Top 10 Lessons I Learned from Loving Kids with Autism

Lessons Learned from Loving Kids with Autism

Editor’s Note: Today is World Autism Awareness Day, so we have a special post to celebrate the wonders that people with this unique perspective bring to the world. Read more about autism in this month’s April ASHA Leader issue devoted to the topic, which includes articles on the importance of helping people with ASD predict what happens next and how to measure clients’ progress in social skills groups.

 

If you’ve had the good fortune of loving kids with autism, you’ve probably encountered a few unexpected lessons in life.  In honor of National Autism Awareness Month and to express my gratitude for what my friends with autism spectrum disorder have taught me, I’d like to share my Top 10:

#10. In a world of too many gadgets and gizmos, a spinning top is pretty cool.

#9. Echolalia keeps my “over 40” brain sharp. I’ve learned to repeat, repeat, repeat.

#8. Parents with patience are the best teachers.

#7. Consistency is so comforting.

#6. Random objects can bring one kid a lot of joy. I’ve learned to appreciate road maps, bathroom signs and every single state’s license plates, to name just a few.

#5. Sometimes, carrying a favorite toy all day long just makes everything go better.

#4. Flapping really does feel good.

#3. The world needs more quirky.

#2. The first spontaneous “hug” is the best one of all.

And the #1 lesson I learned from my clients with autism?

#1. Love is when you take the time to know someone who sees the world differently than you.

 

What lessons have you learned from loving kids with autism? I’d love to know. Let’s start a list here to celebrate and raise awareness of all that the world can learn from these extraordinary, beautiful people.

 

Melanie Potock, MA, CCC-SLPtreats children, birth to teens, who have difficulty eating. She is the co-author of Raising a Healthy, Happy Eater: A Parent’s Handbook – A Stage by Stage Guide to Setting Your Child on the Path to Adventurous Eating (Oct. 2015), the author of Happy Mealtimes with Happy Kids, and the producer of the award-winning kids’ CD Dancing in the Kitchen: Songs that Celebrate the Joy of Food!  Potock’s two-day course on pediatric feeding is offered for ASHA CEUs.  Melanie@mymunchbug.com  

 

 

Just Flip the Lip! The Upper Lip-tie and Feeding Challenges

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While many pediatric professionals are familiar with a tongue-tie, the illusive lip-tie hides in plain sight beneath the upper lip. Because I focus on feeding difficulties in children and an upper lip-tie can be a contributing factor if a child has trouble feeding, then I probably encounter more lip-ties than some of my colleagues. Still, I’d like to encourage my fellow SLPs to just flip the lip of every single kiddo whenever assessing the oral cavity. And document what you observe. Help increase general knowledge among professionals on different types of upper lip-ties by raising awareness of how they may impact the developmental process of feeding.

Upper lip-ties refer to the band of tissue or “frenum” that attaches the upper lip to the maxillary gingival tissue (upper gums) at midline. Although most babies should have a frenum that attaches to some degree to the maxillary arch, the degree of restriction varies. So it’s important to flip the lip of every child we evaluate in order to gain a better understanding of the spectrum of restriction – especially if you are an SLP who treats pediatric feeding.

During the feeding evaluation process, consider four things: 1) The mobility of the upper lip for breast, bottle, spoon and finger feeding; 2) How well it functions in the process of latching and maintaining the latch; 3) If the lip provides the necessary stability for efficient and effective suck-swallow-breath coordination; and 4) If the lip is an effective tool for cleaning a spoon, manipulating foods in the mouth and contributing to a mature swallow pattern.

Dentist Lawrence A. Kotlow has created an upper lip-tie classification system to better identify, describe and consider the need for treatment. The tie is classified according to where the frenum connects the lip to the gums, known as “insertion points.” Envision a child with a very big “gummy” smile and the upper gum line exposed. Divide the gums into three zones, as described in this article by Kotlow:

“The soft tissue covering the maxillary bone is divided into 3 zones. The tissue just under the nasal area (zone 1) is called the free gingival area; this tissue is movable. Zone 2 tissue is attached to the bone and has little freedom of movement… Zone 3 extends into the area between the teeth and is known as the interdental papilla. This is where the erupting central incisors will position themselves at around 6 months of age.”

Now, consider the insertion points. A Class I lip-tie inserts in Zone I and (unless extremely short and tight) does not inhibit movement of the upper lip and should not interfere with breast or bottle feeding. However, if the lip itself is retracted to the degree that a child cannot flange his upper lip for adequate latching and for maintaining suction, further consideration of this type of lip tie may be necessary. Class II lip-ties have an insertion point in Zone 2, where the tissue is attached to the bone. Kotlow describes the Class III tie as inserting in Zone 3, where “the frenum inserts between the areas where the maxillary central incisors will erupt, just short of attaching into the anterior incisor.”  A Class IV lip-tie “involves the lip-tie wrapping into the hard palate and into the anterior papilla (a small bump located just behind where the central incisor will erupt).”

How might an upper lip-tie impact the developmental process of feeding?

The impact of the upper lip-tie can vary according to its classification and, in my professional experience, the fullness of the upper lip also comes into play. But, in general, consider these key points:

Breastfeeding and Bottle Feeding

  • Breast – Inadequate latch: An infant must flange the lips to create enough suction and adequate seal around the tissue that includes the areola and not just the nipple. It is essential that babies take in enough breast tissue to activate the suckling reflex, stimulating both the touch receptors in the lips and in the posterior oral cavity in order to extract enough milk without fatiguing. When the baby suckles less tissue, painful nursing is also a result. One sign (not always present) is a callus on baby’s upper lip, directly at midline. While not always an indicator of a problem, it’s typically associated with an upper lip-tie. It’s simply a reminder to flip the lip!
  • Bottle – Inadequate Seal: Because bottles and nipple shapes are interchangeable and adaptations can be made, it’s possible to compensate for poor lip seal. However, these compensatory strategies are often introduced because all attempts at breastfeeding became too painful, too frustrating or result in poor weight gain…and the culprit all along was the upper lip-tie. It is then assumed that the baby can only bottle feed. I’ve assessed too many children held by teary-eyed mothers who reported difficulty with breast feeding – and no indication in the chart notes that the child had an upper lip-tie. But, upon oral examination, the lip-tie was indeed present and when observing the child’s feeding skills, the tie was at the very least a contributing factor. Releasing the tie resulted in improved ability to breast feed and progress with solids.
  • In addition, an inadequate latch and/or a poor lip seal may contribute to the following partial list of symptoms:
    • Gassiness; fussiness; “colicky baby”
    • Treatment for gastroesophogeal reflux disease, yet to be confirmed via testing
    • Fatigue resulting in falling asleep at the breast
    • Discomfort for both baby and mother, resulting in shorter feedings
    • Need for more frequent feedings round the clock
    • Poor coordination of suck, swallow, breathe patterns
    • Inability to take a pacifier, as recommended by the American Academy of Pediatrics and noted here.

Spoon Feeding

  1. Inability to clean the spoon with the top lip
  2. Inadequate caloric intake due to inefficiency and fatigue
  3. Tactile oral sensitivity secondary to limited stimulation of gum tissue hidden beneath the tie
  4. Lip restriction may influence swallowing patterns and cause compensatory motor movements which may lead to additional complications

Finger Feeding

  1. Inability to manipulate food with top lip for biting, chewing and swallowing
  2. Possible development of picky, hesitant or selective eating because eating certain foods are challenging
  3. Lip restriction may influence swallowing patterns and using compensatory strategies (e.g. sucking in the cheeks to propel food posteriorly to be swallowed) which may lead to additional complications

Oral Hygiene & Dental Issues

  1. Early dental decay on upper teeth where milk residue and food is often trapped
  2. Significant gap between front teeth
  3. Periodontal disease in adulthood
  4. Possible changes in dentition with certain compensatory methods to propel bolus posteriorly for swallowing, such as finger sucking.

After documenting what we observe during the evaluation, clear communication with parents and other professionals will help to determine next steps. In feeding therapy, our role is to provide information for involved parents and professionals (this may include pediatricians, lactation consultants, otolaryngologists, gastroenterologists, oral surgeons and/or pediatric dentists). Our primary role is to determine, document and communicate to what degree the restricted top lip is influencing a child’s difficulty feeding.

For detailed information and additional photos, please read Kotlow’s article, Diagnosing and Understanding the Maxillary Lip-tie as it Relates to Breastfeeding, published in the Journal of Human Lactation in May 2013.

In a future post for ASHA, we’ll discuss tongue-ties (ankyloglossia) and the impact on feeding. Upper-lip ties are frequently associated with tongue-ties, so please remember to look for both during oral examinations.

Have you had an experience with an upper lip-tie impacting the feeding progress of one of your clients? If so, please tell us in the comments below.

 

Melanie Potock, MA, CCC-SLPtreats children birth to teens who have difficulty eating.  She is the co-author of Raising a Healthy, Happy Eater: A Parent’s Handbook – A Stage by Stage Guide to Setting Your Child on the Path to Adventurous Eating (Oct. 2015), the author of Happy Mealtimes with Happy Kids and the producer of the award-winning kids’ CD Dancing in the Kitchen: Songs that Celebrate the Joy of Food!  Melanie’s two-day course on pediatric feeding is offered for ASHA CEUs.  She can be reached at Melanie@mymunchbug.com

 

Picky Eaters in the Preschool Classroom: 7 Tips for Teachers

Two scoop sizes allow children to select a smaller portion for unfamiliar foods.

Two scoop sizes allow children to select a smaller portion of unfamiliar foods.

As a pediatric feeding therapist, part of working in the child’s natural environment is making regular preschool visits to offer teachers and staff guidance when a child is not eagerly participating in mealtimes. Whether a child is a selective eater or the more common picky-eater, here are seven tips for teachers that focus on the seven senses involved in food exploration and eating:

  1. Sight: New foods are better accepted when the sight of them is underwhelming. When serving foods family style, include TWO utensils for scooping from the main bowl or platter [see above]. Present each food with one larger scoop and a standard spoon. The kids at the table can choose which scoop/spoon they would like to use, which allows the more hesitant eater to choose a small sample instead of what might feel like an overwhelming shovel-full. If meals are served pre-plated, offer smaller portions (1 tablespoon) of new foods and allow the kids to request more after their first taste.
  2. Smell: Warm foods often have a stronger aroma and for some kids, this can be a quick turn-off before the food ventures toward their lips. In regards to the hesitant eater, begin passing the bowl of warm foods so that it ends up at his seat last, when it will be less aromatic. For meals that are pre-plated, simply dish up his first but place it in front of him last, so that the food has time to cool a bit. Straws are an excellent option for soups, because they allow the child to sample by sipping. The longer the straw, the farther away they are from the smell. The shorter the straw, the less distance the soup needs to travel to reach the tongue, but the closer the nose is to the aroma. Consider what suits each child best and adjust accordingly. Thinner straws allow for a smaller amount of soup to land on the tongue, but if the soup is thick, you may need a slightly wider straw. Keeping the portion as small as possible also keeps the aroma to a “just right” amount for little noses. Try tiny espresso cups, often under $2, for serving any new beverage, soup or sauce.
    espresso cups
  3. Taste: Experiencing food doesn’t always mean we taste it every time. If the best a hesitant eater can do that day is help dish up the plates or lick a new food, that’s a good start! But when it comes to chewing, encourage kids to taste a new food with their “dinosaur teeth.” A fun option are these inexpensive tasting spoons commonly found in ice cream shops. Keep a small container in the center of the table for kids to take tiny sample tastes direct from their plates.
    tasting spoons
  4. Touch: Like any new tactile sensation, few of us place our entire hand into a new substance with gusto. It’s more likely that we’ll interact with a new tactile sensation by first using the tip of one finger or the side of our thumb. Take it slow – and remember that touch doesn’t just involve fingers and hands. The inside of the mouth has more nerve endings than many parts of our bodies, so it may be the last place that the hesitant eater wants to experience a new texture, temperature or other type of sensation. Start with where he can interact and build from there.
  5. Sound: The preschool classroom is abuzz with activity and thus, noise. Beginning each snack or mealtime with a song or a ritual, such as gently ringing some wind chimes to signal “it’s time to be together with our food” is a routine that centers both teachers and children. Whatever the ritual, involve the most hesitant eaters in the process and encourage their parents to follow the same routine at home if possible. Kids do best with when routines are consistent across environments.
  6. Proprioceptive Input: The sense of proprioception has a lot to do with adventurous eating. One fun routine that provides the proprioceptive input to help us focus is marching! In one preschool classroom, we implemented a daily routine where the kids picked a food and marched around the table with it as a way to mark the beginning of a meal and provide that much-needed stomping that is calming and organizing for our bodies. Download the song “The Food Goes Marching” here (free till February 1, 2015) as the perfect accompaniment!
  7. Vestibular Sense: While we all know the importance of a balanced diet, you may not be aware that a child’s sense of balance has a lot to do with trying new foods! Our sense of balance and movement, originating in the inner ear and known as the vestibular system, is the foundation for allfine motor skills. In order to feel grounded and stable, kids need a solid foundation under the “feet and seat.” Many classroom chairs leave preschoolers with little support and feet dangling. Create a footrest by duct taping old text or phone books together or if you’re extra handy, create a step stool that allows the chair legs to sit inside the stool itself.
    footrest
    An inexpensive version can be made with a box of canned baked beans from COSTCO, like this one. Carefully open the box because you’ll be using it again to create the footrest. Simply remove the cans, empty just two, then rinse thoroughly and discard the lids. Now place the cans back in the box with the two empty cans facing up, so that the legs of the chair will poke through the box and into those two cans. Reinforce with duct tape. Instant footrest!

Melanie Potock, MA, CCC-SLPtreats children birth to teens who have difficulty eating.  She is the co-author of Raising a Healthy, Happy Eater: A Parent’s Handbook – A Stage by Stage Guide to Setting Your Child on the Path to Adventurous Eating (Oct. 2015), the author of Happy Mealtimes with Happy Kids and the producer of the award-winning kids’ CD Dancing in the Kitchen: Songs that Celebrate the Joy of Food!  Melanie’s two-day course on pediatric feeding is offered for ASHA CEUs.  She can be reached at Melanie@mymunchbug.com

Ten Tips for Making Progress in Feeding Therapy

Dad and son at farmer's market

Parents’ Ten Tips for Making Progress in Feeding Therapy

The end of a year is a reflective time for many parents, especially those who have children in any type of therapy.  As a pediatric SLP who focuses on feeding, I asked over forty parents for their number one tip that helped their child progress through feeding therapy.  I found it interesting that typically what popped into their minds wasn’t an oral motor tool or a specific therapy modality or other tips like “practice, practice, practice!”  What struck me was that most parents focused on an emotional component.  When we consider the bond between parent and child, that makes perfect sense.  I learn so much from the parents of the children I treat and I’m grateful for their wisdom.

Here are the Parents’ Ten Tips for Making Progress in Feeding Therapy:

#10: “Meet my child where she is…show interest in what she’s interested in” and build from there.  It builds relationships and that’s the foundation for mealtimes.

#9 “Your child sets the pace.” Expectations and goals are two different things, as described in this article for ASHA.

#8: “Patience.” This was the most popular response.  One…step…at…a…time.

#7:  Pause and “be compassionate.” It’s not easy for many kids to move through the developmental process of eating.  Both physical and emotional pain may come into play.

#6: “Have FUN and PLAY daily in food!”  Join in and get the whole family involved, as noted in this ASHA article.

#5: “Expose kids to the Joy of food” – and not just at mealtimes: Farmer’s Markets were a top pick along with the produce isle at the grocery store.  Focus on sharing time together and the event, not what might or might not happen when the food makes it to the dinner plate.

#4: “Build Trust.”  When a child trusts their mealtime partner, whether it be a therapist, parent or caregiver, that builds confidence in eating skills over time.

#3: Kids get sick and sometimes that stalls progress or causes some regression.  One parent stated that: “It’s just part of being a kid, so it’s also part of the process.”

#2: “Rely on Faith,” and not just the religious kind: Faith in family and faith in your child … but also faith in yourself as a parent.

#1: “Park your own stress in the driveway.”  That’s a tip that I teach to parents – and I am pleased to see it repeated here.  Life is full of stressful moments and it’s easy to bring those into your home.  But family mealtimes are a time to focus on family and if there is one thing I am sure of,  it’s that kids mimic  their parent’s emotions.  Be sure to take care of you too – the  feeding therapy process isn’t always easy, but it’s incredibly rewarding and exciting when you witness even the smallest changes in your child’s ability to enjoy all kinds of food.  Those changes often start with your emotions: Smile when you can, laugh even more and be ready for all the good things to come.

Melanie Potock, MA, CCC-SLP, treats children birth to teens who have difficulty eating.  She is the author of Happy Mealtimes with Happy Kids and the producer of the award-winning kids’ CD Dancing in the Kitchen: Songs that Celebrate the Joy of Food!  Melanie’s two-day course on pediatric feeding is  offered for ASHA CEUs and includes both her book and CD for each attendee.  She can be reached at Melanie@mymunchbug.com.

 

If You Give My Picky Eater Some Turkey…

PickyEaterGirl

An open letter to any relative who plans to invite my family to Thanksgiving dinner:

In the spirit of the season, I want to thank you and yours for inviting my family and our little picky eater to your traditional Thanksgiving celebration.  I should warn you that my sweet 3-year-old isn’t always the most adventurous eater and may turn up her nose at the traditional holiday fare, but I have a few helpful tips for you here:

If you give my picky eater some turkey, she’s going to ask for a hot dog.  When you give her the hot dog, she’ll probably ask you for ketchup.  Then, she’ll ask for more ketchup.  And then, she’ll refuse the hot dog, because it’s “cold”.  It’s a cold dog.  So she’ll just eat the ketchup.

If you give my picky eater green bean casserole, she’ll panic.  She only eats foods that are easily identified.  Green bean casserole is not easily identified.  But, if you put ketchup on it, it’s fine.  I’ve brought her favorite brand of ketchup, which you have to serve in the original plastic bottle so she can see you squirting it onto her plate. Don’t ever remove the bottle from your lavishly-set table. She’s needs to see it at all times.

If you give my picky eater cranberry sauce from a can, she’ll ask: “How did it get in the can?” along with 100 gazillion other questions.  “Why does it jiggle? What are those lumps? Cranberries? What are cranberries?  It looks like red vomit.”  Now, no one at the Thanksgiving table will eat the canned cranberry sauce…even with ketchup. I’m very sorry for that. That’s why I brought you this very expensive bottle of wine. I suggest you open it now.

If you give my picky eater the platter of candied yams and suggest she helps sprinkle on the mini-marshmallows, she’ll stick out her tongue, but then join in.  As she places the last tiny marshmallows on the layer of yams, she’ll ask why the marshmallows stick to yams.  You’ll probably tell her “It’s the sticky syrup on the yams.”  She’ll reply “Oh, I thought it was because I licked each one.”  You’ll have another glass of wine.

If you give my picky eater some mashed potatoes, she’ll gag.  “But, they taste just like French fries!” you’ll exclaim. She’ll gag again and run from the table.  While having a complete Thanksgiving meltdown, she’ll scream “I want French fries!!!” and you’ll make an immediate mental search of what fast food drive-thrus are open on Thanksgiving. You’ll send you husband out to find French fries and he’ll happily agree to leave.

If you give my picky eater some stuffing, she’ll stare at it.  You’ll tell her it’s chopped-up chicken nuggets that your husband bought while he bought her French fries at the drive-thru. She’ll pause…she’ll ponder…she’ll ask: “Where’s the toy?”  You’ll grab three mini-marshmallows, smoosh them together and tell her it came with a toy “Olaf” from Frozen.

If you give my picky eater some gravy, she’ll ask: “What is this?”  So you’ll lie and say “It’s brown ketchup.” She’ll stare at the brown ketchup and ask “If I eat it, do I get dessert?”

Upon the suggestion of dessert, you’ll give my picky eater a slice of pumpkin pie.  After all, pumpkin’s a vegetable, right?  She’ll ask for some whipped cream to go with it.  But not the homemade kind: She only eats the kind in the can.  “Not like the can that had cranberry sauce,” she’ll explain.  “Only the ‘squirty’ kind of can.”  She’ll eat all the whipped cream off the top of her pie, completely missing any remnant of “vegetable” you hoped she would consume.  That is, unless she detects any kind of lump…like those lumpy cranberries…which are red.  The red will remind her of her favorite food: ketchup.  So, she’ll ask for some ketchup.  And chances are if she asks for ketchup, she’ll want some turkey to go with it.

(Many thanks to Laura Numeroff, author of If You Give a Mouse a Cookie, which was the inspiration for this piece.)

 

Melanie Potock, MA, CCC-SLP, treats children birth to teens who have difficulty eating.  She is the author of Happy Mealtimes with Happy Kids and the producer of the award-winning kids’ CD Dancing in the Kitchen: Songs that Celebrate the Joy of Food!  Melanie’s two-day course on pediatric feeding is  offered for ASHA CEUs and includes both her book and CD for each attendee.  She can be reached at Melanie@mymunchbug.com.

You Want My Kid to Play in Food? Seriously?

1messykid
Yep, seriously.  For many kids, food exploration begins with just learning to tolerate messy hands and faces. Many parents who bring their kids to feeding therapy have one goal in mind:  Eating. In fact, as a pediatric feeding therapist, a common phrase I hear when observing families at their dinner tables is, “Quit playing with your food and just eat it!”

What parents may not understand is that the child is not avoiding food—the child is experiencing it. For the hesitant eater, this may be where a child needs to start. The palms of our hands and our fingers are rich with nerve endings, but the mouth has even more. Playing with food provides the child with information about size, texture, temperature and the changing properties of food as little hands squish and squash, pat and roll, or just pick up and let go: splat!

Here are three silly ways to play in food!  Give it a try—some of it just may end up in your child’s mouth in the process. But if it doesn’t, don’t  worry. Learning to be an adventurous eater takes time and the most important part of the journey is keeping it fun!

  1. Pudding Car Wash: For kids who can’t tolerate the feel of purees, learning to play in a consistently smooth puree, like chocolate pudding, is the preliminary step to eventually playing in more textured foods, like mashed cauliflower. The key is water.  Most kids who hate to get messy enjoy water play, for obvious reasons.  If they can’t tolerate water play, then that’s the place to start, and eventually they will progress to pudding.  You’ll need:
  • Cookie sheet
  • 2 large bowls—one filled with water and soap bubbles and the other with clean water
  • Small toy cars
  • Chocolate pudding
  • It’s simple! Dump some “mud” (chocolate pudding) on the cookie sheet and you now have a “muddy run raceway” to drive through till the cars are coated!  Pushing a toy car through the mud is much easier than just playing in the mud with a bare hand.  The bigger the car, the easier it is to tolerate the sensation, because less mud gets on the hesitant child’s hand.  Plop the car in the “wash” (the soap bubble water) and then fish it out.  Plop it in the clear water and begin again.  The water adds a bit of relief for the kids who are tactilely defensive, but the fun of driving the cars through the mud provides the reinforcement for getting messy. Warning: This could go on all day—kids love it!
  • Variation: Use plastic animals and wash the entire zoo!
  1. Ice Pop Stir Sticks: For kids who cannot tolerate icy-cold in their mouths, add cups of water to take off the chill. There is a significant difference between straight-from-the-freezer-frozen and just icy-cold.  When fruity ice pops on a stick are dipped in cool water, the surface of the ice pop immediately begins to melt.  Now, when your kiddo takes a lick, they’ll lick off just flavored cold water. Keep stirring and the water becomes darker and more flavorful.  Add a skinny straw so kids try a taste. Coffee stirrers work well for this, because the narrow diameter of the stir stick allows just the tiniest taste to land on the tongue.
  2. Hand Print Animal Pictures: I always shudder when I see kids in daycare having to make “hand print” pictures if I know they have sensory challenges including tactile defensiveness. The well-meaning teacher grabs the child’s tiny hand and pushes it into a paper plate of paint before pressing it onto a piece of construction paper to make the infamous hand print, which is later transformed into an animal to be displayed in the classroom. Or, and for some this may be worse, the kids get their hand painted with a tickly paint brush.  That can be very upsetting for a child who doesn’t like to get messy.  Instead, try starting with the teacher’s own handprint, then encourage the child to use the tip of his index finger or the side of his little thumb to make the eye of the handprint animal. That’s the part of the hand where most kids are willing to tolerate a little mess. Think about how you pick up a slimy worm on the sidewalk…you snag it with just the tip of your index finger and the side of your thumb and then toss it quickly back into your garden. That quick release is key—kids need that too. Over time, they’ll work their way up to making an entire zoo of hand print pictures!  Here’s a video that will help you create three African animals—your own handprint safari!

So, the next time you get frustrated with your child for playing in his or her food—think of the child as a little explorer discovering all the properties of food! Encourage it…. it just might lead to a closer food encounter with the mouth!

Melanie Potock, MA, CCC-SLP, treats children birth to teens who have difficulty eating.  She is the author of Happy Mealtimes with Happy Kids and the producer of the award-winning kids’ CD Dancing in the Kitchen: Songs that Celebrate the Joy of Food!  Melanie’s two-day course on pediatric feeding is  offered for ASHA CEUs and includes both her book and CD for each attendee.  She can be reached at Melanie@mymunchbug.com.

 

She Didn’t Eat a Thing at School Today!

school lunch
It’s that time of year again and little kids are climbing onto big yellow buses, tiny hands clutching lunch boxes that are packed full with a variety of choices, with their wishful parents praying that they will “just eat something!”  But at the end of the day, especially if the child is a picky eater, parents sigh as they open the lunch box latch and see that lunch has barely been touched.

For children in feeding therapy, treatment doesn’t stop when a child is eating well in the clinic setting.  Once a child has begun to eat even a limited variety of foods, I prefer to generalize new skills to the community environments as soon as possible, even as clinical treatment continues.  The school cafeteria in the one hot spot in the community that most kids visit five times a week.  It can be a chaotic setting, as described in one of my first blog posts for ASHA, which offered some tips on how to help kids eat in the Café-FEARia.  But what can a parent do at home to encourage kids to bring a healthy lunch, even when they only eat only five to 15 foods?  Here are six tips to encourage even the most hesitant eaters to not only eat preferred foods, but phase-in eating those new options showing up in their lunchboxes:

  1. Begin with Exposure: Kids may need to see a new food multiple times before they may even consider trying it.  That means they need to see it at school too.  If you’re thinking, “But he won’t eat it, so why pack it?” remember that the first step is helping your  hesitant eater get used to the presence of that food in his lunch box again and again.  The link to this ASHAsphere post will explain more, including why food doesn’t have to be eaten to serve a purpose in food education.
  2. Pack All the Choices under One Easy-Open Lid: For my school age clients, I use a compartment or bento-style lunchbox, such as EasyLunchboxes® or Yumbox®.  Even little fingers can open the lids quickly to reveal their entire lunch, so no time is wasted when most kids in the public school system have about 20 minutes to enter, eat and exit the cafeteria.
  3. Give them Ownership in the Lunch Packing Process. Kids like predictability and need to feel a part of the process, especially when it comes to food exploration.  For my clients in feeding therapy, once they have the oral motor and sensory skills to eat a few foods, those foods get packed along with other safe choices in their lunchbox.  A child who is receiving tube feedings may still take a lunchbox if he or she is able to eat even a few foods orally.  To make them the Lunchbox Leader, we create a poster board together that has a photo of the inside of their bento box, essentially creating a “packing map.”
    Packing Map #2
    Using colored markers, I help the child list the foods they can eat with arrows pointing to where the foods go in the box. For example, the Yumbox® has compartments with fun graphics representing dairy, grains, proteins, fruit and veggies. If the child is limited to purees, we write “applesauce” next to the fruit compartment on the poster. But we also write a few more future purees that he/she just needs to be exposed to, and those show up too. Parents and kids pack the lunchbox together the night before, and the kids choose from their short lists what goes in each compartment.  If they have exactly five preferred foods and there are five compartments, then we create a rule that they need to pick a new food for at least one of the compartments.
  4. Include a Favorite, But Just Enough:  Selective eaters always eat their favorite foods first, so be sure to include their preferred food, but not too much.  Provide just enough so that you won’t be worried that they are starving, but not so much that the other less-preferred choices don’t stand a chance.  That’s why the bento boxes work so beautifully, because the individualized compartments, along with the “map” to fill them, guide the packing process.
  5. No Comments Please!  When the lunchbox comes home, resist the urge to unpack it immediately. Give everyone a chance to breathe, especially those kids with sensory challenges who have difficulty with transitions from one environment to another. When you eventually open it, no comments about the contents please!  Nothing, not positive or negative. For many kids, it creates too much focus on whether they ate or not.  That’s addressed in feeding therapy. For now, just wash it out and set it on the counter for your child to pack again later that evening.
  6. Keep Up with Other Strategies: Parents who have kids in feeding therapy understand that it’s a steady, step by step process.  Keep  up with strategies listed in this ASHAsphere post or this one and/or those recommended by your child’s therapist.

Whether you have a child in feeding therapy or a “foodie” with a palate that rivals a Top Chef, I encourage you to have all the kids in your family create a packing map and be responsible for their own lunch packing, with the kids choosing from each category while the parent provides the healthy food options and keeps the kitchen stocked.  You might be surprised to see some of your young foodie’s choices shift to the more hesitant sibling’s packing map over time!  Remember, it starts with exposure and builds from there.

Melanie Potock, MA, CCC-SLP, treats children birth to teens who have difficulty eating.  She is the author of Happy Mealtimes with Happy Kids and the producer of the award-winning kids’ CD Dancing in the Kitchen: Songs that Celebrate the Joy of Food!  Melanie’s two-day course on pediatric feeding is  offered for ASHA CEUs and includes both her book and CD for each attendee.  She can be reached at Melanie@mymunchbug.com.

SLPs in the Home: What’s Pot Got to Do with It?

brownie

I never thought I’d be writing an article for ASHA about marijuana, but because I live in Colorado, I’ve got the latest news on weed to pass along to my fellow SLPs. In fact, if you were sitting here with me in the privacy of my own home (and you were over 21), we could chat about it while lawfully smoking a joint, munching on an edible cannabis-laced cookie, sucking on a marijuana lollipop or even, inhaling the vapors from an e-cigarette packed with marijuana oil. That’s just a sampling of the options we have to get high in the “mile high city.” Before you shout “I’m coming over!” I should probably disclose that I’m not a marijuana user, medical or recreational. If your next thought is “But I DON’T live in Colorado (or Washington) so this doesn’t apply to me – at least professionally” please read this entire article. Colorado law is considered a “springboard for other states” to legalize marijuana soon. Plus, illegal shipping to other states, often discovered during a routine traffic violation committed by the average Joe next door, has increased significantly. According to the El Paso Intelligence Center & National Seizure System, the mini-vans and SUVs bringing home “souvenirs” from Colorado aren’t just from the states bordering the Rocky Mountains. New York, Florida, Illinois and Wisconsin were some of the most popular destinations and consequently, you may experience some unexpected safety issues if you are providing home-based care for children and adults.

In an effort to educate therapists on the new laws and our responsibility to inform our families of issues that may arise with recreational marijuana use, Jane Woodard, the executive director of Colorado Drug Endangered Children, is traveling the state providing health care professionals the necessary information to keep ourselves and the families we serve safe. SLPs are required by law to report suspected conditions that would result in neglect/safety issues or abuse of children and adults. However, many of our families are simply not aware of the safety concerns and home based therapists are often the first resource for educating those families who choose to partake in using, growing or processing recreational marijuana.

Given the various populations that we serve, here is an overview of some of the safety issues:

Infants: As a pediatric feeding therapist, just one of the populations in my care are babies who require support for breast and bottle feeding. In this Colorado culture of embracing our new freedom, mothers are commenting to me without restraint that they’re using marijuana to combat nausea during pregnancy or enjoy “a little pot now and then” while breastfeeding.Studies indicate that by age four alarming changes occur in children that have had prenatal exposure. It’s noteworthy that the studies focused on a much lower amounts of delta-9-tetrhydrocannibinol (THC: the chemical that produces the psychoactive effect) than what is present in today’s super-charged marijuana products. The children demonstrated “increased behavioral problems and decreased performance on visual perceptual tasks, language comprehension, sustained attention and memory.” Marijuana use while breastfeeding is contraindicated because the THC is excreted into breast milk and stored in fat and is suspected to impact a baby’s motor development. There are no established “pump and dump” guidelines for THC and it stays in the bloodstream for much longer than other drugs. Consider the increased risks from both second-hand smoke and third-hand smoke or the “contamination that lingers” after smoking, including an increased risk for SIDS and more. For the home-based SLP, exposure to second and third-hand smoke or residue means that I will likely carry that aroma with me to the next home. I am responsible for the safety of all of the children I treat, and many are medically fragile and/or have sensory challenges and would be impacted by these odors. Today, I am faced with difficult conversations with parents that I never imagined I would have.

Children: In four short months, from January to April 2014, Colorado’s Poison Control Center has reported 11 children who ingested edibles, one as young as five months old. Over half of those children had to be hospitalized and two were admitted to the ICU. Consider that those are the reported cases – and what goes unreported is difficult to ascertain. While the law requires that the packaging cannot be designed to appeal to kids, current practices are questionable. Some argue that edibles are packaged too much like junk food, with boxes of “Pot-tarts” similar to the popular toaster pastry, bottles of fizzy “soda-pot” and candy bars with labels that rival Mars® and Hershey’s®.  In April 2014, Karma-Candy was the marijuana candy that a father in Denver consumed just before hallucinating and killing his wife, who was on the phone with 911 dispatchers at the time. She could be heard yelling to her kids to go downstairs as she desperately tried to get help for her family.

Packaging of certain products must also be in an opaque and re-sealable container, but that law only applies to the time of purchase. Plus, most edibles contain multiple servings and it’s not unusual for one cookie to serve six people. Even adults are mistakenly eating whole cookies and in April 2014, one visiting college student consequently jumped to his death from a hotel balcony after eating too much of an edible. A New York Times columnist visiting Colorado ate a whole candy bar labeled as 16 servings, and “laid in a hallucinatory state for 8 hours.” Home baked marijuana options are equally confusing. As a feeding therapist, I used to be comfortable offering foods to a child from a family’s pantry. But now, a tempting plate of brownies may be more than just a plate of brownies. By law, edibles, like any marijuana product (even plants), must be in an “enclosed, locked space.” However, it is not unusual for Colorado therapists to arrive for their home visit and find a bong, topical lotions or a half-eaten edible on the living room coffee table. Early intervention and home health care agencies are considering how to educate families on the first day of contact, during the intake process. Susan Elling, MA, CCC-SLP, who treats both children and adults in the home, notes that “It will be very important to have an open and honest conversation with a patient (and their family) regarding marijuana use as part of taking the medical history – just as we do for alcohol and smoking.”

Adults: Ms. Elling reported that “the population in need of homecare services may be more likely to use marijuana to control pain and nausea” because family members are more likely to suggest it and there will no longer be a need to obtain a medical marijuana card. Ms. Elling also notes that marijuana “affects sleep, balance, coordination, and cognition.  This may be amplifying the conditions a patient is already dealing with related to medical issues.  It can also significantly raise anxiety.  These are all factors that increase fall risk, confusion, lead to poor judgment, and can setback a patient’s recovery. It may be very difficult to determine what issues are related to the patient’s medical condition and which are related to the marijuana use.  Interventions, progress and prognosis may be affected.” Edibles in particular are a safety hazard for this population, because of the inability to self-regulate. There is no predicting how an edible will effect one person or another.

“It’s not your grandmother’s marijuana,” reported Dr. Richard Zane, who is the head of the Department of Emergency Medicine at the University of Colorado Hospital. Well-meaning family members, hoping to control their loved one’s discomfort, may not realize that the strength of today’s marijuana is significantly higher than the pot your cool grandma smoked in the 60’s. In fact, THC levels represent a 121% increase just from 1999 to 2010. Family members may not understand that the strength and effect of the drug varies from product to product. For example, compare two hits on today’s joint and an individual will ingest approximately five mg of the chemicals that produce the psychoactive and/or sedative effects compared to up to 100 mg in one packaged edible. Plus, even using the exact same method of ingestion does not guarantee the exact same dosage every time. Zane reported in this interview with Colorado Public Radio that the “drug isn’t always spread evenly through food or candy, so several people eating the same amounts can be ingesting different quantities of marijuana.”

The uncertainty of dosage and effects has Elling on guard: “I am concerned that the high potency, unpredictable effect, easy availability, and unclear dosage information of edibles may have serious consequences for homecare patients with already fragile health. It is also misleadingly considered quite “benign” and safe compared to alcohol consumption and smoking.  I feel the need to know the signs and symptoms of a marijuana overdose and know the contraindications with any other prescription or OTC drugs they may be taking and be able to educate my patients and their caregivers regarding this issue.”

Additional Safety Concerns: In the course of this short article, it’s impossible to cover all of the safety issues, including those related to growing and processing marijuana in the home. These concerns include electrical hazards from impromptu wiring (not to code); cultivation hazards such a mold and poor air quality for medically fragile patients;  increased carbon dioxide and carbon monoxide necessary for growing; chemical exposures and improper storage of pesticides and poisonous fertilizers; THC on household surfaces and airborne exposure; and exploding hash oil labs. From January to April 2014, hash oil explosions occurred on a weekly basis in Colorado, some triggered just by turning on a nearby light switch.

Consider Family Functioning: The impact on safety is the tip of the iceberg. Woodard explained that home health professionals must consider a parent’s behavior when using marijuana, the impact on a child’s behavior and family functioning overall. Difficult but often necessary questions to ask include: What steps have you taken to protect your children and family members? How do you store your marijuana and paraphernalia? What are you like when you use? Most importantly, she recommended asking yourself “Do I believe that the conditions in this home could reasonably result in harm” to anyone in this household? If so, educate the family and be mindful of mandatory reporting laws.

 

Melanie Potock, MA, CCC-SLP, treats children birth to teens who have difficulty eating.  She is the author of Happy Mealtimes with Happy Kids and the producer of the award-winning kids’ CD Dancing in the Kitchen: Songs that Celebrate the Joy of Food!  Melanie’s two-day course on pediatric feeding is offered for ASHA CEUs and includes both her book and CD for each attendee.  She can be reached at Melanie@mymunchbug.com.

Three Reasons Why Kids Get Hooked on “Kids’ Meals”… and How to Change That

chicken

Let me say this up front: I’m not condemning the American Kids’ Meal that is so common in fast food chains and family restaurants, but clearly I’m not keen on eating that type of food when there are other choices.   My own kids have certainly had their fair share of chicken nuggets, mac n’cheese and French fries, just to name a few of the comfort kid foods that predictably reappear on kids’ menus day after day.   This is not a blog about good vs. healthy nutrition, because most parents (including me) know that the traditional fast food fare is not healthy…and that’s exactly why parents want to change the statistics that 15 percent of preschoolers ask to go to McDonald’s  “at least once a day.”    The millions of dollars spent on advertising and toys to market kids meals certainly makes many of us frustrated when much less is spent on marketing a culture of wellness.  By hooked, I don’t mean addicted, although there is research that suggests that food addiction may be a serious component for a subset of the pediatric population Plus, the added sugars in processed foods have been found to be addictive in lab experiments.  But, for the purposes of this short article, let’s keep kids’ meals in this very small box:  Most kids love them.

Why am I writing about this for ASHA? As a pediatric SLP who focuses on feeding, one of the frequent comments I hear from parents is “As long we’ve got chicken nuggets,  then my kid will eat.”   Besides the obvious “just say no” solution, what parents truly are asking is,  “How do I expand my kid’s diet to include more than what’s on a kids’ menu?”  Whether we are considering our pediatric clients in feeding therapy or simply the garden-variety picky eater, that is an excellent question with not a very simple answer.

In feeding therapy, therapists take into account the child’s physiology (which includes the sensory system), the child’s gross motor, fine motor and oral motor skills  and also behaviors that affect feeding practices.  Therapists then create a treatment plan designed to help that specific child progress through the developmental process of eating.  While the nuances of learning to bite, chew and swallow a variety of foods are too complex to cover in a short blog post, here are just three of the reasons why kids get hooked on kids’ meals and some strategies to avoid being locked into the standard kids’ menu and begin to expand a child’s variety of preferred foods:

  1. Kids barely have to chew.  The common fast food chicken nugget is a chopped mixture of …well, if you want to know, click here.  Warning: it will ruin your appetite for chicken nuggets, so if your kids can read,  clicking might be the first solution.  However, in terms of oral motor skills, bites of chicken nuggets are a first food that even an almost toothless toddler can consume with relative ease.  Simply gum, squish and swallow.  Macaroni and cheese?  Oily French fries?  Ditto.  There’s  not a lot of chomping going on!
  • In feeding therapy, SLPs assess a child’s oral motor skills and may begin to address strengthening a child’s ability to use a rotary chew, manage the food easily and swallow safely.  Many of the families we work with eat fast food on a regular basis and we might start with those foods, but slowly over time, more variety is introduced.
  • For general picky eaters or those progressing in feeding therapy, the key is to offer small samplings of foods that DO require chewing, as long as a parent feels confident that their child is safe to do so.  Starting early with a variety of manageable solids, as described in this article for ASHA, is often the first step.   For older kids, the texture (and comfort) of “squish and swallow” foods can contribute to food jags.  Here are ten tips for preventing food jags, including how to build your child’s familiarity around something other than the drive-thru.
  1. At restaurant chains and drive-thrus, kids’ meals are readily available.  Helpful hostesses grab the crayons and the matching kids’ menus as soon as they spot a parent walking in with little children.  Kiddos quickly become conditioned to ordering mac n’ cheese or hot dogs.   Parents want a peaceful, enjoyable experience dining out, so naturally they like the kids’ menu option because it appeases everyone.  But it’s just that–an option.
  • In feeding therapy,  SLPs assess and often treat a child’s ability to be flexible with food at home and in the community.  A hierarchical approach is often utilized, where exposure to new foods occurs as a gradual process over time.
  • As a parent, if your child likes to stick to the same routine at a restaurant, begin with helping your child order from the “adult” menu, knowing that you can request adaptions to certain dishes if needed.  If the prices feel too steep, order a side for the kids, and give them samplings of everything on your plate.  Keep in mind that often the goal is simply experiencing the presence of new foods, so order a side dish that is a favorite food plus present a selection of new options from your plate if you are concerned your child will not eat anything.  Now you and your child have a new routine and the tasting piece occurs once the routine is established.   If you order a salad in the drive-thru, consider skipping the kids’ meal and creating a kid’s sampling of grilled chicken cubes, sunflower seeds, mandarin oranges or other options directly from your salad when you arrive at your destination.   Request an extra packet of dressing if your kids like to dip.
  1. Kids Meals are QUICK! Quick to buy, quick to eat and quick to raise blood sugars and thus, feel satisfied.  I get it – part of today’s hectic lifestyle is shuttling kids to and from activities and often, mealtimes happen while riding in the mini-van.  Fast food chains understand this too – that’s why it’s marketed as “fast food.”
  • In feeding therapy, this reliance on drive-thru food affects progress in therapy.  For example, it’s not uncommon for elementary school kids in feeding therapy to  have trouble eating in the chaotic school cafeteria and be “starving” when a parent picks them up from school.  The quickest, easiest solution: The drive-thru every day after school.
  • In today’s quick-fix society, our children are losing the valuable skill of waiting.  Feeling hungry and then making a snack or meal together to satisfy growling bellies is one way to practice the art of waiting.  Have some pre-cut veggies ready in the refrigerator to nibble on if waiting for the meal is too challenging.  Besides, it’s the perfect time to place them on the counter while your prepping the entrée because you’ve got hunger on your side!  Hint: Blanched veggies, patted dry and then chilled, hold more moisture and taste slightly sweeter to some kids.  The higher moisture content makes them easier to crunch, chew and swallow.  Most blanched fresh vegetables last for several days in the refrigerator.  Remember, keep presenting fresh foods so that the more common option is a healthy one, rather than the oh-so-well marketed processed foods found on many kids’ menus today.

SLPs and parents, what strategies do you use do limit traditional kid food and help kids become more adventurous eaters?  Please comment and share your tips!

Melanie Potock, MA, CCC-SLP, treats children birth to teens who have difficulty eating.  She is the author of Happy Mealtimes with Happy Kids and the producer of the award-winning kids’ CD Dancing in the Kitchen: Songs that Celebrate the Joy of Food!  Melanie’s two-day course on pediatric feeding is  offered for ASHA CEUs and includes both her book and CD for each attendee.  She can be reached at Melanie@mymunchbug.com.

Preventing Food Jags: What’s a Parent to Do?

picky eater

 

As a pediatric feeding therapist, many kids are on my caseload because they are stuck in the chicken nugget and french fry rut…or will only eat one brand of mac-n-cheese…or appear addicted to the not-so-happy hamburger meal at a popular fast food chain. While this may often include kids with special needs such as autism, more than half my caseload consists of the traditional “picky-eaters” who spiraled down to only eating a few types of foods and now have a feeding disorder.  I  even had one child who only ate eight different crunchy vegetables, like broccoli and carrots.  Given his love for vegetables, it took his parents a long time to decide this might be a problem. The point is: These kids are stuck in food jag, eating a very limited number of foods and strongly refusing all others.  It creates havoc not only from a nutritional standpoint, but from a social aspect too. Once their parents realize the kids are stuck, the parents feel trapped as well. It’s incredibly stressful for the entire family, especially when mealtimes occur three times per day and there are only a few options on what their child will eat.

It’s impossible in a short blog post to describe how to proceed in feeding therapy once a child is deep in a food jag.  Each child is unique, as is each family. But, in general,  I can offer some tips on how to prevent this from happening in many families, again, keeping in mind that each child and each family is truly unique.

Here are my Top Ten suggestions for preventing food jags:

#10: Start Early.  Expose baby to as many flavors and safe foods as possible.   The recent post for ASHA on Baby Led Weaning: A Developmental Perspective may offer insight into that process.

#9: Rotate, Rotate, Rotate: Foods, that is.  Jot down what baby was offered and rotate foods frequently, so that new flavors reappear, regardless if your child liked (or didn’t like) them on the first few encounters.  This is true for kids of all ages.  It’s about building familiarity.  Think about the infamous green bean casserole at Thanksgiving.  It’s rare that hesitant eaters will try it, because they often see it only once or twice per year.

#8: Food Left on the Plate is NOT Wasted: Even if it ends up in the compost, the purpose of the food’s presence on a child’s plate is for him to see it, smell it, touch it, hear it crunch under his fork and  perhaps, taste it.  So if the best he can do is pick it up and chat with you about the properties of green beans, then hurray!  That’s never a waste, because he’s learning about a new food.

#7: Offer Small Portions:  Present small samples.  Underwhelming – that’s  exactly the feeling we hope to invoke.   Besides, if a tiny sample sparks some interest and your child asks for more peas, well, that’s just music to your ears, right?  Present the foods in little ramekins, small ice cube trays or even on  tiny tasting spoons used for samples at the ice cream shop.

#6: Highlight Three or Four Ingredients Over Two Weeks:  You can expose kids to the same three or four ingredients over the course of two weeks, while making many different recipes.  For example, here are nine different ways to use basil, tomatoes and garlic.  Remember get the kids involved in the recipe, so they experience the food with all of their senses.  Even toddlers can tear basil and release the fragrance, sprinkling it on cheese pizza to add a little green.   If they just want to include it as a garnish on the plate beside the pizza, that’s a good start, too!

#5 Focus on Building Relationships with FoodThat often doesn’t begin with chewing and swallowing.  Garden, grocery stop, visit the farmer’s market, create food science experiments like this fancy way of separating egg whites from the yoke.  Sounds corny (pardon the pun!), but making friends with food means getting to know food.  I often tell the kids I work with “We are introducing your brain to broccoli.  Brain, say hello to broccoli!”

#4 Don’t Wait for a Picky Eating Phase to Pass: Use these strategies now.  Keep them up, even through a phase of resistant eating.  Learning to be an adventurous eater takes time.

#3 Don’t Food Jag on FAMILY favorites.  In our fast paced life, it’s easy to grab the same thing for dinner most evenings.  Because of certain preferences, are the same few foods served too often?  Ask yourself, are you funneling down to your list of “sure things?”  It’s easy to fall into the trap: “Let’s just have pizza again – at least I know everyone will eat that.”

#2 Make Family Dinnertime Less about Dinner and More about Family.  Why?  Because the more a family focuses on the time together, sharing tidbits of their day and enjoying each other’s company,  the sweeter the atmosphere at the table.  Seems ironic, given this article is focused is on food, but, the strategies noted above all include time together.  That’s what family mealtimes are meant to be: a time to share our day.  Becoming an adventurous eater is part of that process over time.

And the #1 strategy for preventing food jags?  Seek help early.  If mealtimes become stressful or the strategies above seem especially challenging, that’s the time to ask a feeding therapist for help.  Feeding therapy is more than just the immediate assessment and treatment of feeding disorders – the long term goal is creating joyful mealtimes for the whole family.  The sooner you seek advice, the closer you are to that goal.   I hope you’ll visit me at My Munch Bug.com for articles and advice on raising adventurous eaters and solving picky eating issues.  Plus, here are just a few of my favorite resources:

Websites & Blogs

Doctor Yum.com

Spectrum Speech and Feeding.com

Picky Tots BlogSpot

Books

Getting to Yum

Fearless Feeding

Nobody Ever Told Me (or My Mother) THAT!

Facebook

Food Smart Kids

Feeding Matters

Feeding Tube Awareness

 

Melanie Potock, MA, CCC-SLP, treats children birth to teens who have difficulty eating.  She is the author of Happy Mealtimes with Happy Kids and the producer of the award-winning kids’ CD Dancing in the Kitchen: Songs that Celebrate the Joy of Food!  Melanie’s two-day course on pediatric feeding is  offered for ASHA CEUs and includes both her book and CD for each attendee.  She can be reached at Melanie@mymunchbug.com.