How to prioritize goals in feeding therapy?
As an occupational therapist specializing in feeding, eating, and swallowing in pediatrics, one of the most challenging aspects of my practice is determining how to prioritize goals for my clients. With so much information gathered from evaluations, interviews with parents, and treatment sessions, it can be overwhelming to identify the most crucial areas to focus on. I get asked all the time in mentorship and trainings, where do I start when I am on information overload?
The truth is, any feeding therapist can do this, but it does take organizing your approach to break down the elements of feeding skills into more manageable pieces and just focusing on one step at a time!
What is the order of priority in feeding therapy?
Safety: The safety of the child while eating, drinking, and swallowing is paramount. This includes assessing for any risk of choking, aspiration, or other complications that could arise during mealtimes. No matter how complex or advanced the child that we are working with we must always start with safety!
Nutrition: Meeting the child's nutritional needs is essential for their growth and development. This involves ensuring they receive adequate calories, nutrients, and hydration to support their overall health. While we can refer to consult / collaborate with a nutritionist, oftentimes, Occupational Therapy Practitioners are the “boots on the ground” actively helping parents problem solve HOW do they apply advice they receive from a nutritionist or dietician.
Oral Motor Control: The child's ability to physically control the muscles in their face and mouth is crucial for safe and efficient eating, drinking, and swallowing. This includes aspects such as lip closure, tongue movement, and chewing skills. Before we can ask them to change their behavior we have to enable them with the SKILLS to be able to do the feeding tasks in their families routines.
Food Acceptance: Encouraging the child to expand their diet and accept a variety of foods is essential for promoting independence and social participation in mealtimes. While this may be tempting to focus on before safety, nutrition, and oral motor control, especially for our sensory or picky eaters, that would be a misstep as it is all to easy to overlook they WHYs that explain a child’s poor food acceptance. By placing this item fourth on the list, we make sure that when we do ask a child to expand their foods, we KNOW that they are safe, ready and CAN chew, drink, swallow, etc so that their experience with new foods will be positive!
Prioritization Process: Now that we understand the order of priority, let's discuss HOW to prioritize feeding needs effectively.
Assess Safety: The first step is to assess the child's safety during mealtimes. This involves conducting a thorough evaluation of their swallowing function, identifying any signs of aspiration or choking risk, and implementing appropriate safety measures such as modifying food textures or positioning. Have handy a list of the red flags for aspiration and educate parents and caregivers of safety so that the whole team can recognize if you need to back up and implement some safety changes!
Address Nutritional Needs: Once safety concerns have been addressed, the next priority is to ensure the child's nutritional needs are being met. This may involve working with a nutritionist or dietitian to develop a tailored meal plan that meets their calorie and nutrient requirements, considering factors such as food allergies, intolerances, and sensory preferences. Don’t think that sending a referral is enough! Once families get the info about what their child’s nutritional needs are, there is often much ground to cover with how to modify foods and liquids to identify HOW the child can acheive their nutritional goals within their specific performance abilities.
Improve Oral Motor Control: With safety and nutrition addressed, the focus can then shift to improving the child's motor control for eating, drinking, and swallowing. This may involve implementing specific oral motor exercises, facilitating proper positioning and alignment, and practicing swallowing techniques to enhance muscle strength and coordination. Use the Pediatric Feeding Framework to make sure that your oral motor interventions are solid and include 1) preparatory or passive interventions such as improving PROM in the lips, 2) active interventions such as exercises that target the strength, coordination, alignment and endurance of oral motor skills, and 3) functional interventions that include applying oral motor skills to practical contexts such as eating a new food, chewing with improved maturity, swallowing a thinner liquid, etc! In the functional phase of intervention, we are always on the lookout for compensatory mechanisms!
Foster Food Acceptance: Finally, once the child has developed the necessary safety, nutrition, and oral motor skills, the goal is to encourage food acceptance and expand their diet. This may involve introducing new foods gradually, using positive reinforcement and modeling techniques, and creating a supportive mealtime environment that promotes exploration and experimentation. Check out the book on Amazon “UnPicky Eaters Workbook” by myself and Emily Edwards, COTA/L if you feel that the parents you are working with are overly eager to jump right into addressing behaviors and need a structured step by step plan of how to promote home routines that expand their child’s abilities holistically!
Prioritizing goals in feeding therapy requires a thoughtful and systematic approach that considers the unique needs of each child. By focusing on safety, nutrition, motor control, and food acceptance in order of priority, occupational therapists can effectively guide their treatment interventions and support their pediatric patients on their feeding journey. Through collaboration with families and using your occupational therapy superpowers (clinical reasoning, grading and adapting, HEPs, activity analysis), you CAN empower children to develop healthy eating habits and enjoy mealtimes with confidence.
Happy Eating!
