feeding issues with solid food

[JB]

Hi everyone,

My daughter was born at 29+6 weeks and weighed 2 lb 10 oz. She was in the NICU for 7 weeks and was on the ventilator, cpap, feeding tubes, etc. She is now 13 months old and doing really well on growth (~30% for weight, 95+% for height), but is having difficulty transitioning from formula to solid food. She hardly puts anything in her mouth except cloth items like blankets and stuffed animals or smooth solid items like board books or smooth toys. She doesn't self-feed much at all (this week at feeding therapy she brought a spoonful of food to her mouth for the first time). She never puts finger foods in her mouth, she just plays with them. She also never holds her own bottle, even though she is strong enough to pick it up and throw it. She did bring a sippy cup of water to her mouth to drink once, but she usually just pours it out and plays with it. Sometimes she will take sips from her cup or take bites from cookies or crackers, but usually only when it is put in her mouth for her.

Have any of you had any of these types of issues with your preemies? Her feeding therapist said sometimes preemies have issues with textures around their mouths because of all the tubes and tape and ventilators, etc. that they were exposed to in the NICU, and that is probably why she is slow to take to solid food and self-feeding. If you have had these issues, did your babies eventually grow out of it? Do you have any advice for things that helped? My daughter currently sees her therapist once a week and is making some progress each week, but it still feels slow.

[lemons]

Hi JB. I'm so glad to hear that your daughter is doing so good. Wow, 30% for weight is great! My daughter was born at 30+0 weighing 2lbs 9oz and now at 18 months she is only at 2.5% for weight! I think that for many babies, not just preemies, the switch to solid food is a difficult time. Instead of being snuggled with mom and happily sucking away on bottle or breast, baby now needs to figure out how to eat while not having that comfort. Throw in the extra sensory issues that preemies often have and it can be a stressful time for everyone!

I am glad to hear that your daughter is seeing a feeding specialist but I am a bit confused as to why the specialist is even suggesting that your daughter should be self-feeding with a spoon?? If I am correct, your daughter's adjusted age is ~10 to 10.5 months. My daughter's adjusted age is 15.5 months and she is JUST starting to use a spoon on her own. And neither her pediatrician or her developmental specialist is at all concerned. And my girl is incredibly stubborn- even though she CAN hold her bottle, she refuses to. Instead, she likes to snuggle with me and have me hold it. So, instead of trying to force her, we have slowly been getting her to use a sippy cup- again, she has just started in the last few weeks to really be interested in it. At first, I just left it out for her to pick up when she wanted and to explore without the idea that she had to drink from it. It took a couple of days to a week before she even put it to her mouth. And once she was comfortable with the cup and realized that she could have a drink when she wanted one, she just decided that she liked it. Within a few days she was using it like a pro. And now, she only gets a bottle in the morning and right before bed- I still snuggle with her and hold the bottle for her. The rest of the time, she drinks from the sippy cup. I still at least once a day, snuggle her and hold the sippy cup for her, same as I would with a bottle. Her pediatrician told me at her 18mo appointment that switching to the sippy cup is good but that he isn't worried that she still gets some bottles. And that her adjusted age is much more important than her actual age when it comes to these adaptive skills.

Does your daughter see a developmental specialist in addition to the feeding therapist? A developmental therapist may have some ideas for you in regards to how to get your daughter to be less sensitive to putting things in her mouth. And I think developmental therapists and occupational therapists often have a different view of how to structure "mealtime" than feeding specialists- suggesting that you really encourage baby with a lot of positive praise when she puts a new food in her mouth. And that you can encourage baby to explore special "toys" with her mouth to get her more used to other sensations in her mouth. I don't have any specific advice to offer, since my daughter actually has the opposite issue- she sticks EVERYTHING in her mouth. She even tried to chew on the corner of my wall. But I think overall, I urge you to remember that you daughter is only just at the beginning of transitioning to solids and that it is a big milestone that sometimes needs to be taken very slowly. Good luck and I'm happy to answer any other questions.

[danielsmom]

I've heard that it's mainly the tubes placed in their mouths for extended periods of time (ventilator & oral-gastric feeding) that raise issues, like tongue thrust and texture aversions. Daniel wasn't on the vent for long (maybe 14 days total broken up?), and the nurses tried to keep his feeding tube in his nose (NG)for this reason I think. I'm not sure how much help I'll be, but here's some of our experience.

We had some difficulty transitioning to a sippy cup. I found one with a bottle-like soft tip and I put breastmilk in it. We tried 1-2 feedings in that a day until he was confortable with it. Then I switched to a hard-tip sippy cup and removede the valve so it was free flowing, eventually stepping down to keeping the valve in. Put something in there that she really likes (apple juice or whatever). I know it's weird, but try out the sippy cups to see if they're hard to get liquid out. I had a few that would make me blue in the face, and I thought, how could a baby do this?

Also - I know it's hard - take your hands off the bottle when she's really hungry to encourage her to feed herself. Have you tried that? It was so hard for me... I was trying to get every calorie down his neck possible because of his early growth restriction, but I had to balance that with not doing things for him for developmental reasons. And if the feeding took too long he'd lose patience and shut down. Too much stress!

I remember Daniel preferred things of a smooth texture for awhile. I think that's kind of normal at first. You did say that she'll take crackers as long as someone feeds it to her. That's good! Because of that, I don't think you have a real texture aversion thing there. She'd be gagging and worse if it was that, in my non-medical opinion. Maybe she just has princess-in-the-pea syndrome and likes things done for her, lol! Can't blame her! Our therapist gave us a neat trick for developing the pincher grasp: putting cheerios or puffs in an ice tray. Each cube is only big enough for a few fingers.

Seriously, it's good that you have a therapist involved and they're watching over things. It's amazing how kids won't do something for so long and then one day - poof! - they flip the switch and then they're doing it all the time. You mentioned she put a spoon to her mouth this week. Maybe that's the beginning of the switch? Just keep giving her opportunities to do it again, and lots of praise when she does it. Daniel did better with a fork, and we made a game out of stabbing his food.

Also, Daniel was never a big finger-in-the-mouth guy either, but he'd put toys in his mouth. My therapist was satisfied with that. He was still taking in information about X object through his mouth. He was never a finger/thumb sucker either. It's normal for babies to start NOT putting things in their mouths around 12 months.

I worried about the spoon/fork thing for awhile because he wasn't really independent with it until after 2 years old. But there again, the light bulb went off and then he was eating his entire meal (same thing we eat) with a fork. Now he has better table manners and loses less food on the floor than my father-in-law. Keep at it and don't be discouraged. She'll come around. Also remember to factor in her adjusted age, not her real age, until she's 2. Then that gap starts to close.

[JB]

Thanks for the replies ladies, it really helps to hear some different opinions/experiences!

My daughter initially was seeing both a physical therapist (she had issues with her flexor strength due to not getting that last trimester of being snuggled up tight in the womb) and a speech pathologist (for language and feeding evaluation) about every 2-3 months since she came home from the hospital. At her 12 month (unadjusted) appointment they said she probably only needed to come in for physical therapy evaluation one more time after she started walking, but they were concerned about her feeding issues enough to recommend starting weekly appointments for that. She wasn't holding her bottle or bringing finger foods to her mouth, or even licking food off her fingers. Also, the few times we tried dry crunchy food (graham crackers or those meltable baby puff things) she would just gag to get them out of her mouth. Since we started the weekly evaluations she has made progress. Her teeth are in enough now that she can really bite things, and she will sometimes take sips from the sippy cup, and seems to be eating more things than she used to.

The feeding therapist has been having us work a lot with exposing her to new textures and has given us lots of suggestions (like getting her to chew on textured toys/cloths, playing in different types of dry cereal like rice crispies and rice chex, playing more on grass and other textured surfaces, etc.). She has also given us ideas for introducing new textures to her food, like gradually mixing dry rice cereal into her smooth food a baby spoonful at a time to build up the thickness/texture, and she also has us use the sippy cup without the valve inserted so that the water/juice mixture free flows. The therapist has pointed out that it seems my daughter doesn't quite swallow food so much as she lets it dissolve in her mouth. When some of the heavier textures don't dissolve as quickly she tries to gag them out. She has been gradually getting better with that (she is starting to swallow some and has begun chewing things with her teeth), but the therapist thought it was probably due to the tubes in the throat issue Danielsmom was talking about. She was on the ventilator a lot in the NICU (her left lung collapsed twice during the first two weeks) and had a feeding tube for a couple of weeks after that. The therapist also emphasizes positive reinforcement when she does something right, and even when my daughter chokes a little on her food or drink (she says that choking is a way babies learn the swallow reflex and that we shouldn't act concerned because that will make the baby upset about it and avoid it).

I talk to my mom a lot (she lives in another state but my daughter and I skype with her every day) and she doesn't think my daughter is really that far behind in feeding. She had five kids, and although none were premature she says all were different and all did things at different times and that my daughter doesn't seem behind compared to me and my brothers. Like you pointed out, Lemons, my daughter is really only about 10 months adjusted, so I'm not sure if the therapists are just more cautious about nipping potential problems in the bud, or if she really is behind enough to need so much focused attention. My pediatrician said that she agreed with the increased feeding therapy, and she has always seemed to evaluate my daughter based on her adjusted age. I'm reluctant to change what we are doing because my daughter has made progress since we started going weekly, and my insurance is still paying for it. I think I will keep doing it and just stop worrying so much

Danielsmom, we have noticed the same thing with our daughter about a switch flipping and she suddenly knows how to do things. She was having a hard time with crawling because of her upper body strength issues, but then one day she simply did it and didn't stop. It was the same with biting down on the cookies/crackers. Now she knows exactly what to do with them. I'm hoping the same thing will happen with bringing food to her mouth herself. I don't really care so much about holding a bottle because she's going to be weaned off that eventually, but I would like her to be able to pick up finger foods and drink from her cup. My new baby is due in about a month and it is going to be a handful taking care of him and still doing all the feeding for my daughter. She does hold the cup handles with both hands and pour it out, and did bring it to her mouth for a sip once, so I think she is getting there. You are also probably right that I need to just stop holding things for her and try to make her do it herself. That's what my mom keeps telling me, too

This was sort-of a long answer and probably not very coherent because I'm a little tired, but thank you both so much for your advice and thoughts. It makes me feel less stressed about it.

[lemons]

Hi JB. I have to admit that I've come to appreciate that feeding issues are probably the most stressful issue a baby can have. My daughter is involved with the Early Intervention program in our community and through it I have met a number of other mothers experiencing what you are describing. Feeding our children is such an important part of their well being and sometimes we can judge how good we are at being a mom by how well our children eat and sleep. It was really hard to see other babies drinking from their sippy/straw cups while my daughter wouldn't even hold her bottle. But I agree with Danielsmom, development isn't always a smooth learning curve, sometimes it comes in leaps and bounds. My daughter also had trouble with her flexor strength- she crawled and pulled to standing before she sat. But the crawling helped build up her stomach muscles enough so that on the day that she REALLY wanted to play with a toy, she just sat up like she was doing it for weeks. And now her gross motor skills are average for her actual age. The switch flipped and she figured it out. And that pattern has repeated itself again and again- with using a spoon, with using a sippy cup, with eating "lumpy" textured foods (all of which have only happened in the past 4-6 weeks, so at 18 months actual/15.5 adjusted).

It sounds like your feeding therapist has a great plan in place to help your daughter become more accepting of new textures in her mouth and in general. It is great that you are able to have weekly therapy. I definitely wouldn't change it- take advantage of the expertise and help. I was just suggesting that maybe too much emphasis is being put on using a cup and a spoon. Again, these are benchmarks that we use to judge ourselves and that isn't quite fair to ourselves or our babies. And I'm glad to know that positive reinforcement is the method of choice. I have heard from more than one mom that their feeding therapist took a no-nonsense approach to mealtime and that the babies weren't responding well at all. I mean who wants to fight with a toddler over whether or not they eat, not me, but I guess that is why my daughter survived on dry, crunchy cereal for a week or two before she was willing to try something new!

Reading your description of your daughter's therapy, it sounds like she is actually making great progress- taking bites and using the sippy cup. Maybe it would be helpful for you to keep a journal of the new things that your daughter tries every week and whether she just looks at it, touches it, brings it to her mouth, puts it in her mouth, gags it back out , actually swallows it. My daughter also was a prolific gagger- she gaged on anything that was not either completely smooth or completely dry and crunchy. It was tough to watch her gag and I actually had to tell my mom on multiple occasions to relax or leave the room when it happened because my mom would get upset and jump up to help my daughter. The good news is that my daughter only gags occasionally now. There is hope!

I'm sorry that I don't have any direct advice to help you help your daughter. I just wanted you to know that you are not alone tackling feeding issues and that there is hope. And as the saying goes, patience is a virtue that mom's of preemies often need in bucket-fulls!

[Rbrown2010]

Wow- I wish I would have found this post 6 months ago. My son was born at 31 weeks and we have been having these same eating/texture issues. It took a lot of convincing with therapists and doctors who said just guve it time but I knew it was more than just he wasnt ready yet for food. He ate spiral mac and cheese today without it being pureed (he is 16 months) which was a huge step for us. Our feeding therapist is definitely working! We are working on pulling up to everything and it is true, things just click.

jB, congrats on your second this summer. i am due in April after having PE/HELLP and am a nervous wreck about delivering early. Were you able to escape PE this time?