Barriers to improvement in feeding might include:

• Difficulty implementing strategies consistently perhaps due to associated stress.
• Parents not believing or trusting that strategies will work e.g. Parents think Sam is lazy with feeding and don't believe that learning to eat will parallel general development.
•  Heightened parental anxiety regarding growth leading to over feeding via nasogastric tube reducing opportunities for Sam to experience and respond to hunger. 
• Personal or cultural beliefs about feeding children conflict with suggested strategies e.g. belief that parent is responsible for all aspects of feeding is associated with risk of force feeding and disruption of the feeding relationship.
• Changes in social circumstances.  
• Change in Sam's cardiac function or general health.  (Referral back to medical team may be indicated.)

Options for management of barriers might include:

• Modify strategies to improve compliance. 
• Ensure strategies are practical and do not add to stress with feeding.
• Aim for strategies to be implemented in smaller steps, consider reprioritising goals and or strategies. 
• Tactfully challenge parents beliefs to create a shift in thinking.  Depending on the issue consider asking:  
• What do you think would happen if......? 
• How do you think Sam might feel when.....? 
• What do you think Sam's developmental age is.......?
• Reassess possible contributors to Sam's feeding difficulties. Consider:
• Has full history been obtained?
• Were all details in history considered in the initial assessment?
• Consider referral to another health professional for assessment or further opinion while you maintain your involvement e.g.
• Increasing parental anxiety with feeding or the development of a behavioural component to Sam's feeding may warrant a referral to a psychologist for assistance.
• If Sam was being managed in the community shared care between a Speech Pathologist and Dietitian may be indicated.
• Liaison with medical team to ensure Sam's medical condition is not contributing to feeding difficulties.

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