Before choosing strategies or providing anticipatory guidance involve Lyla’s parents in prioritising goals for her feeding.

• At this stage Lyla’s physical skills are the main barrier to her feeding development and seating is anticipated to be a high priority. With correct positioning using specialised seating feeding skills are likely to improve. In the long term feeding with Lyla positioned on the lap is not practical. Discussions aimed at increasing an understanding of the connection between postural support and stability and the development of oral motor skills may be needed.
• Discussions on typical feeding development and potential difficulties recognising the strategies that have already been used to minimise the impact of Lyla’s feeding difficulties may also be helpful.

Once goals have been prioritised choose one or two strategies to begin with. As these strategies are successfully implemented and Lyla grows and develops goals strategies may change.

Suggested strategies and anticipatory guidance may include:

• Provide and encourage the use of specialised seating that provides postural support and stability.
• In this case Lyla was being assessed by a team able to make recommendations for seating. As a community health practitioner referral to a Physiotherapist or Occupational Therapist may be indicated.
• Modify feeding techniques to reduce impact of tongue thrust.

Consider:

• Using slight pressure with the spoon, down and in on the tongue to help Lyla to keep her tongue in her mouth and prepare for swallowing.
• Presenting the spoon to the side of the mouth to encourage Lyla to use her tongue to move food to the back of the mouth.
• Continuing to use puree foods and formula to meet nutritional requirements while also providing graded textures experiences for promoting development of oral motor skills for example offering soft dissolvable pieces of food towards the end of a meal.
• Ability to manage food with increasing texture will parallel skill development not age.
• Encourage regular growth monitoring.
• Poor weight gains as evidenced by a decline of growth percentiles is an indicator of increasing impact of Lyla’s feeding difficulties.
• Ensure mealtime routines are relaxed and enjoyable.
• Meals are already taking a longer time than typically expected. As food requirements increase mealtimes have the potential to take longer resulting in reduced mealtime enjoyment and increased stress.  As the time spent feeding increases there will be less time in the day for other activities further increasing the impact of feeding difficulties for both Lyla and her parents.   Mealtimes longer than 30 minutes on a regular basis may warrant referral to a dietitian for high energy diet strategies.
• If growth slows and or mealtimes become prolonged the use of high energy diet strategies and referral to a Dietitian may also be recommended. 
• Ensure other carers use appropriate strategies when feeding Lyla.
• Other carers may need education on how to feed Lyla this may include details on the importance seating and feeding posture, how to present spoon, textures required and reading Lyla’s cues.  This will be important if Lyla attends childcare on a regular basis.

Resources

Positioning at mealtimes

General guidelines for assisting with eating & drinking

Oral motor skills and texture progression

Speech Pathology resources – coming soon

High energy eating

Follow-up

Feeding difficulties for Lyla are likely to change over time.  Being responsive to Lyla’s cues and engaging with Early Childhood Intervention Services with ongoing support from a range of health professionals will help Lyla to minimise the impact of potential feeding difficulties and enable Lyla to achieve her full feeding potential:

• Physical development will determine level of feeding independence.
• Communication skills will impact the ability to indicate food and feeding preferences.
• Social emotional and cognitive development may contribute to behavioural aspects of feeding.

Ongoing medical follow- up which includes growth monitoring is recommended, with referral to a dietitian if growth slows.

Back to Case Scenarios