Carrots and apples and cookies, OH MY!

Dear parents of young children,

We need to talk about choking.

I know many of you are nervous to give your tot foods he can hold in his hands when you spend most of your day diligently chasing him to make sure he does not put small items in his mouth. It's scary and it's confusing! "How can I give my child a cracker when he might choke on a block the same size?!" "How can she possibly chew fruit with no teeth? "She gagged on a cracker so she’s not ready!" "It's dangerous..."

I know it's scary. I know because you tell me. As a feeding therapist and a friend to many new parents, I have listened to these fears. I also see it in your eyes when I suggest trying a piece of fruit or a cracker for the first time. I hold your hand and reassure you as we watch your cherub explore the new solid. We watch your baby scale his first of many new mountains and stumble and get back up. It is no doubt scary.

However, there is a difference between scary and dangerous.

I know I can't possibly understand what it's like to give a child of my own something so potentially dangerous! That’s true, but I can tell you that I have watched someone I love choke. My mother choked on a cookie while we were walking in a mall when I was 12. It was terrifying. I started screaming and a Good Samaritan gave my mom the Heimlich to expel the piece of white chocolate macademia lodged in her trachea.

Why are you telling me this horrible story while telling me not to worry about choking?!

First, to tell you that I understand why you are scared, the fear of choking is real and visceral. I get it.

Second, to make a plug for taking a first aid and CPR course so you know what to do 'God forbid' something does happen to your child or anyone else around you. (Thank you to that Good Samaritan at Garden State Plaza in 1995 whoever you are!)

Third, to point out that choking can happen at any time and at any age, but certain circumstances make it more likely. I know you are concerned about giving your 1-year old a cracker, but I am much more worried right now about your 3-year old walking around with a bowl of grapes** or running while eating fruit snacks. If you want to implement one rule that will help reduce your child’s risk of choking, try my favorite rule: "You sit when you eat". Your toddler can eat snacks or run around but not at the same time. Your preschooler can try eating a carrot like a rabbit but not while hopping around like one. She can sit on your lap, a couch, a park bench or the ground! She just needs to be sitting.

I know that children don't like rules we don't follow ourselves. (You could try to implement it as a household, which would probably be the latest fad diet since it reduces snacking. However, it's probably not very realistic in our harried lives).Your rules do not have to apply to you though. There are kid rules, and that is okay! You do not have to hold an adult's hand when you cross the street because you are one. Likewise, you don't have to sit while you learn to eat because you learned to eat; your children are still learning!

Eating takes a lot of cognitive effort and attention before it becomes automatic. Your child needs to focus his attention on the act of eating and all the oral motor skills and sensory integration it requires. Like with any other complex motor activity, mastery requires experience. Which brings up my last point, the Herculean task of eating takes practice.

Practice with different textures and sizes of foods helps your child learn how to control his tongue and more safely navigate food around his mouth. Jarred “babyfood” does not give him this practice. If your child does not encounter solid foods until he is 16 months, he is not going to magically know how to control it in his mouth because he is chronologically older.  He increases his skills through practice. Improved skills mean safer eating and lower risk of choking!

Practice won’t always be pretty. When a child learns to ride a bike, she will often fall off several times. Likewise, you will watch your child spit, sputter, gag and maybe vomit. However, gagging is not choking. Gagging can look scary, but it is amazingly protective! Eating safely means that a child learns how to get food out as much as she learns to chew and swallow safely. The gag reflex on an infant is much closer to the front of the tongue than ours is, and it is only through mouthing objects and foods (experience!) that the gag reflex migrates further back on the tongue and ultimately to the back of the throat.

So, if you offer your child a new food and she starts gagging, sit on your hands for a moment and let her practice getting it out before rushing in to help. Put on your best flight attendant face (the one that hides your fear inside) and then celebrate her trying a new food! Your tot will most likely react to your concern more than her gag reflex, so try your best to stay positive and cheery even if you are flailing on the inside. There is a lot of research that confirms just how reactive a child is to your emotions (check out Joseph Campos’s work https://www.youtube.com/watch?v=p6cqNhHrMJA). Your tot may not try a new food simply because your facial expression is saying “Beware!”.

Parents, I know how little support there is for you in this endeavor. I do not mean to belittle you or to make light of the task of feeding. It is difficult and scary, and I have the utmost respect for how hard you work and how much you love your child! I wish I could be there for each of you to hold your hand through this, but do not be afraid to ask for help. Ask a family member, a friend or a neighbor to be there next to you while you give your infant a new food; you will feel better knowing you are not alone! Also, ask questions about feeding to other parents or the teachers at your child’s daycare. Feel free to write or call me with questions as well. It takes a village!

Sincerely,

A caring and concerned OT

** As mentioned in previous post, certain foods are greater hazards than others.http://pediatrics.aappublications.org/content/125/3/601

American Academy of Pediatrics (AAP) has listed these foods as particular risks: Hot dogs hard candy, peanuts/nuts, seeds, whole grapes, raw carrots, apples, popcorn, chunks of peanut butter, marshmallows, chewing gum, and sausages

However, by cutting them appropriately, making sure your child is always sitting while eating/snacking and helping to model safely biting and chewing these and other foods, your child can learn to manage new foods safely.

The Forgotten Milestones

With social media, it is hard to miss the baby milestones of your friends' cherubs. It is so cute to watch a baby's face as he realizes he successfully managed to mobilize independently even if clumsily toward a favorite toy or parent. Who does not want to cheer like their favorite athlete just won a gold medal after a Herculean effort? Even more exciting, is to watch the proud expression on his parents' faces. Crawling! Walking! Milestones indeed.

2 years old and trying salmon sushi and teppanyaki! 

However, there are other milestones that are less obvious, less celebrated and nonetheless important. I might argue more important. Barring some motor-specific diagnoses, the large majority of toddlers will walk. They may make take first steps later than their age mates (which I know feels important at the time), but by 4 years or 6 years old, it is hard to distinguish the 1year old walker from the 15 month old walker. I taught first grade, and I had no idea which of my students were 'early' walkers and which were 'late' walkers. They were walkers. They were jumpers. They were players. But some were not eaters.

There are milestones in eating, but these are often uncelebrated, taken for granted or neglected. This is not to place blame on parents. We talk as a society about 'learning to walk' and 'learning to talk', but how often do we talk about 'learning to eat'?

 I went to a fantastic 4-day training on feeding assessment and therapy using the SOS method delivered by Kay Toomey, Ph.D. and Erin Ross, Ph.D. As a clinician, I found the information and strategies very useful and could immediately apply the techniques in the clinic. However, my biggest takeaway from the conference is that most parents have no idea of what they are doing or not doing when it comes to feeding! This is no fault of their own. How could they? We put food in our mouths, chew and swallow, don’t children do the same?

 Broadly, we as a society have very little information and/or reverence for the difficult process that is eating. We don’t understand that it is a learned not acquired or innate set of skills. People make comments about French children and how they eat everything and cookbooks have been written to “get your baby to eat like a bébé”, but it really comes down to this- French babies learn to eat and often American babies don’t. French people understand it is a process to know and to manipulate and to make sense of different foods and textures in their mouths and have a department in the government and national curriculum dedicated to teach these things! We don’t.

 Children come into the world with a sucking reflex and several other primitive reflexes that keep them on autopilot for the first couple of months while we [as adults] figure out what we are doing. By the time sucking starts to become voluntary (~3months) their sucking has changed; they actually have learned to do a more mature and efficient suck rather than a suckle to get milk. They learn and practice by doing and they improve!

 Children do not automatically move their tongues and their jaws in a coordinated fashion. They do not innately know to take bites off of larger foods. They do not know how to grade the pressure of each bite of food by looking at it (otherwise babies wouldn’t bite on the spoon!)… They watch, they mouth, they experiment, they play, they gag and they learn!

By 18- 24 months, children should have all the necessary motions and movements to manipulate any food that comes their way. They may not be perfectly efficient, and they will continue to refine their jaw motions and learn to chew with closed lips. They will gain speed. However, they should be able to bite, chew and hopefully swallow all the foods that are sitting on your lunch or dinner plate. They should ideally try (taste, bite, chew) at least 85% of the foods that are put in front of them.

However, many factors have conspired against us/them and taken away lots of primary learning and practice opportunities. We are busy. We are eating on the fly. We are scared of choking**. We are dieting. They are stubborn. They are picky. There are kid’s menus. There are pouches. There is little support for parents around feeding. There are 1000s of different kinds of spoons, plates, cups, etc. The list goes on…

Here’s the upshot. Given the same reward (let’s say a $100 bill), would you choose to run 100 yards or a mile? You are going to choose the path of least resistance and so is your child! Your toddler is picking goldfish crackers and frozen chicken nuggets not just because of the simple and delectable flavors, but because he is smart!  1.  It is easier to chew reprocessed meat and dissolvable crackers than real foods like chicken and carrots. 2. Chicken and carrots always change- the flavor, the consistency, the size, the dryness, etc. Given your choice of a $5 coffee, do you gamble or go with the grande skinny 2-pump hazelnut latte that will taste the way you are expecting? If your child hasn’t had much practice with new foods, he is going to steer clear and stick to what is safe. If he hasn’t practiced eating ready hard or chewy foods, he isn’t going to waste his time and energy on a bite of steak or piece of apple. And if he does, he will probably spit it out because he has not figured what to do with it in that black hole that is his mouth (can you see your own mouth while you eat?). 

In this first post, I haven’t done much in the way of addressing the problem but just outlining it. There are many small things that you can do from the time your child is very young (7-9 months!) to help avoid trouble down the road. There are things that you can do now with your 2- or 4- year old to start helping them catch up on practice and exploration they have missed. I will go over strategies in future posts. But for today, you can start by posting photos of your children exploring foods on your plate, spitting out new foods and making messes, and you can like and comment on the photos of your friend’s little tots doing the same! Celebrate these milestones!

** Choking is a real hazard, and certain foods are greater hazards than others. http://pediatrics.aappublications.org/content/125/3/601

American Academy of Pediatrics (AAP) has listed these foods as particular risks: Hot dogs hard candy, peanuts/nuts, seeds, whole grapes, raw carrots, apples, popcorn, chunks of peanut butter, marshmallows, chewing gum, and sausages

However, by cutting them appropriately, making sure your child is always sitting while eating/snacking and helping to model safely biting and chewing these and other foods, your child can learn to manage new foods safely.