When the ultimate goal of a program is to find joy in eating, who could argue? Food chaining is an approach to help children expand their diets by using their favorite foods or drinks as a launching pad to gradually beef up their eating repertoire. Developed by Cheri Fraker, MS, CCC-SLP, with Laura Walbert, MS, CCC-SLP, of the Koke Mill Medical Center, in Springfield, IL, and Sibyl Cox, RD, LD, of the Southen Illinois University School of Medicine, food chaining complies with best practices for treatment of feeding disorders.1
About 25-35 percent of children, including those developing typically, have a feeding disorder of some kind, according to Fraker. However, more than 70 percent of premature or medically fragile children have a feeding disorder, and up to 90 percent of children with cerebral palsy have a significant feeding or nutritional problem. All of these children are candidates for food chaining.
"The main goal of food chaining is to expand the diet and have children eat food from all food groups. Not necessarily all foods, but food they enjoy," Fraker told ADVANCE. "Enjoyment is one of our biggest goals."
Best-practice guidelines recommend a low-pressure approach to feeding. Clinicians need to provide children with multiple exposures to food, become familiar with the swallowing aspect of feeding, and understand some children lack certain skills to eat some foods. They may appear picky, but in many cases they are probably avoiding particular foods because they don't know how to eat them successfully.
"My belief is, children eat the crunchy crackers and chips not just because they like them, but because they only have the skills to eat those foods. They eat those foods because they can breathe around them or they are successful. I don't necessarily think they love those crackers," she said.
In food chaining, the clinician put foods in an order and builds the child's oral motor skills. "We have to develop flexible oral-motor skills," Fraker said. "These kids literally do not know how to sequence the motor patterns to eat food of different textures. For example, with a challenging food like meat, you need to stabilize the bolus of food inside of the cheek, chew a piece off, and then swallow a portion of it and repeat. We teach the mechanics of eating different foods. I tell them, 'You drink soup differently than you eat a pretzel, mashed potatoes or a steak.' If you use the same pattern over and over with those foods, you'll gag, choke, and be unsuccessful."
To put food in order, clinicians first must look at a child's core diet. What do they eat? What are they good at eating? A food is considered part of the core diet if a child can comfortably eat at least a portion of it and not just one or two bites.
Clinicians also should study the child's upper airway system. Are the adenoids enlarged? Is the child swallowing well? Is the child handling everything well? Could the child begin to head down the right path if the clinician expanded the intake of breads and grains? For example, children can be given banana or apple bread to expand fruit flavor in a texture they can handle. The clinician then can start working to progress the chewing process.
Ewan, who has autism, dysphagia and eosinophilic esophagitis, was eating just 10 foods when he started food chaining. He now eats all foods, including a wide variety of meat, fruit and vegetables.
"I might go after dried fruits at first. I tell them they are a little gummy or a little chewier, and I show them where to put it in their mouth, what their tongue does, and where it moves the food," Fraker said. She sometimes uses puppets to model the process.
She also may put children on a therapy ball and bounce them up and down as though they were a piece of food in their mouth. "I say, 'We push it to the side,' and I take them to the side of the ball. Then I say, 'We push it to the middle.' I teach them the big motor plan."
Food chaining also utilizes the "Get Permission" approach developed by Marsha Dunn Klein, MEd, OTR/L, as well as her ideas of "mouse bites" and "elephant bites." "I expand the flavor of food before I expand the texture of food," Fraker said. "I just want to get kids tasting something new in a way they can handle. I don't want them gagging on the texture or not being able to chew it. I want them to experience it and see what they like."
For children with feeding disorders, the introduction of new foods can be a very frightening experience, she said. "They are very scared. When you bite into an orange, you bite through skin. You have this white stuff on the outside, and all this juice comes out. They are dealing with two food consistencies, liquid and fruit, and they never stay the same. The food is complexly textured. It becomes mushy, and they don't know what to do with it."
She instructs children to bite into the fruit and drink the juice first. "I've had kids standing up, tipping their head down, trying to let the juice run forward in their mouth," she said. "I tell the parents they want the fruit; they just don't know how to do it. Once we teach them and they have the confidence, the food chaining takes off because they feel, 'I can do this, and I can be safe.' They can really explore flavor and then more textures."
At the beginning of food chaining, clinicians need to be aware of any gastrointestinal issues or food allergies children have. Can they digest certain foods, or do they experience severe constipation? Do they have reflux esophagitis or an eosinophilic disorder? "We need to know the signs of those disorders and when to refer," Fraker said.
The next issue is nutrition. Are children growing? Are they getting enough micronutrients?
Lucy was a 27-week preemie with severe allergies, adenoiditis, dysphagia and severe aversion. At 11 months, she is now eating a wide range of foods and working to transition off her g-tube for liquids.
Clinicians need to consider the sensory side of feeding. Take special note of a child's behaviors. Only 3-12 percent of children have a purely behavioral feeding disorder, yet over 90 percent of what people do to treat it is behavioral, she said. "You've got to build oral-motor and sensory skills, and you've got to get the body feeling well, or the child is going to say 'no.' It's not a behavioral 'no,' it's a 'No, my body can't handle this.'"
After reviewing a child's swallowing, it's time to focus on food. "We break down food for therapists so they can offer a food matching a child's oral-motor skills, swallowing skills and taste texture preferences," she said.
Clinicians can scare children when they change food. For children with autism, a change in food can be like a bug or a hair in our food. "They go into panic mode, and that can interfere with appetite," Fraker said. "You want to teach the child to handle the changes and let the child be in control of their food."
It's important to customize food chaining to each child. In fact, it's the only way.
"I tell people all my kids are snowflakes - their eating issues are different," she said. "We tell therapists to trust their skill and develop eyes that see. They shouldn't feel like they have to do a cookie-cutter approach because they won't be successful. They have to zoom in on what's going on."
There are three techniques involved in food chaining that put children on the path to success:
- flavor mapping,
- transitional foods and
- flavor masking.
In flavor mapping, clinicians map out a child's favorite flavors. Are they all sweet? All salty? Then they need to figure out ways to expand the child's flavor menu. A child who only likes salty crackers, for example, might want to try to eat a Club or Ritz cracker that is slightly sweeter.
"We start a progression by trying to introduce them to a range of flavors. We might put a tiny amount of food on their tasting straws or their finger and see what they like," she said. "Then we rate the child's response to the new food from one to 10. How did it taste? Is it a one, a five, a 10? We keep track of that and offer more foods like the higher-rated items."
In the second phase, which involves transitional foods, clinicians can ask children to take a bite of a familiar food, such as bread, followed by a bite of a new food. "You taste a food you really like and then try a bite of a new food, and we go back and forth. I've done that with drinks, too, to kill the aftertaste for kids," she said. Some children with autism have reported tasting a new food for days because the aftertaste is so strong.
Flavor masking is when the clinician dips a new food in a flavor the child likes, such as ranch dressing or barbecue sauce. "I will dip foods and say, 'You're going to taste your ranch dressing first, and then tell me what you think about the rest of the food.' We work progressively to decrease the amount of the dip," Fraker said. For children who don't like dip, clinicians can use "dry dips," such as garlic salt or cinnamon sugar. "I have one little boy with autism who will eat anything now if I put Mrs. Dash on it."
The rating scales in food chaining can help clinicians find the right direction for therapy. "When the kids rate food, I tell them, 'This helps me continue to make a map for you.' They may surprise me. Kiwi might be a 10 when I didn't expect that. I'm going to go in that direction with them," she said.
It's important to let children know they are in control. Not only does it lead to more success, but it increases the trust level.
"It's not healthy to take control of someone's eating because it can spiral into an eating disorder of another kind," Fraker said. "Once I put food in front of them, it belongs to them. I don't try to force them, and I never say, 'Take a bite.' I model, and I let them feel that control and trust because that is absolutely key. I have expectations for them, and they know that, but I don't let it become a battle. I always try to leave on a success."
Planning themes is a big part of food chaining. One day might be Baseball Day, with a focus on the foods found at a ballpark, while the next day could be all about Hawaii. Other themes could focus on crunchy or spicy foods or the colors of foods and drinks.
"When I wrap it up in a theme of language and learning, they calm down. Food is so dynamic," she said. "Food can be melted, and it can be sliced. There's so much language involved in it, and it's so social. I have a little boy who puts peas on a toothpick. He loves Star Wars, and we talk about Star Wars the whole time. I combine feeding and language therapy."
She tells parents eating should be enjoyable. "In so many of these kids, there's no joy in eating because it is too hard," she said. "We try to build confidence and enjoyment to help children become healthy eaters for life."
- Lumeng, J. (2005). Is the picky eater a cause for concern? Contemporary Pediatrics, March 1.
- Fishbein, M.,, Fraker, C., Cox, S., et al. (2004). Food chaining: A systematic approach for the treatment of children with eating aversion. Journal of Pediatric Gastroenterology & Nutrition, 39 (S51).
- Food Chaining with Cheri Fraker and Laura Walbert, http://cheriandlaura.blogspot.com
- Fraker, C., Walbert, L., Cox, S., et al. (2007). Food Chaining: The Proven 6-Step Plan to Stop Picky Eating, Solve Feeding Problems, and Expand Your Child's Diet. New York: Da Capo Press.
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Jason Mosheim is an ADVANCE contributing editor.