10 Tips to Transition from Tube to Oral Feedings
After Mia’s traumatic event, she was intubated and was receiving TPN (Total Parenteral Nutrition). This is a method of feeding that bypasses the digestive system to supply nutrients to the body through an IV line or a PICC (peripherally inserted central catheter) when one cannot receive fluids or feedings by mouth. As Mia grew stronger after surgery, she was able to receive feedings from an NG (nasogastric feeding tube) with my supplied breastmilk, and eventually formula when my supply decreased. A nasogastric feeding tube, is a tube that is used to send food or medicine directly into the stomach through the nose. Mia would remain on NG feedings for about a month and a half before graduating to oral feedings. Helping Mia relearn how to take food by mouth was a stressful process, and we are still fine tuning her oral motor functions today. Here are ten helpful tips to transition your little one from tube to oral feedings.
Before we dive in, remember, I am not a licensed medical professional or therapist. These tips are techniques I have learned over time with the help of an occupational therapist, nurses, and trial and error. Please see my full disclaimer here. These tips are designed to help with transitioning from tube feedings, but may be helpful and applied to feeding littles that are not on tube feedings
Seek Help From a Therapist
Chances are that if your child requires a feeding tube, modified diet, or supplemental nutrition, you already work with a therapist. If you do not, or need help, seek help from a therapist immediately. Signs that your child may need help from a therapist include but are not limited to, gagging, trouble chewing or swallowing, is easily distracted during mealtimes, has trouble self feeding, arches back while eating, cries or is cranky at mealtime, or holds food in their mouth and cheeks. Mia works with many therapists, but an occupational therapist helped Mia in the hospital transition from tube feedings, and an outpatient occupational therapist has helped Mia expand her diet from liquids and purees, to solid table food. These licensed professionals are experts in oral and fine motor skills. They help equip you with the necessary tools to ensure you are feeding your little one safely. Having a therapist watch and show you the proper and technical aspects of feedings at each stage, is monumental. I was unaware of the process, and the safety concerns that can arise if you are feeding too fast, or feeding a food that the child is not able to consume appropriately. Mia’s occupational therapist allowed for us to have a separate session each week to work on oral motor skills. Everything from breathing, tongue placement, biting and chewing, self feeding coordination, and speed, were all monitored closely.
Take Thing Slow
It was hard knowing that Mia had to relearn how to eat. So naturally, I was very anxious for her to regain those skills. Slow and steady is the name of the race. Your child’s therapist should sit down with you to create short and long term feeding goals. This should be a collaborative effort in helping your family work towards transitioning (if that is medically safe to do so). Mia first had to be out of the woods medically to be introduced to my breastmilk again via an NG, after first receiving TPN. She would receive tiny amounts, and would eventually work up to a substantial amount (set by the nutritionist) that would run over thirty minutes several times a day. While Mia would receive her feedings, we would help her practice learning to suck on a pacifier or finger. This helped create a correlation between sucking, hunger, and satiation. Once she mastered the pacifier, we then would use a slow flow nipple, with about 1 mL of milk in a bottle a few minutes before her scheduled feedings. Once milk was reintroduced, taking things slow was crucial, because Mia would aspirate while feeding. Aspiration is when food or liquids enter your lungs. This was evident by her breathing and coughing. We worked our way up to 5 mL so that Mia could take a modified barium swallow test. This test uses barium, which is a liquid that can been seen on X-ray. The liquid coats the insides of the mouth and esophagus to determine if liquid or food passes into the lungs. With the help of her therapist and a second attempt, Mia passed the barium swallow test without aspirating.
When working your way up from liquids to solids, it is important to move in steps. As mentioned earlier, with collaboration and help from a therapist, you can slowly work your way up to more advanced feedings. Introducing new foods and textures can be a choking hazard for your child. With Mia, we started with milk thickened with baby cereal. This then lead to thickened purees. At this stage, techniques such as giving cues, are especially important to help your child learn differences between bottle nipples and spoons. After you have begin to understand your child’s hunger cues, using a bit of pressure on the bottom lip can encourage your child to open their mouth to a spoon. When spoon feeding, it is important to allow your child to pull the food off of the spoon themselves, and for you to not scoop the food up into their mouth. After you give a spoon cue, place the spoon in the child’s mouth and wait for them to close their lips around the spoon. Then, remove the spoon and reload.
Dry Swallowing
As Mia was learning to eat thickened liquids, she was a bit confused by the texture. She would often hold the food in her mouth, or it would fall out. To help her, we implemented dry swallowing techniques. This is done by inserting a pacifier (if your child uses one) or an empty spoon into the child’s mouth. Ideally, your child will close their lips around the spoon or pacifier, encouraging them to suck, and therefore swallow. This is necessary to ensure that gravity won’t takeover, causing the food to slide down the child’s throat risking aspiration.
Designated Feeding Area
As you are transitioning your child to more advanced foods, I recommend having a designated feeding area for your little one. Things will certainly get very, very messy. Messy mealtimes can be rather frustrating, I know. You’re concerned with food and liquids not ruining the floor and their clothes, or creating a welcome party for ants. Try a catch all mat like the one here, from Target. This one is made of polyester so it has a bit more weight than plastic, and should hold up underneath rolling highchairs. The reviews seem great so I’d check it out! Having a catch all mat can save you the trouble of having to stop in the middle of meal time to wipe the floor, and allows for you to be more present with your child. Aside from the floors, allowing your child to get messy can be beneficial. Encouraging your child to touch and explore different textures is great for cognitive and sensory processing. The kitchen, or another hard surface area is ideal for easy and quick cleanups from spills and exploring little ones.
Having a designated feeding area like in the kitchen also helps create familiarity and a routine for your child. Establishing a routine helps alleviate fear, and allows your child to anticipate mealtimes. Mia kicks, smiles, and dances as soon as she is placed in the highchair. Even entering the kitchen or rolling her highchair closer to the island creates excitement and increased desire for mealtime.
30 Minute MealTimes
Limiting mealtimes is an important tip that I am still working on implementing with Mia. It is common to think that if my child still accepts food, then I should keep feeding. In actuality, stretching mealtimes past thirty minutes is not very beneficial. Thirty minutes is plenty of time for meals. When meals exceed thirty minutes, you run the risk of your child burning more calories than they consume. For little ones that are learning new feeding techniques, chewing and swallowing can be tiring. Limiting mealtimes helps prevent frustrations, and keeps mealtime enjoyable.
Patience
As cliché as it sounds, nothing happens overnight. Mealtime can be frustrating, so it is important you are patient with yourself and your child. As mentioned before, things WILL get messy. Your little one does not have the same understanding of food, utensils, and cleanliness as you do. You have to get used to knowing that it will take time for your child to learn the mealtime and feeding techniques you are trying to implement. You will find yourself doing the same thing over and over again. Understanding your need for patience early on will make this process much easier. When you find your patience running thin, take a deep breath, and remember your goals. If that is not enough, take a break. If you child is safe in the highchair and out of reach from food, get up, grab a drink of water and take a breather. If not, remove your little one from the highchair, and the both of you can take a breather, together.
Create A Calm Environment
If you follow the tips already outlined, you are on the right track to creating a calm environment. You want to create a relaxing environment that fosters trust between you and your child. Establish a routine in an area free from as many distractions as possible (i.e. the television). It if often hard for Mia to concentrate when there are competing sounds and light. This allows for you to be free from distractions as well. The biggest distraction I struggle with is my phone. I am trying to be more present with Mia in all areas, especially mealtime. I want her to know that she has and deserves my full attention, especially when we are trying to implement new techniques. I understand this is not always realistic. If you have to check your phone, tell your child. I am trying to say things like “Mommy has to check her phone” and “Mommy is back”. You want to give your child your full attention first and foremost for safety reasons. You should be watching their breathing and swallowing to ensure they are eating safely. Your attention also helps foster stress free eating. Your child sends you many cues while eating and can become frustrated if you are constantly missing their cues, creating a stressful experience. Mia has often communicated to me that she wanted more food, but I was distracted by something on my phone, causing her to whine and scream. Feeding is a joint effort between you and your child. Remaining present strengthens your bond. Remember, your ultimate goal is to have a happy child that is fed and has a desire to eat.
One method to help create a calm environment is music. Mia hated the tumble form we used to help her practice for the modified barium swallow test. Music therapy was instrumental in helping to relax and soothe her. We would play calming music, or have a music therapist join our sessions. He would play guitar and sing her favorite songs to remind her that she was in a safe and loving environment.
Additionally, you want to work towards alleviating the pressure to eat. I know that I am often overwhelmed, so I know Mia has to be. Never force your child to eat. Your child will let you know when they are hungry. Additionally, it can sometimes take many times exposing your child to a particular food.
Introducing conversation at mealtimes can also be beneficial. Try talking to your child about things other than food. Mia can communicate with a couple of signs and gestures, along with babbles, smiles, laughter, facial expressions, and body movements. I will comment on any one of those things, make her laugh, and talk to her as I do throughout the day. This aids in making mealtime pleasurable.
Communication
Communication is essential no matter what stage your little one is in. I briefly mentioned hunger cues earlier. This can vary from child to child. A common one I’ve seen in Mia is a visual interest when she sees food. She demonstrates this by the widening of her eyes and a little happy body shake. Others have included salivation, tongue clicks, and reaching for food. Within the past year, we have been working with adding sign language words centered around mealtime with the help of her speech therapist. Mia has been able to learn the signs for “eat” and“more”. We are currently working to incorporate “drink” and “all done” into her vocabulary. The addition of sign language has aided Mia tremendously in communicating her wants and needs during mealtime. As children get older, they desire some control. We often forget that our children are just tiny humans. They’re not always as hungry as they were the day prior, ready to eat at the same time, or excited for what has been prepared for them. Mia is able to let me know when she is hungry or ready for more. No worries if your child is not yet able to sign. There are many additional features that are just as communicative. Mia will often reach when she wants more. She will smile, laugh, or kick when she enjoys something. When she has had enough or does not want what is offered, she will shake her head, shut her mouth, toss things (that’s another post for another day), purse her lips, or clench her teeth. She may not be saying anything vocally, but I can hear her loud and clear!
Does your little one have the ability to speak with you? Great! Work to include them in meal prep if it is safe to do so. Ask them what they would like for dinner and a snack. Talk with them about their day during mealtime and have natural conversation. All of this helps your child feel included, helps alleviates pressure, and makes mealtime feel much more natural.
Consistency
Whatever you are working to implement in your life or with your child, consistency is key (there goes another cliché). There have been times when I have felt that Mia was not making any progress and then all of a sudden, a breakthrough would happen. This comes from consistently implementing the same therapies and techniques over and over again. If you want to teach your child how to sign “eat”, then you need to consistently model the sign and show your child with their hands how to sign “eat”. Then when your child signs independently, celebrate! This can be a tedious process, however, it is effective. I live with my parents, and my older sister and brother in law often watches Mia for me. It was important for me to ensure that my family was on the same page with whatever we are implementing or practicing. If not, it can be detrimental to your progress. They know, that Mia is required to use her sign words to communicate “eat” and “more”, and to also help her practice signing “drink” and “all done”. Mia will often revert to reaching for food and fussing when she becomes frustrated, or chooses to forgo her sign words. When this happens, we remind her of how to ask for more food. Then we ask if she would like more, or, ask her how she tells us she wants more of something. Giving into her requests when we know she is capable of signing will only hinder the advancement of her commutation skills.
Praise
One of Mia’s biggest motivators is praise. She thrives off of it. I made it a point to celebrate each and every victory (feeding and non) no matter how big or small, so that she could knew she was making progress and doing an amazing job. There have been times when she was learning how to roll over, she would start to celebrate before I’d even have a chance to. She was proud. When working on feeding with your little one, it is important to offer praise to show approval of behaviors and eating techniques. This helps your little one know that they on doing well and on the right track. The key difference between praise and positive reinforcement, is that positive reinforcement is when you add something to increase the likelihood of a behavior occurring again. Praise simply acknowledges and shows approval of that behavior. I have not quite mastered positive reinforcement with Mia as it relates to mealtime and her other therapies, since most time I am unable to offer a reward immediacy following the behavior. Any suggestions are more than welcome!
Below are some examples of foods we introduced at each stage
Purees: apple, pear, spinach, green beans, mango, strawberry, yogurt (all of these can be thickened with baby cereal)
Dissolvable solids: puffs, graham crackers, veggie sticks, yogurt melts, plain Cheerios
Fork Mashed solids: steamed potato, steamed sweet peas, steamed apples or pears,
Soft solids: Avocado, cheese, banana, cooked carrots, pasta
Solids: shredded chicken, diced uncooked apples, cucumber, beans, diced strawberries
These are just examples. Always consult with your child’s therapist or doctor when selecting foods for your child to try. Some foods are dangerous for your child as they can be choking hazards or hard for your child’s stomach to digest.
I hope you have found some tips that can be useful in helping your little one. If you have any suggestions that are not listed, comment them below and let me know what has worked for you! Contact me if you’d like to discuss anything I’ve mentioned in further detail!
Happy Feeding!