Mealtime Partners, Inc.

Specializing in Assistive Dining and Drinking Equipment

August 2016 Independent Eating and Drinking Newsletter

	August Topics: Independent Eating for Children Considerations for Helping People Eat
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Independent Eating for Children

From the moment they are born, children start developing skills. Gradually they learn how to sit, walk, talk and feed themselves. These steps are known as developmental milestones and mastery should come during a predictable time frame. However, some children are unable to reach these milestones in one or more of the main areas of development: cognition, social and emotional, speech and language, fine motor skills, and gross motor skills.

Because developmental milestones are achieved in a sequential fashion, mastery of one skill will lead to another. Therefore, if one milestone is missed, the following ones are difficult or impossible to reach. For example, babies first learn to sit with assistance, and then without assistance. A few months later they are pulling up and standing, holding on to furniture. Soon after that they walk independently and then run.

Even later they learn to hop, skip and jump. Without the sequential development of these early skills, the infant would not have learned how to run. These building blocks of learning are very obvious during the first few years of life as infants grow and develop rapidly, and so many changes take place. During this time, the beginnings of independence emerges. The infant becomes mobile, begins meaningful communication, begins to self-feed, and eventually becomes potty trained, learns to brush their own teeth and bathe with little help.

In normal development, the infant learns how to pick up objects and frequently explores the object with their hands, feet and mouth. As the pincer movement of the hands develops and the fine muscles in the fingers become stronger, the child develops coordination. They become able to pick up food and put it in their mouth and “gum” it into a texture that allows them to form a bolus (a ball of food mixed with saliva in their mouth), and swallow it. Finger feeding is gradually replaced with the use of utensils, but mastery of the use of a spoon or fork can take many months for some children. During this time they frequently will revert back to finger feeding when they become frustrated.

For a child who does not develop the fine muscle control of their hands that is necessary for finger feeding, mastery of handling a utensil is far more difficult. Thus, the building blocks necessary to evolve into an independent eater are interrupted and the child misses out on experiences that will help them develop in many areas, not just independent eating. Children who are unable to put “things” (toys, food, fingers, toes, etc.) in their mouth do not develop their tongue and mouth muscles at the same rate as their peers. They also do not harden their mouth to the touch of different textures in the same way that their peers do.

It is important that children with developmental delays master as many skills as possible during a similar time frame as their peers. For many, those skills are difficult or impossible to reach in the traditional way. However, with the help of assistive technology (AT) many times those skills can be acquired. For example, independent mobility can be achieved through the use of walkers, wheelchairs, or a variety of other products. With the support of AT, the child is able to explore and gain knowledge and experience in their natural environment. Communication can be supported with sign language or communication aides.

However, eating is more difficult to facilitate. Food comes in assorted shapes and textures, some of which are eaten using fingers and others that require a spoon. Many children with developmental delays eat soft textured food for a longer time than their peers because their oral motor skills are inadequately developed for them to safely eat textured foods. This creates a situation where a child who is experiencing difficulties with gaining independence eating, needs to eat soft textured foods that are difficult, if not impossible, to eat using fingers. Therefore, for them, the simple act of getting food into their mouth independently becomes complicated by the need for a utensil.

Comparing picking up food with your fingers and placing it into your mouth with picking up food on a spoon and placing it in your mouth, illustrates the increase in complexity of the task that occurs when a spoon is needed. A simplistic description of the external body requirements is as follows (issues of oral motor muscle control will be discussed in a later Newsletter): when finger feeding, the child needs eye hand coordination to locate the food, a finger/thumb pincer movement to pick-up the food, a small amount of wrist rotation, and enough elbow flexion to raise their hand to their mouth. When using a spoon, the child first needs to be able to grasp the handle of the spoon. Once they have the spoon in their hand they use eye hand coordination to locate the food (usually contained in a bowl) and they must manipulate the spoon into a bowl and move it around in the bowl so that food is either intentionally or accidentally loaded onto the spoon. This action typically requires significant wrist rotation. Next the spoon must be raised to the child’s mouth. To retain more than just a coating of food on the spoon, the bowl of the spoon must be kept on a level plane while the spoon is being raised from the bowl to the mouth. This is a very complicated movement that requires at a minimum both wrist rotation and elbow flexion. Normally, the arm is also raised at the shoulder and some shoulder rotation is evident. Throughout this process the child must maintain a grasp on the spoon. The entire event of taking a single bite of food using a spoon is dramatically more complicated than taking a bite of food using your fingers and requires a higher level of cognitive processing, and the coordination of many more muscles and more energy.

Many parents, and the medical professionals supporting them, are so concerned about learning how to provide care and support for a child who is identified as having developmental disabilities, that their main concern about eating is providing adequate calories (or nutrition) in a timely fashion (unless a child has a significant eating disorder). They are busy with so many issues that the child becoming an independent eater is not a priority. However, the child is missing out on experiences that will help them achieve developmental milestones. A simple example of this is choice making. If a child self-feeds, they can easily show their preferences in foods. They either do not eat the food items that they don’t like, or, more commonly, they simply drop it onto the floor. They are selecting what they will, and will not, eat. They are making choices, which is healthy for them in developing their independence.

It is desirable that the transition from feeding to eating be a natural evolution for a child with developmental disabilities, as it is for a child without disabilities. Children, who are fed out of necessity beyond the normal developmental time frame, in many cases, continue to be fed rather than learning how to eat. This is an easy oversight on the part of the person feeding the child. It is simple to continue doing what you have done since the child started eating solid foods. Yet if food is put in the child’s mouth without them actively participating in removing it from the spoon, they will not be given the opportunity to practice, and therefore they will not become good (i.e., develop the skills) at closing their lips around a utensil.

Good lip control contributes to clear speech. Lip closure should be encouraged and when necessary, demonstrated and assisted. Always explain to the child what you are doing and why. Initially, to assist with lip closure, the person feeding can use the thumb and index finger of the hand that is not holding the spoon, to gently close the lips of the child over the bowl of the spoon. The spoon is then gently removed from the child’s mouth. During the removal process an upward movement of the spoon should be avoided as it wipes the spoon on the top teeth/gums of the child. Once lip closure begins to evolve the next step is to develop the child’s ability to move their mouth onto the spoon and then close their lips. At this stage the person feeding should still remove the spoon from the child’s mouth. However, as the child exhibits their ability to move onto the spoon to take food, they should then be encouraged to move back, away from the spoon, with their lips closed, so that they take the food off of the spoon and keep it in their mouth. All of this is more easily accomplished when the child is positioned appropriately for eating and is able to produce a chin tuck when taking food from the spoon (refer to both articles in the Mealtime Partners July 2015 Newsletter for more information on promoting a chin tuck, and both articles in the January 2015 Newsletter for more information on good positioning for eating).

For many parents this process is slow and frustrating. It can create tension and stress at mealtimes that is very undesirable for both parent and child. To avoid creating a negative environment, they can work on feeding for the first few bites of every meal when the child is hungry.

When a child is being fed it should be remembered that they are unable to physically choose what they eat and it is up to the person feeding them to give them the opportunity to select what they will eat. Always respect their rejection of food, as long as they have had a taste of it. Allow them to communicate that they do not want what is being offered or that they would like more. Mealtimes are a wonderful opportunity for communication and if given the chance, children will let you know what they want.

A future Newsletter will discuss strategies to facilitate independent eating for those who have limited hand/arm control and who have the potential to self-feed in the traditional manner.

 

The Mealtime Partner Dining System is the Closest Thing to Having a Custom Built Dining Device Ever Made
	The Mealtime Partner is so flexible it is almost like having a custom designed dining system. From multiple mounting options to adjustable timing, the Partner can adjust to meet the needs of everyone from small children to adults, regardless of their diverse eating needs. For more information about the Mealtime Partner Dining System, you can visit the Mealtime Partners website, and/or view our 4 minute video. (The video transfer my take a few seconds, so please be patient.)
If you need help in choosing the dining system that is best for your needs, you can email your questions to us at info@mealtimepartners.com, or call us at (800) 966-8607. We are always pleased to provide information to help you make the best choices.

 

Considerations for Helping People Eat

For an individual who lacks the ability to self-feed, their prior experience with eating should be taken into consideration when evaluating how to provide assistive technology to facilitate their gaining mealtime independence (whether it is an adapted utensil or a more sophisticated powered dining device). This is necessary because the strategies used to implement the use of any equipment will need to be different depending upon the individual’s history.

There are two major categories of people who are dependent upon others for their nutritional needs: those who were born with a disability; and, those who acquired their disability through an accident, illness, or disease. The people who have an acquired disability have experienced what it is like to feed themselves. Therefore, they do not need to be told how to eat even though they are currently being fed. Rather, they need to be assessed as to the most appropriate equipment to allow them to regain independence in eating and to be provided with training on the new equipment.

For those who have never experienced eating independently, much more instruction will be required. Many people wrongly assume that because someone has observed other people eating, that they will understand how to do it themselves. Despite observing other people eating, without actually experiencing eating, there are gaps in people’s understanding of all of the elements necessary to eat. Articles in the May 2010 Newsletter and June 2010 Newsletter discussed Promoting Self Feeding and Eating Versus Being Fed. The information in these articles provides a basic explanation of how the lack of experiencing independent eating puts the user at a great disadvantage when they begin to learn to eat using assistive technology. For example, many people who have always been fed do not understand that they must take food off of a spoon to eat it. They expect the food to be placed into their mouth because that is how it has always been done for them. When a spoonful of food is placed near their lips by a dining device, they may wait for the food to be put into their mouth by the device. The caregiver or healthcare professional working with them may be required to prompt them to take the food off of the spoon.

Regardless, of their level of ability, the steps that go along with eating independently should be broken down and explained to the consumer. Don’t expect someone to automatically close their lips over a utensil if they have never placed a utensil in their mouth before (because they have always had other people do it for them before). Likewise, do not presume that they will understand that they need to either remove the utensil from their mouth or move backwards off of the utensil, or that they will keep their mouth closed during this process to clear the food from the utensil into their mouth. For most individuals simply explaining what they must do is enough for them to understand what is needed. For others, verbal prompting and physical assistance in doing what is necessary may be required.

Head positioning also varies between the two groups of people being discussed. Those who have fed themselves will keep their head (if physically possible) at about the same level as they did before becoming disabled. For those who have never fed themselves, their inclination is to raise their chin. It is wise to encourage those who tip their head upward to lower their chin when they are eating for improved safety, as we have discussed in many of our Newsletters.

In summary, it is important to understand the differences in the support that will be needed for those with congenital disabilities and those who have acquired disabilities, and provide a far more comprehensive level of support to those who lack the experience of independent eating regardless of whether they are going to use adaptive utensils, mobile arm supports, non-powered dining equipment, or powered dining equipment like the Mealtime Partner Dining System.