Before choosing strategies involve Sam’s parents in prioritising goals for his feeding.
This may involve discussions aimed at increasing the parents understanding of:

• Feeding development.
  • Prolonged hospitalisation is associated with some transient delays in Sam’s development.
  • Learning to eat is expected to parallel development in other areas. Encourage a focus n Sam’s stage of development rather than his age.
• Typical child growth. Unrealistic expectations for Sam’s growth have led to increased volumes of feeds associated with vomiting.

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

Suggested strategies may include:

• Review Sam's growth and feeding plan to ensure:
• Feeds meet fluid requirements and are adequate for growth.  Ensure expectations for growth are realistic. 
• Feed volumes and rate of feeding does not contribute to vomiting.
• Feed plan is manageable and developmentally appropriate.  As Sam grows he may manage larger feeds less often. He can be expected to sleep longer at night and not need feeding.  Try to avoid feeding Sam when he is asleep as this limits opportunities for social interactions at feed times and for learning about hunger and satiety.  Feeding too frequently during the day limits opportunities for play and increases stress for parents.
• Manage expectations and disappointments
• Acknowledge mum's commitment to breastfeeding and continuing to express milk for Sam.  Sam has had all the benefits of breast milk even although he has not breastfed.  Sam's distress at breast feeding should not be interpreted as a rejection of mum.
• Consider providing Sam with opportunities for skin to skin contact without attempting to breastfeed. 
• Continue to hold Sam while tube feeds are being given as this is developmentally appropriate.
• Develop realistic expectations for Sam's learning to eat.  Learning to eat parallels development in all domains of the Feeding Development Framework.  Transition from breastfeeding to independent feeder typically takes more than 2 years to complete.  Due to Sam's transient delays in development he may take a little longer to progress through some stages.   
• Introduction of solid foods. 

Sam has made steady gains in his development since leaving hospital. He is showing some signs of readiness for solids.  Both Sam and his parents may benefit from positive new feeding experiences.  Strategies to support success include: 

• Offer solids once per day only if Sam and parents are happy and relaxed.
• Focus on enjoyment not the amount of food eaten.  Provide tiny amounts as a taste experience only. 
• Follow Sam's cues.   Stop if Sam indicates he is not interested or has had enough.
• Match food texture to oral motor skills.  Sam's oral motor skills for feeding are immature.  It may be helpful for his first foods to be a thin puree.
• Ensure seating provides for postural stability during feeding.
• Introduce a cup as an alternative to breast or bottle.
• Try a small open cup (e.g. a medicine cup) that has a wide opening and a narrow base. Ensure Sam is supported and secure in caregiver's arms/lap. Hold cup so that it rests on the lower lip. Slightly tip cup when Sam shows interest in the fluid (e.g. lapping or suckling action with tongue).  Allow fluid to drip down chin without wiping/interrupting the positive feeding experience. Consider adding a small amount of rice cereal to assist oral control of fluid.
• Try a sipper cup (if preferred) for experience. Carer will need to control volume and flow rate for Sam. You can remove the valve from inside the lid of the sipper cup when he's first learning cup drinking. Slow down the flow rate by angling the cup up and down as appropriate, and provide gentle reassurance if coughing and spluttering are noted.
• Use cups during play at bath-time to help Sam learn from watching how to use cups (i.e., pouring water from cup, etc.).

Resources
Oral motor development and texture progression

Seating – to come

Speech pathology resources – to come

Occupational therapy resources – to come

Feeding Cues video

Follow-up

Regular follow up is recommended to:

• Evaluate progress and effectiveness of strategies.   It is likely that Sam will take longer than typically expected to progress from first foods and increase the variety of foods and textures in his diet.   Parents often need support to stay on track and recognise the progress that is being made.
• Build on initial strategies that are considered beneficial and review those that don't appear to be helpful.
• Ensure feeding and mealtimes are enjoyable for both Sam and his parents.
• Monitor growth and adjust nasogastric feeds in line with skill development and oral intake.
• Prevent or manage problems before they escalate.  

Sam is expected to become an independent oral feeder.  Dependency on tube feeding is expected to reduce gradually in line with his general development.  The rate at which Sam's development catches up after prolonged hospitalisation will vary but could range from 6-12 months.  Children with ongoing medical issues, intercurrent acute illnesses or who develop a behavioural component to their feeding may take considerably longer.  Encourage parents to focus on Sam's progress rather than the time frame.

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