The Potential of Responsive Feeding and Responsive Feeding Therapy
Responsive feeding (RF) is characterized by being in-tune with and responding appropriately to a child’s hunger and satiety cues.
Responsive Feeding Therapy (RFT) is exemplified by supporting internal motivation, embracing autonomy and curiosity, supporting the parent-child relationship, and developing skills, competence, and confidence.
In short, it promotes the development of healthy eating habits and sane relationships with food and body.
Many organizations support/recommend the use of RF/RFT such as Health Canada, Canadian Paediatric Society, Dietitians of Canada, and Breastfeeding Committee for Canada, the American Academy of Pediatrics (AAP), the World Health Organization (WHO), and the United Nations Children’s Fund (UNICEF) to help children develop lifelong healthy relationships with food and overcome feeding difficulties.
The 2022 article and case study by Biscan et al. illustrates the positive effects of a RFT program on the development of feeding skills. The case study highlights a tube-fed infant but the principles apply to children with varying feeding challenges.
The RFT pyramid’s foundation is to do no harm, build trust, create responsive family mealtimes, and discover internal motivation to eat. At the top of the RFT pyramid is the support of skill development and thriving.
Figure 1 from article: The responsive feeding therapy pyramid. Source: Biscan, A, Foster, L, Moreland, H. (2022). Responsive feeding intervention – Impacts on mealtime engagement and skill development. OT practice. 16-19.
The case study followed baby G, an ex-extreme premature (25 weeker) infant with very low birth weight (VLBW) who had multiple co-morbidities and an extensive neonatal intensive care unit (NICU) stay.
He was discharged home on gastrostomy tube (GT) feeds with little-to-no interest in bottling secondary to reflux, oral immaturity, and potentially blunted hunger and satiety cues.
This case study resumed baby G’s journey through from being 100% tube-fed to self-feeding family meals 100% orally, with little-to-no help, within 3 months.
Left: NICU baby practicing bottle feeding while still have nasogastric (NG) feeds. Right: baby self-feeding a chicken leg with assistance from caregiver. Source: Canva.com
Occupational therapists (OTs) worked alongside pediatricians to determine readiness to wean and to set parameters, such as hydration requirements and maximum allowed weight loss, to guide the therapy.
The program focused on the employment of a 5-day hunger induction period, a 10-day intensive period, followed by a 6-month guided progression to develop feeding capacities such as swallowing, biting, chewing, using hands, using utensils, eating purees, and using a straw.
Tube feeds were cut by 10% daily for 5 days prior to beginning the 10-day intensive portion. This reduction in tube feeds was necessary for the development and discovery of internal hunger cues, rather than external cues such as time of day.
The 10-day intensive period included the therapist in daily family meals where they could coach families every step of the way. Coaching included developing a positive association with food and feeding (i.e. removal of negative aspects such as prompting, rewarding, and praising), honoring the child’s lead (i.e. if food was refused), and responding to the child’s cues (i.e. providing more food when elicited).
A family meal, shared by all members of the household.
Source: Canva.com
Once the 10-day intensive period was complete, therapists maintained their relationship with the family for at least 6 months (or until successful completion) via videoconference.
Baby G followed the hunger-induction protocol and began to show interest in food when he joined family mealtimes. He began reaching for food more frequently and eventually joined in on the mealtime experience in a non-pressured manner.
A caregiver offering broccoli to and infant in their highchair.
Source: Canva.com
Baby G asserted his independence quickly; refusing to be spoon fed but accepting pre-loaded spoons. Amazingly, over the 10-day intensive period his feeding skills
Swallowing
Biting
Chewing
Purees
Hand and utensil use
Straw drinking
all showed marked improvement from baseline. In addition to skill, his food intake/volume progressed daily.
By the 3-month mark of the program baby G was no longer relying on his GT for nutrition, only for fluids and medications!
By the end of the intervention baby G was eating a variety of foods, which was important for overall nutritional status, growth, and development.
In addition to feeding skills and competence, baby G positively developed behaviors such as being in tune with initiation of eating by following hunger cues, maintaining his attention during mealtime, and enjoyment of mealtime, which is an underpinning goal of RFT.
Health professionals and families worked together to establish internal cues, such as hunger, and to teach the importance of the feeding relationship, trust, and autonomy.
Joining families during mealtimes allowed the OT to guide the family in the right direction with RFT to help baby G progress every step of the way.
Outcomes from this case study support the employment of a responsive approach to feeding therapy to help children with feeding difficulties overcome their challenges and become happy, healthy eaters.
A happy baby self-feeding.
Source: Canva.com
The overarching goal of the directed therapy is to create a positive mealtime for baby and family. This work opens up a floodgate of possibilities for individualized RFT for children with feeding difficulties. It illustrates the importance of a multidisciplinary approach and how vital it is to have parents on-board withing the feeding relationship. Importantly, it demonstrates the amazing capacity that little ones have and how proficient they can be.
RFT has the potential to help many children who struggle with eating, whether the child is tube fed or has an underlying condition that may make it difficult to wean and/or eat independently. With expert guidance from trained professionals all children, regardless of the challenges they face, may indulge in the pleasure that it is to eat!
The Starting Solids Network joins health professionals from around the world for perspective and continuing education on infant and child feeding, with a foundation built on responsive feeding. Click here to learn more or join the network.
Reference:
Biscan, A, Foster, L, Moreland, H. (2022). Responsive feeding intervention – Impacts on mealtime engagement and skill development. OT practice. 16-19.
