Key elements of your assessment include:

• Parent’s perception of the problem.
• Medical, developmental, growth and social history.
• Dietary assessment.
• Observation of feeding.

Your assessment reveals the following details:

Parent’s perception of the problem

• Ava’s parents report, “Ava started solids when she was almost 6 months old.   She seemed ready.  She was very interested in watching her sisters eat.  However she didn’t really seem to enjoy the foods I gave her.  She would spit a lot out.  She liked the commercial baby foods better than the foods we made for her.  They seem smoother and she managed them better.”
• “When I tried her on the next stage foods with the lumps but she gagged and looked like she was about to choke.”   
• “We waited a while before trying again but she still gags on the tiniest lumps.  It is getting worse and now she vomits if she finds a lump. We are sure she has a swallowing problem.”

Medical, Developmental, Growth and Social History

• Ava was born at term.  There are no concerns regarding her development and her growth has tracked consistently around the 25th percentile.  She has not had any significant illnesses.
• Ava lives with both her parents.  Mum does not work and is the primary carer for Ava and her two older sisters.  Dad is employed full time.

Dietary assessment

• Ava has smooth infant cereal for breakfast.  Lunch and dinner typically consists of smooth commercially prepared foods that include meat and vegetables.  This is usually followed by puree fruit with yoghurt or custard.  She is either fed by mum using a spoon or self feeds by sucking food directly from the ‘pouch’.   
• Sometimes Ava will mouth toast or biscuits until they go soggy but she doesn’t appear to swallow any.
• Ava was breast-fed until around 10 months of age. She then commenced infant formula and is currently having 3 small bottles per day. She also has water from a cup.

Mealtime Observation

• Ava is well supported in a high chair.
• She is offered lunch as described above.  She is observed to be happy and interactive when being spoon fed and enjoys the independence of feeding herself from the pouch.
• Mum agrees to offer Ava some fork mashed fruit so that the observer can make an assessment of Ava’s response.
• As mum predicts Ava gags and vomits.  The observer notes that mum fusses over Ava when she gags.  She has a bowl ready at the table to ‘catch the vomit’ and prevent a mess.
• It appears that mum has a low tolerance for mess as Ava is also not encouraged to use a spoon to self-feed.

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Note: the same or similar goals may be shared by more than one domain of the Feeding Development Framework. The priority of potential goals should be determined in discussion with Ava's parents.

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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 link to chart in feeding development section has been used before

Speech Pathology resources – coming soon

Learning to chew for infants.   Suzanne Evans Morris

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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Possible barriers to improvement in Ava’s feeding might include:

• Ava’s parents don’t believe or trust that strategies will work.  They maintain an underlying belief that there is a swallowing problem.
• Difficulty implementing strategies consistently
• Continued use of food in pouches for convenience.
• Parents too busy to provide graded experiences and allow time for self-feeding.
• Unable to tolerate mess
• Personal or cultural beliefs about feeding children e.g. feeding independence is not encouraged.  
• Changes in social circumstances.

Options for management of barriers might include:

• Aim for strategies to be implemented in smaller steps.
• Re assesses possible contributors to Ava’s feeding difficulties.
• Consider possibility that full details were not obtained or not all information was provided or taken into consideration at the initial assessment.
• Consider referral to another health professional for assessment or further opinion while you maintain your involvement e.g.
• Medical referral to confirm or reassure parents that there are no medical issues contributing to Ava’s feeding difficulties.
• Speech Pathology referral if concerns regarding a swallowing problem continue.    
• Note: Feeding difficulties may sometimes be present before other issues that may result in a diagnosis emerge.
  • Dietitian referral if growth falters while changes are being implemented.  Short term slowing of weight gains may occur while changes are being made but these are expected to be short term and will not affect height.

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