Many parents worry about their baby’s food intake, whether breast- or bottle-feeding or trying to transition to solids or from tube to oral feedings. It can be a very isolating and frustrating experience. PTLC’s Jeanne Pichoff, LOTR, CLT, is an excellent resource for parents of infant and toddlers. She collaborates with physicians, lactation consultants, and nutritionists as needed and provides a specific treatment plan to get your baby back on track. The approach to infant feeding therapy is holistic, examining multiple factors that can influence success, including sensory processing concerns, positioning difficulties, and/or oral-motor skill deficits (like sucking difficulties) that are making feeding problematic.
Jeanne has completed the TOTS: Tethered Oral Tissue Specialty Training, a professional course that educates clinicians on the latest research on treatment of tongue/lip ties, how to evaluate for the presence and impact of tongue and lip ties on function, and on implementation of a treatment plan both before and after a release procedure. She routinely sees babies after tongue/lip tie release procedures for oral motor training and active wound management to enable feeding success after the procedure. For more information on PTLC’s work with Tongue Ties or Lip Ties, click here.
Feeding Evaluations: What to Expect
If your baby or toddler is referred for a feeding evaluation, a therapist will call you prior to your appointment to find out detailed information about the concerns that led to the referral. You will be asked questions about your baby’s feeding behaviors, feeding schedule, medical history, etc. Our office will email you a detailed medical history questionnaire with questions about feeding and you and/or your baby’s symptoms surrounding feeding. Please bring these forms with you to your appointment (or scan/fax them prior, to (337) 706-7612). You may be asked to fill out additional forms specific to feeding or sensory processing, including questionnaires or a log of food intake over several days prior to your child’s appointment.
On the day of your evaluation, you will need to bring the following:
- Feeding tools your child regularly uses (bottles, breastfeeding pillow/positioners, pacifier, spoons, cups, etc)
- Breastmilk or formula (if applicable)
- Completed medical history forms, questionnaires, or anything sent from office
- Smartphone, to enable video of oral motor home program if deemed necessary
- Bring foods that you know your child will easily accept along with foods he/she has refused or cannot eat well if your child is being evaluated for feeding performance on solids
Evaluations typically last 80 minutes. During this time, an oral motor exam will be conducted. The baby’s sucking will be assessed using a gloved finger to examine the way your baby moves his lips, tongue, jaw, etc. An examination of oral structures may be included depending on your symptoms (if breastfeeding) or your child’s symptoms (i.e. looking under the lip or tongue for restrictions), as well as observations of facial tone, symmetry, etc.
Recommendations for therapy will be discussed at the conclusion of the assessment based on your child’s evaluation findings. If therapy is recommended, the front office can help you with scheduling sessions.
Breastfeeding or Bottle-feeding Evaluation
If your baby is bottle fed, the therapist will bottle feed your baby using the tools you provide to gain information about your baby’s feeding skills. We carry a variety of alternate bottles/nipples, which may be utilized to “trial” a new tool during the feeding evaluation based on your baby’s performance.
If your baby is breastfed, you will be observed nursing your baby to assess latch and oral motor function for breastfeeding. Feedback about positioning and/or latch techniques may be provided as well as education on how to tell if your baby is transferring milk effectively. A referral to a lactation consultant may be recommended to further troubleshoot any breastfeeding difficulties.
We understand that babies don’t always feed on a strict schedule, but trying to time feedings so your baby will be motivated to eat during his/her evaluation is a good idea. This may mean offering a snack or partial feed to hold your baby off briefly if a feeding would normally be conducted immediately prior to your baby’s evaluation time.
For both bottle and breastfed babies who demonstrate difficulties with suck, working on oral motor skills is beneficial to enable them to become more efficient with sucking. You will be taught oral motor exercises within the evaluation to help to improve sucking. Handouts are often provided, as well as web references for reputable information on breastfeeding, if applicable.
Evaluation after Tongue Tie Release
If your baby has been referred for therapy after a tongue or lip tie release, the therapist will examine the surgical sites under the lip and/or tongue, providing instructions on necessary aftercare wound management as needed. An oral examination will be conducted along with observations of breastfeeding, bottle feeding, or solid feeding as applicable to your child. Click here for more information about Tongue and Lip Ties.
Evaluation for Difficulty Transitioning to Solids
For older babies who are evaluated due to difficulty transitioning to solids, assessments usually start with observing you feed your baby/toddler as you do at home. Our clinic has high chairs for feeding treatment; if your child uses an alternate positioner, please notify us. As your child “warms up” she will participate more in the feeding process, and she will closely observe your child to assess their oral motor skills and sensory responses to the feeding process. Oral sensory toys or tools are likely to be utilized during the evaluation to assess your child’s reaction to touch around the mouth and to elicit specific movements of the tongue, lips, and cheeks that are important for feeding. Part of the evaluation may include an assessment of general motor skills, play, and sensory processing, as difficulties in any of these areas can contribute to difficulties with feeding. Recommendations to progress with feeding skills will be discussed on evaluation day, with a more detailed home program provided at a later date if it is recommended that your child attend feeding therapy sessions.
How long will I have to wait for an evaluation?
Every effort is made to schedule babies and toddlers who are struggling with feeding difficulties ASAP. We recognize that feeding problems can be urgent in nature and a major source of stress for families, and we strive to minimize wait times. Evaluations are usually scheduled within a week of referral, though this may not always be possible depending on the caseload. Please note that you will need a prescription for therapy from a physician or dentist before an evaluation can be conducted.
Feeding Therapy: What to Expect
What do feeding therapy sessions look like for babies/toddlers?
Treatment sessions are 40 minutes in length. For infants breast or bottle feeding, sessions will likely consist of oral motor therapy, breast and/or bottle feeding to assess progress since the evaluation, and interview/discussion to troubleshoot new problems as they arise. For older babies, “therapy meals” will be conducted during sessions, where the therapist will introduce your baby to new foods and model strategies to use at home to progress with feeding skills. It is strongly preferred to have a parent present, as a major goal of sessions is to teach home strategies for progress, and receiving accurate updates from week to week is important to tailor your baby’s individual treatment plan.
How long will my child need to be in feeding therapy?
Duration of therapy varies widely from child to child. If your baby is being seen following a tongue or lip tie release, only 1-2 sessions after your procedure may be necessary if things are going well. Other infants/toddlers may need therapy for several weeks or months to work on more complex feeding skills.
Does my breastfeeding baby need therapy?
Getting off to a good start after birth is crucial to breastfeeding success. However, many women encounter difficulties in the process, and some have difficulty finding the support they need to be successful. Early treatment for breastfeeding difficulties is crucial, as milk supply is established early after birth. Achieving a proper latch is key, but this can be deceptively difficult! An evaluation by a feeding therapist may be warranted (in addition to receiving support from a lactation consultant), especially if problems with the baby’s oral motor skills are suspected to be contributing to difficulties. A feeding therapist is trained to look at multiple additional issues that may be contributing to breastfeeding problems, such as torticollis or problems with muscle tone. Often, a team approach between a feeding therapist and a lactation consultant can promote breastfeeding success with babies and mothers who are having problems.
Consider an infant feeding therapy evaluation if the following signs/symptoms are noted:
- Nipple damage ( cracking, bleeding, bruising, misshapen nipple when unlatching)
- Repeated bouts of mastitis or plugged ducts
- Pain when nursing that continues throughout the feeding
- Decreased milk supply
- Discouragement with breastfeeding
- Difficulty achieving a good latch despite help from a lactation consultant on positioning, technique, etc.
- “Lazy” nurser or falls asleep quickly with feedings
- Excessively frequent feeding
- Decreased weight gain
- Gumming/chewing nipple
- Fussiness at breast/colic
- Profuse suck blisters on the lips
- Difficulty flanging lip or opening mouth widely for latch
- Poor latch or shallow latch
- Latches well initially but slides down the nipple repeatedly during a feeding
- Clicking noise when sucking
The signs/symptoms above can occur as a result of difficulty with latching/positioning, oral motor difficulties, or structural problems like tongue and/or lip ties. With breastfeeding, a mother’s symptoms are just as important as the baby’s symptoms in considering feeding performance. Breastfeeding is a two person activity, and if things are not working well for one or both parties, sustaining breastfeeding becomes very difficult. Please see here for more information on tongue and lip ties.
Does my bottle-feeding baby need therapy?
The following signs/symptoms may indicate the need for a feeding therapy evaluation:
- Coughing, choking, or gagging during feedings
- Feedings take excessively long (30+ minutes)
- Clicking when sucking or appears to chew the nipple
- Frustration when feeding (i.e. crying, unlatching repeatedly from bottle)
- Spillage from corners of mouth when feeding
- Wide jaw excursions that interrupt the seal on the nipple when sucking
- Poor weight gain
What are the red flags for babies having difficulty transitioning to solids?
Most babies transition to table foods and cup/straw drinking between 10-14 months; there is a wide range of “normal” based on individual differences and exposures. However, the following red flags may indicate the need for a skilled evaluation to determine if there is an underlying issue inhibiting a baby’s ability to transition from a bottle or breast feeding to solids/cup drinking:
- Prolonged gagging with exposures to new foods or attempts to chew foods (gagging is normal in the process of learning to eat, but should fade quickly with exposure to new foods)
- Refusing/turning head away with attempts from an adult to feed
- Appears interested in new foods but vomits or gags when places them in the mouth
- Appears distressed with exposure to new foods
- Resists touching or tasting new foods consistently
- Appears to suck on foods vs. chewing them
- Takes a prolonged period of time to chew foods
- Crying/agitation routinely during mealtimes
- Unable to transition to a cup or straw from a bottle
- Accepts limited variety of foods
- Coughing/choking when feeding
- History of not putting objects in the mouth for exploration (non-food)
What about babies transitioning from tube feedings to oral feedings?
If your baby is in need of supplemental feedings by tube (NG, OG, or g-tube), preserving oral motor skills is critical, especially if the long term goal is to wean from tubes at a later date. An evaluation and/or treatment with a feeding therapist can help with providing guidance on how to preserve maximal oral motor function and evaluate a baby’s ability to safely wean to oral feedings. A feeding therapist should collaborate with physicians and other disciplines (like nutritionists) to help to develop a plan to wean from tubes while promoting optimal oral motor skill development.