Solids are recommended at around 6 months when babies show signs of being developmentally ready. Possible reasons for not introducing solids during this time may have included:

• Prolonged hospitalisation has led to transient delays in Sam's physical development.  He currently does not show signs that he is developmentally ready for solids.  Opportunities for him to discover and mouth his hands, explore toys and have tummy time developing his motor skills have been limited. The Physio and Occupational Therapists have provided Sam's parents with strategies to promote his physical development.  Links to come OT resources
• Nasogastric feeding and hospital routines can make it difficult for babies to learn to recognise or give cues to indicate hunger and satiety.   Sam's parents may also have had limited opportunities to learn to read his cues.  
• Sam is being offered the breast and or bottle prior to nasogastric feeds.  He is currently only taking small amounts.  Adding another feeding task at this stage may not be helpful.  

A few weeks developing routines at home, getting to know each other and allowing time for progression in Sam's physical and oral motor development may be beneficial to his feeding development.

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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 Sam's feeding

Consider: Has their perception of Sam's feeding changed since discharge?

• Sam's prolonged hospitalisation has been stressful for his parents.  While they are pleased to have Sam at home they find feeding stressful.  It is not going as they had hoped.
• Mum continues to maintain a good supply of breast milk but is becoming increasingly disappointed that Sam will not breastfeed.  Sam is becoming increasingly upset when put to the breast.  
• Mum is also frustrated that Sam is currently taking very little from the bottle. Earlier on he seemed to do better.  Parents feel the nasogastric tube is making him lazy.   
• He wakes for most feeds during the day providing cues to hunger. However during the night he sleeps through his nasogastric feed.

Medical, Developmental, Growth and Social History.

Consider changes that have occurred since discharge.

• While Sam requires ongoing medical care for his congenital heart disease his condition remains stable.
• Sam has made steady gains in his development. He is now mouthing his hands and toys and control of his head and trunk has improved.  During his admission Sam's weight dropped to below the 5th percentile.  However prior to discharge weight gains had increased and he was tracking just below the 5th percentile on the WHO growth charts which was considered satisfactory.
• There are no changes in Sam's social circumstances. He lives with both his parents and older sister aged 2 years

Sam - Length	Sam - Weight

Dietary assessment

• At discharge Sam was being fed 4 hourly 6 times per day.  Volumes were adequate to meet fluid requirements and growth had improved.  He was tolerating feeds well with only the occasional vomit.
• However, on review Sam is vomiting at most feeds.  It is reported that feed volumes have been increased as there were concerns that Sam needed to gain weight more rapidly.  Increased volumes have not increased weight gains.

Feeding Observation

• Sam was observed attempting a breastfeed.  He was clearly distressed, and difficult to calm.  Feeding was not enjoyable for Sam or mum.
• Mum reports that at home she likes to hold Sam during NGT feeds.

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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.   Link SP/OT resources when available
• 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

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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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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