Brian. 1 year old. "Picky eater".
Brian. 1 year old. "Picky eater".
Many of Brian's feeding difficulties stem from his previous craniosytosis
Accepts bottle with formula & pureed foods
Only accepts food from caregiver
No use of cups or utensils
The bonding experience between caregiver and child is interrupted due to Brian's feeding issues.
His refusal/inability to eat finger foods or eat independently creates a greater burden for his caregiver
Brian's picky eating decreases his opportunity to experience some of the sensory experiences that occur with new flavors, textures, etc.
Brian's physical issues such as posture and torticollis are portentially negatively affecting his feeding patterns.
Brian's endurance and cognitive load threshold were lowered due to his previous condition that caused irritability, fatigue, and trouble feeding
Brian's physical conditions such as torticollis, low UE WB, and abnormal posture have decreased his ability to fully participate in play
He struggles to visually track his toys and activities due to the torticollis
His endurance is decreased due to the energy it takes to sit uprights and WB in his UE
His posture affects his ability to have both hands free while playing
Brian's play exploration is affected due to his previous fatigue and irritability. Play exploration is still new for him.
Brian's sitting posture, torticollis, and inability to WB in his UE decreases his ability to see and reach for new toys to explore
Brian has issues with social participation because he has not met the same milestones as many children his age.
His torticollis & inability to weight bear in his UE affects how he can interact socially
His eye contact with others and vision of their activities is decreased
His ability to turn to acknowledge voices or someone trying to interact with him is affected
Not using utensils, cups, or even eating finger foods disallows him from participating in group snack times at play groups etc.
Since he is still recovering from his craniosynostosis operation, he sleeps more than usual but it is often fitful sleep.
His torticollis and postural issues make it difficult for Brian to get comfortable.
Prematurely fused cranial suture (craniosynostosis)
Repaired with cranial vault surgery
Symptoms include: irritability, fatigue, poor feeding, projectile vomiting, high-pitched cry, and bulging fontanelle.
Premature birth via C-section
Fetal heart arrhythmia
2 wks in NICU after birth due to difficulty breathing
Using a food diary will allow Brian's caregiver to track how he reacts to the different flavors and chunky textures that will be integrated into his diet.
Help Brian's caregiver to understand how to slowly transition from pureed foods to more textured foods. Also teach distraction techniques for times when he is apprehensive.
Train her to understand the problems with feeding that are caused by postural issues and when it is appropriate to provide support
Emphasize the importance of exploration of different textures in other areas such as play etc. so that it can translate to other occupations.
Give Brian toys with different textures and encourage him to chew on them etc. so he can experience varied textures outside of the feeding experience. This will later translate to feeding.
This can be graded up or down by A) included more or less familiar textures and B) providing more or less postural assistance
Encourage Brian to explore mouthing things by providing him with postural assistance when needed so he can mouth his fingers, hands, toys, new foods etc.
Slowly integrate small chunks into his pureed food by simply blending it a little less. Work up to thicker textures and more chunky/grainy textures.
This can easily be graded up or down for Brian. Using more familiar textures would make it less challenging and more chunky/crunchy textures will make it more challenging. However, this should be done in progression.
Use gradual adjustments so Brian can adjust to the sensorimotor feedback of the adjustments.
Start by readjusting his pelvis/hips while he is in the sitting position. This can be done during playtime or feeding. Over time work from sacrum, to spine, to shoulders, and finally to the head.
It may be necessary to provide some lateral support with a cushion etc. initially due to Brian's thoracic curvature and torticollis. These will have altered his center of gravity.
This will positively impact all of the areas of occupation listed: feeding, play participation, play exploration, sleep, & social participation.
It is necessary to address the torticollis or else other postural adjustment will likely be fruitless. Resolving the torticollis will improve Brian's performance in the following occupations: social participation, sleep participation, play participation, play exploration, and feeding.
Stretch the affected SCM
Strengthen the opposite SCM
Radial digital & raking grasps only
No demonstration of bimanual coordination
Limited imitation skills
Asymmetrical sitting posture
WB through left pelvis and thoracic curvature to R
Posterior pelvic tilt with rounded shoulders
Difficulty maintaining WB in both UE in quadreped
Torticollis with limited rotation to L
In 9 weeks, child will demonstrate ability to self-feed finger foods of varying textures with minimal assist and minimal tactile cues from the caregiver in order to accomplish the occupation of feeding in 3 out of 5 attempts daily per parent report.
In 3 weeks, child will demonstrate ability to self-feed bottle and pureed drinks with minimal assistance and minimal verbal cues from caregiver in order to accomplish the occupation of feeding in 4 of 5 attempts daily per parent report.
Infant/Toddler Sensory Profile 2 (SP2)
After completing the assessment, it is evident that Brian has some oral sensory processing issues. He also is easily distracted by unexpected auditory input because he cannot easily find the source of the sound. It also became clear that Brian's caregiver/mother gets stressed out that Brian doesn't feed himself but she will do just about anything to get him to eat. Her priority is simply that he eats, it doesn't matter what or how he eats. Per parent report is is difficult to say whether the feeding is solely affected by the sensory issue or if the torticollis makes some foods harder to eat as well. The results show that Brian is not simple a picky eater but that he has specific issues related to feeding. Brian's other medical history is included above.
Model/Frame of Reference
Person-Environment-Occupation-Performance Model (PEOP)
The PEOP model is an appropriate lens to use in the case of Brian because it considers Brian as a person, the occupations he wants to participate in, his environment, and his performance.
Brian's environment must be considered because distractions etc. can be part of the issue with his feeding.
Brian as a person is important because we must consider his torticollis, postural issues, possible sensory feeding requirements, and his WB tolerance when developing his plan of care.
Brian's occupations are central here because he may or may not see his occupational barriers as an issue. It is important to consult the caregiver and observe in order to find out what Brian considers to be his most important occupations.
Of course performance of occupations must be addressed in order to decide where and how to improve his current occupational performance.