between what is meant by feeding and eating must be clarified. Many people are dependent upon another person to receive all of their nutrition; however, some of these individuals are fed and others eat. The difference is how food gets into their mouth. When fed, the person providing mealtime support puts each bite of food into the person’s mouth. If the individual eats, they are offered a bite of food, but the person eating takes the food off of the utensil, into their own mouth, at their own pace. The advantage of eating versus being fed is that it is a safer way to receive food. If a person chooses when each bite of food enters their mouth, they are less likely to choke on the food or to aspirate. (There are approximately 40,000 deaths in the U.S. each year due to aspiration pneumonia. One of the best predictors for the development of aspiration pneumonia is being fed by others.) (Calhoun, Wax & Eibling¹, DeLegge²).

For those who are fed, old habits are usually well established and body movement patterns have become second nature. For example, many people who are fed lean slightly backwards throughout the meal. When in a slight backward recline, their mouth is at an easy angle to receive a spoonful of food and the food is unlikely to fall out of the person’s mouth after it has been put in their mouth. When in a reclined position the chin naturally is raised. Often this position has remained from early childhood. It is common for infants to be “tilted” backwards when they are fed. Some people lean as far forward as they can. They move as far towards the spoon as they possibly can. This is commonly a result of a desire to eat (hunger) or to be helpful to the person feeding you. Both of these positions hamper the person’s ability to eat.

To eat, you must be able to freely take a bite of food off of a spoon when the food is offered. To do this, you must be able to move your mouth forward, onto the bowl of the spoon, and then reverse the movement to get your mouth off of the spoon. In other words, the individual must be able to move their head forward and backward, at will. If you are reclining, even slightly, moving your head forward to the spoon demands tensing the muscles in the shoulders and back of the neck to move the head against the pull of gravity. The normal muscle pattern used to move the head back and forward, when it is upright, is a combination of all of the neck muscles. Additionally, gravity helps to tilt the chin downward when the head is upright. If your head is fully extended forward, there is no way to move farther forward onto the bowl of the spoon to take a bite. Therefore, with either scenario, the individual who wants to eat versus being fed, must change their mealtime seating and positioning to incorporate the essential body movements necessary for them to eat. Obviously, for those who recline, the goal should be to adjust their seating to accommodate a more upright position; for those who are in a forward position, the goal should be to have them move back to a more upright position.

When addressing positioning changes, special attention should be paid to the individual’s stability. It is extremely difficult to move in a controlled fashion if your body is not well supported. Modifying someone’s body position and movement patterns requires that their muscles are taught the new information and gain new muscle tone that is adequate to support the changes. Simply changing positioning does not assure that the person will be able to move their head in a controlled manner. They must be given adequate time for the muscle control to develop.

For the greatest probability of success, all changes should be undertaken in small increments. First, modify the individuals seating position, but continue to provide all food in the customary way. Once the new positioning is familiar to both the person being fed and the person feeding them, the first several bites of each meal should be presented so that the person can eat rather than being fed. To do this, the person providing food should place the spoon close to the individual’s lower lip and hold the spoon in that location. If the person learning to eat does not automatically move forward and take the spoon into their mouth, the feeding partner should provide verbal prompting to encourage them to do so. If they still do not move onto the spoon, the tip of the spoon can be placed on the person’s lower lip (not inside their mouth). If the individual still does not take the spoon into their mouth, the spoon can be gently wiped on the lower lip, with a forward and backward movement. (A slight downward pressure on the lower lip is sometimes helpful). If the individual still does not take the spoon into their mouth, the feeding partner can gently encourage forward movement onto the spoon by placing their hand on the base of the individual’s neck and moving the head and shoulders forward very slightly. Whichever method is used to teach them to eat rather than being fed, previous methods of feeding should be gradually eliminated as the user becomes more familiar with the pattern of eating. When a comfortable new eating pattern has developed for the beginning of the meal, the number of bites eaten rather than being fed should be expanded until the entire meal is being eaten.

Great patience is required and must be exhibited on the part of the feeding partner as the ability to eat is learned. Impatience in the feeding partner is easily sensed and the person trying to learn often hurries and the pleasure and pride of acquiring a new skill is diminished and sometimes simply abandoned because they sense the frustration of their mealtime partner.

Regardless of whether someone is eating with a person providing the food, or using dining equipment like the Mealtime Partner Dining System to eat, it is always safer to eat rather than being fed, because eating diminishes the risk of choking or aspiration when the person eating controls each bite of food placed in their mouth.