Key elements of your assessment include:

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

Your assessment reveals the following details:

Parent’s perception of feeding

• Mum recognises that Lyla has some difficulties with feeding but at this stage does not consider this to be a significant problem.
• Lyla had some early feeding difficulties.  “She struggled with breast feeding. I then tried several different teats before finding one that suited Lyla.  She has always been good at letting me know when she is hungry.  Her hungry cry is different to her other cries.” 
• Solids were introduced at around 6 months. “I had planned for Lyla to wean herself onto soft pieces of food rather than use puree foods but due to her difficulties in bringing her hands to her mouth I had to change my mind.  She really enjoys her food and knows when it is mealtime.” 
• Lyla has a strong tongue thrust so she spits out a lot of food.  “I know that she is not doing this to tell me that she has enough or that she dislikes the food being offered but it does take longer to feed her compared to her brother at a similar stage.  I have tried her on lumpier foods that children of her age are supposed to manage but she gags and spits out the lumps.”
• A standard high chair is not suitable for feeding due to Lyla’s dystonia and need for additional supports with seating.   “Before the developmental assessment I was feeding Lyla on my lap.  I have now started using the chair that was recommended at our last visit but Lyla is still getting used to it.  So I start the feed in the chair and finish with Lyla on my lap.”

Medical, Developmental, Growth and Social History

• Lyla was born at term and has been generally healthy since birth. She was difficult to settle as a baby and was prescribed medication for reflux which she continues.
• Lyla presented at 7 months of age to a Paediatrician with concerns regarding her motor skills. She was subsequently diagnosed with   quadriplegic dystonic cerebral palsy with mild spasticity and referred for an Allied Health Developmental Assessment.  Assessment was conducted by an Occupational Therapist, Physiotherapist and Speech Pathologist and based on observation and parent reporting.   She has been provided with some advice on positioning for play and feeding and is now attending for follow-up.
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• In the first few weeks of life growth was reportedly slow before finding a suitable teat for feeding however since then growth has been tracking 10th-25th percentile on the WHO charts without concern.    
• Lyla lives with both parents and her 3 year old brother who is typically developing.  Mum is currently on maternity leave but plans to return to work in around 15 months.  Dad works full time.  

Dietary assessment

• Lyla is currently having around 5 small bottles (Total volume approx. 600-700mls) of infant formula /day. 
• She also has around ½ a cup of puree solids 3 times per day. 
• The length of time Lyla takes to have solid meals is longer than expected for this amount of food.  It can take up to 30 minutes for her to finish.

Mealtime Observation

• This mealtime observation occurred at Lyla’s first follow up visit.
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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 Lyla’s parents.

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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.

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