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Brian - Picky Eater - Coggle Diagram

- - - - With Brian sitting in his chair, play a song and walk up his arm with fingers or a toy or teddy bear. Walk from his hands to his face, and end with a kiss. This intervention will prepare Brian for direct touching of the face and mouth during mealtime (Morris & Klein, 2000).
      - Grade Up - introduce more tactile input around the mouth/ lips with a wider variety of objects/ textures
        Grade Down - remove tactile stimulation from face/ mouth, or remove tactile stimulus altogether
    - - With Brian sitting in his chair, place safe, soft or squishy toys on his tray while preparing his food. This will encourage mouthing of his fingers and toys while he waits, providing the stimulus to himself which he is more likely to accept than if someone else provided it for him (Marcus & Breton, 2013). Introduce non-preferred foods by placing a small amount onto a preferred toy and allow him to mouth the toy with the novel food. Dipping a mouthing toy in a familiar flavor will encourage sensory discrimination in and around the mouth (Morris & Klein, 2000).
  - - - The goal for the adapted highchair is to place Brian's pelvis, trunk, neck, and head into neutral positions to allow for more functional eating, feeding, and swallowing patterns (Colangelo & Shea, 2020).
      - Placing Brian in a sitting position encourages slight anterior pelvic tilt, more trunk stability to allow for more upper extremity mobility, and stabilizes shoulder girdle to allow for arm movements (Colangelo & Shea, 2020).
      - Research has proven that overall postural alignment and stability increases when provided with external supports. Improved postural alignment and stability leads to more independent functioning, and increased head control, communication, feeding, and play abilities (Colangelo & Shea, 2020).
      - Improved postural support will also provide a stable foundation for mouthing hands and toys, thus encouraging more independence in feeding (Morris & Klein, 2000).
      - Grade Up - remove supports as he gains postural strength and stability
        Grade Down - add additional supports if current supports and/ or positioning are not stabilizing enough to allow him to feed and swallow functionally
    - - Engage in "tummy time" on a physio-ball, providing stimulus to his right to encourage Brian to turn his head to the right and maintain body symmetry (Morris & Klein, 2000).
      - Engage in play activities with Brian on parent's lap facing parent. Parent can support Brian's pelvis, trunk, and neck by bending knees and letting Brian recline on their thighs. Encouraging eye contact will stimulate Brian to move head to midline (Morris & Klein, 2000).
      - Improve head and trunk stability during play by placing Brian on parent's lap facing away from parent. Brian's pelvis and trunk should be support by the parent's core, lap, and hands where necessary. Parent can then gently bounce legs up and down to stimulate contraction of core muscles that contribute to postural stability (Morris & Klein, 2000)
  - - - Brian's aversion to sensory stimuli around his mouth leads him to refusing cups. Teaching him to drink from a straw is appropriate because it limits the amount of liquid that would spill outside of his mouth and on his lips; he also has the necessary lip closure and suction abilities to drink from a straw. While this intervention addresses his sensory aversions, straw drinking also allows Brian to drink without extending his head and neck, making it suitable for addressing his postural limitations, as well.
      - Use a flexible container with a straw such as a juice box or plastic bottle with a straw, then squeeze the container to transfer the liquid into the child's mouth (Marcus & Breton, 2013).
      - Grade Up - let him suck the liquid through the straw instead of squeezing the liquid into the straw for him
        Grade Down - draw liquid into the end of a straw by dipping it into the liquid and plugging it with a finger, then place the straw into his mouth and unplug the end of the straw, allowing the liquid to drop into his mouth (Marcus & Breton, 2013)
    - - Using a cup with a cut-out to fit the child's nose allows the child to drink without extending their neck (Marcus & Breton, 2013). Brian's limited neck ROM affects his ability to drink from a normal cup; this type of cup will allow him to drink without the need to move his head or neck.
  - - - Placing Brian in a "nest" during supine play will promote hand to mouth behavior by allowing the head to stay midline, more flexed posture, greater shoulder adduction, and greater elbow flexion (Lobo et al., 2015).
      - Behaviors of general exploration, reaching, and object exploration are all key for early learning and development, and will affect future neuromotor and cognitive outcomes in children (Lobo et al., 2015).
      - Examples of toys to improve bilateral integration, midline crossing, and eye-hand coordination:
      - Grade Up - remove the "nest" during supine play once he is strong and stable enough to engage in functional movements; choose toys that are more challenging i.e., bead stringing or coloring activities
        Grade Down - provide more support during play to align pelvis, trunk, neck, and head; choose simpler toys or activities with less sensory stimulus i.e., more monotone in color, toys without sound
      - Have Brian learn to hold his own bottle during feeding to improve bilateral manipulation and eye-hand coordination.
    - - The existence of a mealtime routine can help avoid meltdowns because the child is prepared for what's to come, can increase participation through modeling and imitation, can promote health habits by sitting at a table without distractions which may lead to eventual overeating and decreased socialization, and can encourage cooperation and socialization (Doll, 2014).
      - As the family is an intricate, dynamic system, routines help orchestrate the complex demands of family life and contribute to the emotional fabric and well-being of families (Evans & Rodger, 2011).
      - The family mealtime routine should include sitting down for meals at the same times each day, instituting a calming transitional routine before eating, eating as a family whenever possible, and modeling appropriate eating and social behaviors (Satter, 2019).
- - - - Brian was born at 34 weeks via emergency C-section as a result of fetal heart arrhythmia
      - Brian was intubated in the NICU for 2 weeks and received treatment for difficulty breathing
      - At 6 months old, Brian received an MRI and CT that both indicated normal results
      - Most recently, Brian underwent surgery to correct craniosynostosis
      - Brian currently presents with torticollis with limited rotation to the left.
    - - Brain drinks between 48 and 64 ounces of formula every 24 hours.
      - Brian eats between 4 and 8 servings of purees every 24 hours.
      - Time spent feeding Brian is minimal, reportedly due to caregiver frustrations over Brian's avoidance behaviors
      - No new foods introduced over the 72-hour period
  - - - Interpretation of Brian's sensory profile as reported by his mom indicated that Brian responds to oral sensory stimulus much more than others, which could explain his aversion to self-feeding (mess around lips and mouth) and solid foods (novel textures).
    - - Interpretation of AIMS scores indicate delays in prone, supine, side-lying, and sitting postures. Observation reveals asymmetrical postures weight-bearing while sitting. Delayed antigravity movements in upper extremities lead to inability to self-feed using fingers or utensils, and limited bilateral manipulation and eye-hand coordination.
    - - Interpretation of MCH-FS scores reveal severe difficulties with feeding. Areas of high concern include maternal concerns about feeding, mealtime behaviors, family reactions to child's feeding, and oral sensory. Areas of moderate concern include parental strategies used and oral motor. Areas of low concern include appetite.