# Presentation: 035525

## Feeding Relationships

**New Mexico WIC Program**
**in collaboration with New Mexico State University and Ellyn Satter Associates**
**     ****Esther Devall****	**
**     ****Shirley Jaquez **
**	****Lisa Shields**

## Feeding is a Metaphor

-  For parent-child relationship.
-  For family functioning.

**Notes:**

“Feeding” is a Metaphor for a families relationships.
Metaphor is a figure of speech in which a word denoting one object or idea is used in place of another to suggest a likeness between them.

There is a connection between “Feeding” and the parent-child relationship.  There is also a connection between “Feeding” and the family functioning.  “Feeding” is a reflection of how well or poorly this parent-child relationship or family functioning is operating in the family environment.

## Levels of Intervention

-  Primary
-  Secondary
-  Tertiary

**Notes:**
Primary Intervention
  assist parents in establishing positive feeding
  help solve simple feeding problems
  identify and refer out any families with complicated or long lasting       
   problems Re:  growth, food selection and/or feeding
  this can be accomplished through
             watching video tapes
             reading materials
             facilitated discussion
             nutrition counseling sessions
  when standard solutions don’t work, family is referred to secondary intervention
Secondary Intervention 
  works with parents who are dealing with complicated problems
  parents are able to respond to teaching and problem solving
   accomplished through WIC staff who receive training in secondary intervention
Tertiary Intervention
  assist parents in dealing with long lasting problems
  helping parents with psychosocial and situational issues
  assisting parents so that they can act in the best interest of their child
  accomplished through a referral to a community mental health professional

## Primary Intervention

-  Teach positive feeding.
-  Detect risk.
-  Provide anticipatory
-     guidance.
-  Support parents.

**Notes:**
WIC will work with clients on a primary intervention level, for the most part.  In doing so we plan to:
  Teach Positive Feeding - during our facilitated sessions
  Detect Risk - during our certifications
  Provide Anticipatory guidance - during our certifications, refer to secondary if    
   necessary
  Support Parents - all the time

## Further Interventions

-  Secondary - WIC nutritionists with 		       additional training.
-  Tertiary - referral to therapists    		          in community.

**Notes:**
Secondary Intervention
WIC Nutritionists will be trained to provide additional counseling to the family when the standard solutions addressed in the Primary Intervention have been found to be ineffective or have not worked.

This additional counseling is given to parents who are dealing with more complicated problems affecting the child.

Additional counseling works well if parents are open to and respond well to teaching and problem solving.

Tertiary Intervention
WIC Nutritionists will be trained to identify and refer when parents:
  are dealing with long lasting complicated problems 
  need help with psychosocial and situational issues
  need to act in the best interest of their child

The WIC Nutritionist will assist parents by referrals to a community mental health professional when the secondary intervention is ineffective.  A referral can be made to the community mental health professional immediately, if in the Nutritionist opinion the problem warrants swift action and an immediate response. 

## Issues in Feeding Children

-  Food Selection.
-  Feeding Relationship.

**Notes:**
Shirley’s Notes
Issues of Feeding Children focus around two major areas.  It is very important for parents to consider:
  Food Selection - Good food selection/preparation based on well -balanced meals  
   and snacks
  Feeding Relationships - Positive relationships at all times, especially during     
    meals between the parent and the child lead to harmonious interactions and better   
    feeding for all family members including the child during meals.

Infants and children are, after all, a captive audience in the Feeding situation.  They are completely dependent on the parent(s) and other adults to satisfy their needs for food and a positive environment.

## The Issue in Feeding     Children is Trust

- Children are internally regulated.
-  Require trust to regulate.
-  Ignoring their needs interferes with
-     internal regulation.
-  Ignoring their needs undermines their self-
-     esteem.

**Notes:**
Shirley’s Notes
The critical issue in feeding children is “Trust”
Ellyn says, “ Children have finely tuned mechanisms for determining how much they need to eat, mechanisms that automatically take into account variations in the food they eat, as well as, activity level, growth, metabolism and body chemistry.  This is called regulation.  If we ignore those needs, we can interfere iwht that regulation and ultimately their Self -Esteem.”
Any attempt to control or modify the child’s eating can begin a feeding struggle that can be problematic for both the parent and the child.  Particularly, for the child as they move into adolescence and adulthood.
  When parents become controlling, children lose their capabilities with eating
  Trust encourages Internal Regulation
  Trust that the child will eat enough to survive & they do - studies show that  
   over a week or two, children eat unlikely combinations that add up to a   
   nutritiously balanced diet.
Infants and children eat best when parents provide appropriate foods based on the child’s developmental readiness along with a positive environment.  When this environment does not coerce or limit, they learn to regulate their own food intake.  
If a parent feeds too little, too much or takes too long before responding to the infant cues of hunger, then feeding becomes unpleasant.  The child learns to fight the feeding and/or fight the parent, accommodates hunger or submits to the parents wishes or demands.  
They learn that the parent is in control of the feeding situation which can affect the child’s self esteem.  Feeding becomes disrupted and becomes a negative feeding experience and a negative feeding relationship ensues.

## Regulation Process

- _INTERNAL_
-  Hunger
-  Appetite
-  Satiety

- _EXTERNAL_
-  Calories
-  Food
-  “Shoulds”

**Notes:**
Shirley’s Notes
The Infant/child is guided solely by “Internal Cues”.  As the parent(s) or Adult meets these needs they develop “TRUST”.  If the parent(s) or other adult couple this with a positive environment the infant associates hunger with a pleasant feeding experience.  

As children mature with feeding, they learn “External Cues” for Eating/Feeding Management.  Many adolescents and Adults have learned to manage their eating solely through these learned controls.

Adult who are externally driven eat:
   low fat everything
   count calorie after calorie
   are haunted by what they “should” or “should not” eat
Adolescents and adults that are “externally driven” in their eating and feeding management experience that:
Eating has become a “moral dilemma” and a constant struggle.
They have lost pleasure in eating.

If adults relied more on “Internal cue” for eating and feeding management they would experience that:
Eating is simply, “One of Life’s Greatest Pleasures”

## Children Are Erratic     With Eating

- Food acceptance varies.
- Accept/reject food unpredictably.
- The amount they eat varies.
- They don’t eat a square meal.
- They eat what tastes good.

**Notes:**
Shirley’s Notes
Infants and children instinctively know how much to eat.  They can make up for their own errors in regulation.  They over eat sometimes and under eat sometimes!

  Food acceptance - accept food based on reasons we may not understand  
   (ie  what tastes good, looks good, what they heard on TV or what feels good 
   to them or what they saw you eat) on any given day any given meal
  Accept/reject food - love a certain food, then suddenly refuse to eat it 
   (ie  certain foods cannot touch other food items on the plate)
  Amount eaten - eat an enormous breakfast & snack, then nothing else for the   
   rest of the day
  Don’t eat a Square meal - eat only one or two food items to the exclusion of 
    others (ie  2 cups of Broccoli and nothing else or dessert and nothing else)
  Eat what Tastes Good to them - Very sensitive to likes & dislikes (ie Chicken 
    nuggets every meal for what seems like months)

## Equation for a Good Diet

-            Well Balanced Meals & Snacks
-                                +
-             Positive Eating Environment
-           __________________________
-                =  Well Nourished Child

**Notes:**
Shirley’s Notes

Equation for a Good Diet:

Well Balanced Meals & Snacks  (serve well balanced Meals & snacks & let the child choose)
                    +
Positive Eating Environments     (assure that family mealtime and other time is pleasant)

                    =

Well Nourished Child          (Happy Healthy Child)

## Division of Responsibility

-  Parent:    What
-  Infant:     How Much and Whether
-  Parent:    What, When, and Where
-  Toddler:   How Much and Whether

**Notes:**
Infant - first 6 months
Parent does very little decision-making regarding “Feeding”
Parent decides whether the child is breast fed or bottle fed
Parent decides what goes into the bottle
Parent devotes themselves to the child
Parent works with the child to keep them calm & happy
Parent must feed in a fashion that allows the child to be successful at feeding (vacuuming)
Child runs the feeding - Parent allows the child to determine
Tempo, Timing, Frequency, Level of Skill
Toddler
Different from infant
Figuring out that they are separate form their parent(s)
A strong need for autonomy plays out in oppositional behaviors
Need limits and structure – also true with feeding
The division of responsibility changes
Parent gradually helps their child move into a feed regularity
Help the child move to a meal plus snacks routine at the family table
The family table is a valuable part of this transition (society has moved away)
Allows the child to fit into the family meal time
Setting the stage for the parent to provide the what, where and when of the FR
The child is responsible for:
How much they eat
Regulating the quantity of their food intake
Whether or not they eat what the parent has made available

## Parent’s Tasks

- Choose and prepare food.
- Have regular meals and snacks.
- Make eating time pleasant.
- Provide mastery expectations.

**Notes:**
Division of Responsibility:  Depends on some assumptions about the parents tasks

Parents tasks:
  Parent is responsible for choosing and preparing regular meals and snacks
  Parent is responsible for making the meal time pleasant
  Parent is responsible for holding some mastery expectations of the child 

If the parent does this, the child will:
  Have considerable capabilities with eating, eating is an innate capability
  to manifest these capabilities the parent must fulfill their tasks.

## Children’s Eating     Capabilities  

-  Children will eat when
- 	 hungry.
-  They know how much to
-      eat.
-  They will eat a variety of
- 	 foods.
-  They will grow predictably.
-  They will mature with
- 	  eating.

**Notes:**
Parents need to internalize the concept of Division of Responsibility (this can be difficult for some)

Parents must trust the children will eat
     without prompting (don’t forget to eat your vegetables)
     forcing (eat everything on your plate or you get no dessert)
     bargaining (make mommy happy and take one more bite)
Children know how much to eat
     due to their internal regulators
     that tell a child when they are hungry or full
     many adults have abandoned these internal regulators (Thanksgiving)
Children will eat a variety of foods
     if they are made available to them
Children will grow predictably
Shirley will cover this in depth later on in the training
Children will mature with eating
     gain new eating skills
    develop a taste for a variety of textures and flavors   

## Developmental Stages

-  Homeostasis – Birth to 3 months.
-  Attachment  -  3 to 6 months.
-  Separation-Individuation - 6 months to 3
-     years.
-  Initiative  -  3 to 5 years.

**Notes:**
Esther’s Notes:

Four stages, birth to 5 years

Goals of each stage vary

Feeding needs to be in tune with the developmental stage.

Discuss handout:  Developmental Principles Guiding Feeding

## Developmental Stage

- Homeostasis  (Birth – 3 months)

**Notes:**
Esther’s Notes

Homeostasis - Regulate states (asleep, awake, fussy and alert)

Newborns sleep 18 - 20 hours a day and cry 2 -3 hours a day.

## Parent’s Tasks in       Homeostasis

-  Calm and organize.
-  Respond to infant cues.

**Notes:**
Esther’s notes:
1.  Help child wake up and stay calm
2.  Pay attention to cues
3.  Cues are of 2 types - engagement and disengagement
4.  Responding to cues develops trust in the baby.  Ignoring their needs 
     interferes with regulation and homeostasis
5.  For infants, feed on demand.  They are not hungry on a rigid   
     schedule.
6.  Feeding is an important organizer for babies.  Feeding interactions propel them form a state of isolation and self-absorption to active engagement with other people and the world.
Go over handouts:
1.  Control of Feeding (RM 8)
2.  Show Video of Colleen and Megan
     How did they share control of feeding? (RM 8)
     Discuss what interferes with homeostasis 
       Scheduled feedings                         Propping bottle
       Difficult temperment                         Sick baby
       Premature baby	            Drugs during Pregnancy
3.  Discuss Handout
      How to Feed Your Baby (RM 6)
4.  Show Video of Sandra and Patrick
      Analyze with How to Feed Your Baby (RM 6)

## Developmental Stage

- Attachment  (3 – 6 months)

**Notes:**
Esther’s Notes
1.  Attachment - connect with caregivers  “Falling in Love”

2.  Very important to later development that infants form a secure attachment instead of an 
     anxious attachment.  Related to school performance, peer relations, job success, and later
      intimate relationships

Secure

Secure Base
Curious, Explores
Able to relate well to others

Anxious

 Afraid to explore
 Feel abandoned or rejected
 Can be clingy or aggressive
 Doesn’t have energy or desire for other relationships

## Parent’s Tasks in      Attachment

- Maintain reciprocity.
- Engage child.
- Modulate arousal.

**Notes:**
Esther’s Notes
1.  When the baby smiles - parent needs to smile back
     When the baby coos or makes a noise, the parent needs to talk back
2.  Eye contact and physical closeness help foster attachment.
3.  Respond to cues appropriately
4.  Can’t spoil a crying baby.  Cry less at older ages if respond quickly to distress
5.  Help child not to get too distressed or over-stimulated

Go Over Handouts  
   Control of Feeding (RM 8)
Show Video of Mona and Myrna
    Discuss using Control of Feeding ( RM 8)
Show Video of David and Matt
    Discuss what interferes with attachment 
           Parent’s agenda for eating,sleeping and growing
            Child temperament is difficult
            Prematurity
    Discuss using Control of Feeding ( RM 8)
Discuss Handouts
    Starting on Solid Foods (RM 11)
    How to Feed Your Baby Solids (RM 12)
Show Video of David and Matt
    Analyze using How to Feed Your Baby Solids ( RM 12)

## Developmental Stage

-  Separation–Individuation (6 months – 3 years)

**Notes:**
Esther’s notes

1.  This is the stage where the infant tries to establish autonomy.
2.  Realize they are a separate person
3.  Want to do things for themselves  (hold spoon, pick up food)

## Parent’s Tasks in     Separation-Individuation

-  Provide opportunities to explore.
-  Support autonomy.
-  Provide structure.
-  Set limits.

**Notes:**
Esther’s Notes
1.  Make it safe for child to explore
2.  Give choices where appropriate
3.  Let them try to do things for themselves
4.  Discipline by redirecting, distracting, time-out
     Physical discipline is not appropriate
5. Can follow simple rules
6.  No longer feed on demand after 12 months
7.  Period of many transitions
    Bottle to solids
    Demand feeding to meals  &  snacks
    Attachment to separation
    9 months seems to be the highest incidence of non-organic failure to thrive
Discuss handouts
    Feeding Children (RM 21)
Show Video of Elsa and Parents
    Analyze using Feeding Children (RM 21)
Show Video of Andrew and Caregiver
    Discuss using Feeding Children (RM 21)

## Developmental Stage

- Initiative  (3 – 5 years)

**Notes:**
Esther’s Notes
1.  Stage of learning and doing
2.  Get ideas and follow through
3.  Proud of learning new skills

## Parent’s Tasks in Initiative 

- Make maturity demands.
- Have realistic expectations.
- Remain present and available.
- Support without intruding.

**Notes:**
Esther’s Notes
1.  Expect more mature behavior
2.  Realize still a young child with lots to learn (how to eat Spaghetti, share toys)
3.  Be supportive of efforts and interests
4.  Try not to take over activities (participate and support, not direct)

Discuss Handouts
    How to Feed Your Preschooler  (RM 23)
    Feeding Children (RM 21)
Show Video of Laurie and Children
    Analyze with Feeding Children (RM 21)
Show Video of Adam and Parents
    Analyze using Feeding Children (RM 21)

## Feeding Periods

- Early Infancy - Nipple feeding.
- Late Infancy - Transition to solids.
- Toddler - Modified adult foods.

**Notes:**
Esther’s Notes

Feeding Periods
    0 - 6 months:  Nipple Feeding
    5 -  12 months:  Transitions to Solids
   10 months on:  Modified Adult Foods

1.  Overview of stages in moving from drinking to eating

Discuss Handouts
   Eating Skills
   What Should You Feed Your Baby?  (RM 9)

## Eating Skills in     Early Infancy

- Roots for nipple.
- Sucks.
- Swallows.

**Notes:**
Esther’s Notes

1.  Basic Reflexes
2.  Some infants may have physiological problems (cleft palate, poor suck)
3.  Premature infants may have less developed reflexes

## Eating Skills in     Middle Infancy

- Begins sitting.
- Follows food with eyes.
- Lips close over spoon.
- Moves semi-solids to
-    back of tongue.
- Swallows semi-solids.

**Notes:**
Esther’s Notes

1.  Avoid starting solids before infant is able to sit up and to swallow
2.  Take it slow while feeding
3.  Young children often gag as they learn how to swallow food

## Eating Skills in     Late Infancy

- Tongue moves food to side of mouth.
- Positions food In mouth.
- Delays swallow.
- Munches.
- Palms food.
- Scrapes food into mouth.

**Notes:**
Esther’s Notes

1.  Able to start feeding self (cheerios, bits of cheese or banana)
2.  Don’t worry about it being messy.  Take off clothes, put down plastic, bathe  
     afterwards.

## Eating Skills in Toddler         & Preschool Years

- Chews.
- Moves food around in mouth.
- No pause in side-to-side transfer.
- Begins to use utensils.

**Notes:**
Esther’s Notes
1.  Can eat foods that require more chewing
2.  Can feed self using spoon or fork, but will often use hands

## Child Characteristics That       Risk Feeding

- Difficult temperament.
- “At risk” or very small.
- Eats very large or very small amounts.
- Illness.
- Prematurely born.
- Physical or cognitive limitations.
- Requires a modified diet.

**Notes:**
There are some child characteristics that increase a child’s risk for feeding challenges:
Temperamentally negative or standoffish
hard for a parent to interact with
doesn’t give the parent very much encouragement
hard for the parent to know  if their being successful or not
doesn’t know where they are with the parent/child relationship
At Risk or very small child
increased the parents anxiety which results in the parent trying too hard
at risk of attempting to control the feeding relationship
can really backfire (Chatoor example)- make the problem worse not better
set up power struggle between child and parent in which no one wins
Eats very large or very small amounts
any child who is performing on the extremes, even if it is normal, may cause parent
 to become alarmed and therefore overcompensate
strong desire to try to reel the child toward the middle
Child that has been ill
fear that they may lose this child; this fear may easily translate in to a parents active attempt to rescue their child
type of stress is extremely difficult and is a big factor feeding risk
Child that was prematurely born
tend to be harder to settle down
may be harder to read their cues
more difficult to get on the same wave length
are smaller and many times given labels (failure to thrive)
Neuromuscular or cognitive limitations	
are our special needs kids
have a history of needs for secondary interventions
The child that requires a modified diet
a diagnosis for example diabetes or heart disease
very easy for a parent to step in and regulate the child’s eating

## Parent Characteristics         That Risk Feeding

- Over-active, too stimulating.
- Under-active, not engaging.
- Chaotic or disorganized.
- Rigid or over-controlling.
- Over-concerned about child’s food    selection or weight.
- Under-concerned about child’s food selection or weight.
- Has a particular agenda for growth.

**Notes:**
Parents that is overactive, too stimulating
may become too stimulated and not be able to eat well
may go to the other way and retreat and go underground and sort of shut the parent out
Parents that is underactive and not engaging
Some children will lose interest in the interpersonal interaction with the parent in order to be involved with eating, the child needs to be involved in that interpersonal interaction
Parents that are chaotic or disengaged
this type of eating environment makes it hard for a child to eat
child is going to be erratic and coupled with chaotic parent the child has no stable foundation to work with
child can become frightened due to the lack of predictability in their life 
children need to know where their next meal is coming from an feel certain that they will be fed consistently and at certain times
children depend on this predictability to feel safe and fulfill their emotional and social needs
Parents that are rigid or over controlling
likely to intrude on child’s eating
depends on the child as to how this translates into eating
Parents that are over concerned about child’s diet or weight
may over react to every blip in the growth chart
parents may even have their own issues about their own weight
Parents that are under concerned about the child’s weight
may hamper their ability to follow  through on the parents tasks regarding feeding
Parents that have a particular agenda with growth
“my child is going to grow up to be a big strong football player”  

## Factors In Growth 

- Medical.
- Psychosocial.
- Feeding Relationship.
- Nutritional.

**Notes:**
Shirley’s Notes

1.  Growth is an overall indicator of  good Health 
2.  Factors to consider in growth or lack of growth:
       Nutritional - Nutrients work in combination with each other for optimal growth & health
       Medical - Medical conditions and/or diseases can affect growth and health
       Psychosocial or Emotional - Mental and emotional state can affect the body’s growth and  
                 health
       Feeding Relationships - Interactions around “Feeding and Eating” can affect the body’s 
                 growth and ultimately, health
3.  If all these factors are within normal limits than the child will grow to it’s predestined growth  
      potential - “Heredity”

Children have a natural way of growing that is right for them.  They know how much they need to eat to grow that way.  If parent(s) do their job in feeding and if they let the child decide how much they want to eat, the parent doesn’t need to worry about the child growing normally - it will happen!

## Growth Patterns

- _Normative_
- Consistent
- Smooth
- Gradual changes

- _Divergent_
- Unpredictable
- Uneven
- Dramatic changes

**Notes:**
Shirley’s Notes
Normative - Normal, smooth, gradual, modest (< 2 S.D.)
Divergent - Abnormal, extreme change, rapid (> 2 S.D. in either direction)

Importance of Growth Charts:
1.  Actual % - iles do not matter!  What matters is that there is consistent pattern of  
     growth or a smooth/gradual pattern of growth.  Do not over react & become     
     compulsive at every variation. 
2.  Comparing a child to other children is not important - what is most important is 
     comparing a child to himself....Ht/Wt chart
3.  Some infants have “catch up” growth if they were born early or small at birth
4.  Some infants have “slow down” growth if they were big at birth
5.  The child’s “true growth” pattern does not appear until age 12 month.
6.  A child’s growth adjusts in the first 7 years to the average of his parents height
7.  Slowly crossing percentiles can be normal.  Once the growth pattern is established
      that is where they are likely to stay.
   A child whose growth is consistent at trhe 5th %-ile is just as appropriate as a child whose growth is consistently at the 75th %-ile.  This is not like a grade in school, where 75 th %-ile is better than 25th %-ile.
   Since growth is statistically unusual in the child with 5th %-ile & 95 %-ile growth, we tend to become vigilant as parents & health care workers.  Is it consistent?  Monitoring that growth is merely a verification that that growth is appropriate & predictable

## Feeding Relationships in      WIC Clinics

- _Certification_
- Risk factor.
- Nutrition goal.
- One-on-One counseling.
- _Nutrition Education_
- Facilitated discussions.
- _Additional Counseling_
- Primary or secondary intervention.

**Notes:**
Shirley’s Notes
Feeding Relationships in the WIC Clinic
Certification - During certification 
 1.  Identify Risk Factor 425 - Inappropriate Feeding Practice for Children by using the Feeding Relationships 
      Assessment Tool
 2.  Counsel one-on-one with Parent(s) on Primary Intervention techniques when a child has been identified with 
      an Inappropriate Feeding Practice
 3.  When a more serious or complicated Feeding problem is identified, refer to a trained WIC professional for 
      counseling with Parents utilizing Secondary Intervention techniques.
 4.  Assist the parents in identifying Nutrition Goals in the parents own words that are realistic to what the parent 
       to what they can manage given their resources and abilities related to   “Division of Responsibility”
Nutrition Education - During Facilitated Sessions
1.  Facilitate nutrition education sessions continually with as many clients as you can sharing and facilitating the 
     Feeding Relationships philosophy and key components with parent(s) in a group and individual settings. Utilize 
     the new open-ended questions around Feeding Relationships in your Facilitated Nutrition Education sessions
One-on-One Counseling 
1.  Counsel one-on-one with Parent(s) utilizing Primary Intervention techniques when a child has been identified 
     with an Inappropriate Feeding Practice and the time allotted during certification was not enough to counsel the 
     parent
Secondary Intervention Techniques
1.  When a more serious or complicated Feeding problem is identified the trained WIC professional will counsel 
     with Parents utilizing Secondary Intervention techniques in one-on-one counseling sessions.
Tertiary Intervention Techniques
1.  When a serious long lasting problem of a  Psychosocial or emotional nature is identified, refer to a community
    Mental Health Professional.

## Concept Map of Feeding   Relationships 

**Division of Responsibility**

**Child’s Responsibility**

**Parent’s Responsibility**

**Infant:****	****How Much & Whether**
**Child:****	****How Much & Whether**

**Infant:****	****What**
**Child:****	****What, When, & Where**

**Notes:**
Shirley’s Notes

This Concept Map depicts the clear and very strong connection between Feeding Relationship and Division of Responsibility.  It delineates the Responsibility of the Child and the Responsibility of the Parent.

This can be a good tool for use in Bulletin Board Education.

It can also be used in Facilitated Nutrition Education Discussion sessions utilizing 
  open ended questions related to the Feeding Relationships Philosophy.

This message is a very powerful message in “improving the health of young children by improving parents’ feeding knowledge and skills through Facilitated Nutrition
Education discussions”.