Before choosing strategies involve Ava’s parents in prioritising goals for her feeding.

This may involve discussions aimed at increasing the parents understanding of:

• The gag reflex and the difference between gagging and choking. She has been seen by a paediatrician and speech pathologist and is not considered to have any underlying medical cause to her feeding difficulties.
• The influence of parent responses to children’s learnt feeding behaviours i.e. gagging can become a learnt response.
• The importance of graded experiences to promote oral motor skill development and progression of food textures.

Once goals have been prioritised choose one or two strategies that will assist in achieving goals. Choose strategies that parents feel confident they can achieve and that build on Ava’s strengths. As these are implemented further strategies can be added.

Suggested strategies may include:

• Make small just noticeable differences to the texture of Ava’s food
• Ensure a variety of foods are used to promote progression of food textures.
• Prepare breakfast cereal to a slightly thicker texture.
• Mix commercial baby food with smooth mashed potato to increase texture by making a thicker puree.
• Use a food that Ava likes such as puree apple or pumpkin and gradually change the texture from thin puree → thick puree→ finely mashed → coarsely mashed → soft pieces.    
• Introduce bite ‘n’ dissolve textures such as toasted crisp breads. 
• Encourage Ava’s feeding independence
• Self-feeding will encourage oral exploration and the development of oral motor skills to manage lumpier foods.
• Provide a range of finger foods including hard munchables.
• Encourage Ava to self-feed with a spoon.  Avoid sucking food from the pouch as this does not promote the development of oral motor skills.
• Provide mum with strategies for managing the mess.
• Avoid giving attention to Ava when she gags and vomits
• By giving attention to Ava she may be encouraged to continue to gag and vomit with lumpy foods.
• She may also learn to gag and vomit in response to external cues e.g. seeing the bowl that is used to ‘catch the vomit’.
• Encourage use of a cup and reduce use of bottles
• Increased use of the cup will help promote development of oral motor skills.  
• Ensure formula intake does not exceed 500-600 mls per day and reduce appetite for other foods.  As food variety increases consider changing to cow’s milk.  
• Build on Ava’s strengths
• Maintain Ava’s social enjoyment of mealtimes. Continue to provide regular meals and snack.
• Ava shows a lot of interest in the activities of her older sisters. Encouraging them to model eating behaviours like self-feeding and chewing   may provide motivation.
• Plan attendance at play group where other children are eating.  Offer foods but simply allow to play or ignore.
• Provide reassurance to Ava’s parents
• As there is no underlying medical reason for Ava’s feeding difficulty it is expected that her feeding will change. She is unlikely to stay on purees forever.

Resources

Oral motor skills and texture progression

Speech Pathology resources – coming soon

Learning to chew for infants.   Suzanne Evans Morris

Feeding Cues video

Follow-up

• Evaluate progress and the effectiveness of suggested strategies. Progress may be measured in terms of changes in both Ava’s eating and parental concerns and anxiety.
• Build on initial strategies and ensure continued progress in Ava’s feeding development.
• Support parents to be maintain a consistent approach to Ava’s feeding.

With graded texture experiences, positive role modelling and changes to how Ava’s parents respond to her gagging and vomiting Ava is expected to gradually reduce her gagging response to lumpy foods. Over several months Ava will progress towards becoming an independent feeder.

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