Key elements of your assessment include:

• Parent’s perception of the problem.
• Medical, developmental, growth and social history.
• Dietary assessment.
• Observation of feeding or interactions between Jack and his parents.

Your assessment reveals the following details:

Parent’s perception of the problem

• Jack’s parents report that feeding problems began at around 9 months when Jack required admission to hospital for severe gastroenteritis.
• During this admission he lost a significant amount of weight and it took a lot of effort for this to be regained. This was especially concerning as he has always been smaller than his peers.
• After the gastro Jack seemed to prefer his bottle and pureed or mashed foods. Parents were happy with this as they could feed Jack and be sure he ate everything. It was also less messy. However mealtimes now take forever. Sometimes he still hasn’t finished after 40 minutes. He has lost all interest in self feeding. He is reported to eat better at childcare where he will attempt finger foods.
• Parents are not concerned about other aspects of Jack’s development. He enjoys messy play at childcare.
• Both parents are frustrated and stressed with feeding but are reassured by the fact that “at least he drinks his milk”.

Medical, Developmental, Growth and Social History

• Apart from the gastroenteritis there is no other history of illness.
• Jack has achieved all developmental milestones as expected.
• Plotting his weight and length measurements on appropriate growth charts shows that Jack did lose weight while unwell. However weight has been regained and growth is now tracking as previously along the 25th percentile as shown.
• Jack is an only child who lives with both his parents. His father works full time and mother part time. He attends child care 3 days per week.

Jack - Length	Jack- Weight

Dietary assessment

• Jack’s diet consists of 5-6 bottles of cow’s milk with small amounts of a variety of mashed foods.
• Comparing Jack’s estimated requirements for energy (Kilojoules or Calories) to his intake shows that milk is meeting approximately 85% of his requirements reducing appetite for other foods.

Mealtime Observation

• Mealtime observation was not possible however Jack attended the consultation. During this time he was given his bottle and was frequently prompted to have a drink even although he is happily playing with his toys and did not indicate that he was hungry or thirsty.

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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 Jack’s parents.

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Suggested strategies may include:

• Reduce milk intake and cease use of bottles. 

Possible steps to achieve this might include:

• No bottles during the day – offer drinks of water in a cup.  May use bottle on waking and before bed in the evening.
• Once Jack is managing this, then eliminate morning bottle followed by bed time bottle.
• Aim to reduce milk to a total 500-600 mls/day.
• Establish sharing of feeding tasks with Jack and his parents.

Parents:

• Provide regular meals and snacks – include new foods and textures with familiar foods.
• Provide opportunity to explore new foods and textures even if messy and food is not eaten. 
• Allow Jack to feed himself – perhaps negotiate turn taking with feeding.   
• Meal and snack times have a clear beginning and end. Only water is provided in between.
• Mealtimes are limited to 20-30 minutes.

Jack:

• Determines when he has had enough.  Coercion and force feeding are not used.
• Focus on social interactions and enjoyment of the mealtime rather than the amount of food eaten.
• Build on Jack’s strengths e.g. Jack has shown at child care that he is more interested in food and self-feeding when milk is not available.

Resources

• Healthy eating and play for toddlers (1-2 years)
• “Try it – you’ll like it” Vegetables and fruit for children
• Why no sweet drinks for children
• Managing toddler mealtimes
• Raising Children Network
• Ellyn Satter Institute

Follow-up

Regular follow up is recommended to:

• Evaluate progress and effectiveness of strategies. Progress may be measured in terms of changes in both Jack’s eating and parental anxiety.
• Build on initial strategies and ensure continued progress in Jack’s feeding development.

With reduction in milk intake and consistent implementation of agreed strategies Jack should show significant improvement in his eating over the next few months. The variety of foods and textures will gradually increase as he progresses towards becoming an independent feeder.

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Possible barriers to improvement of Jack’s feeding might include:

• Parents don’t agree with strategies e.g. may not want Jack to ‘Give up’ the bottle. 
• Parents don’t believe or trust that strategies will work e.g.
• Overriding concern that growth will slow if milk is reduced and Jack doesn’t eat.  Then what will they do?
• Continued belief that there is a medical cause for Jack’s feeding problems.
• Difficulty implementing strategies consistently.
• Personal or cultural beliefs about feeding children e.g. belief that parent is responsible for all aspects of feeding or letting a child go hungry is not good parenting.  Differing beliefs and expectations of others involved in Jack’s care such as grandparents or extended family could be impacting consistent implementation of chosen strategies.
• Changes in social circumstances.   

Options for management of barriers might include:

• Modify strategies to help improve compliance.  Aim for strategies to be implemented in smaller steps.
• Tactfully challenge parents beliefs to create a shift in thinking.  Depending on the issue consider asking: 
• What do you think would happen if......? 
• What would need to change for mealtimes to become enjoyable for you and Jack?
• Re assess possible contributors to Jack’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 Jack’s current feeding difficulties.
• Dietitian referral for assessment of nutritional adequacy of Jack’s diet, advice on mealtime environments and food requirements for a two year old or reassurance regarding growth.
• Speech Pathology referral if concerns regarding food textures are contributing to parental anxiety.

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