Eating and Drinking – Five Steps to Function Booklet

Sefton Community Children’s Occupational Therapy

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What are the ‘Five Steps to Function’?

Occupational Therapy is all about function! Through purposeful activities, occupational therapists can support and help children and young people achieve their goals in daily life.
The following five steps are steps to consider when completing any activities with your child:

1. Promote independence
   Whenever possible, children should be encouraged to take part in activities, whether it is for the whole activity or part of the activity, so they are taking responsibility for their actions and developing their independence.
2. Develop skills
   All activities that your child takes part in will develop their skills. Activities that are familiar can become more fluent or faster, and new activities present challenges that so children can make sense of them, problem solve and learn to adapt to achieve success.
3. Increase confidence and self-esteem
   When children try something new and are successful, or gain success through practicing an activity they have been trying for a long time, their confidence increases. This is especially true when children feel that their peers are able to do something that they cannot. This sense of achievement helps children when trying other new activities, as they can reflect and be reminded of their previous achievements.
4. Make activities meaningful
   When activities are meaningful to a child they are more motivated to try them. Activities that are themed around your child’s interest can make a big difference to their enthusiasm! If your child is old enough, they can talk with you about what they want to achieve and set goals themselves. This could be making a sandwich, riding a bike, or simply doing an activity without having to ask for help.
5. Have fun!
   One of the most important parts of learning something new is that it is fun! Children are much more willing and motivated to participate in activities that are fun. Whilst new activities can lead to frustrations, stay patient and relaxed. Encouraging your child to keep trying even when they have made mistakes is important skill for them to learn.

Why are eating and drinking skills so important?

Eating and drinking are an important part of self-care and developing independence. Self-care skills are the everyday tasks children do and are often called Activities of Daily Living (ADL’s).
Eating and drinking are two of the most important things children do for their health and development and are complex skills that require your child to use lots of different skills at the same time to be successful.

• Oral Motor Movement: Your child must be able to move their lips, cheeks, tongue and jaw, to chew and swallow effectively.
• Active Movement: Your child must be able to move muscles voluntarily in order to move their trunk (stomach and back) and limbs (arms and legs).
• Joint Mobility: Children must have full voluntary movement in all their joints.
• Co-ordination: Your child must be able to co-ordinate and plan movements to be able to stabilise their joints, use their eyes, arms, hands and fingers, and mouth together.
• Balance and stability: Your child should be able to maintain sitting and standing balance, and have stability in their core (stomach and back) and pelvis (hips) to sit upright with postural control (without support).
• Arm and hand control: Children should have a hand preference, be able to use both hands together (bilaterally) and be able to use their hands in a lead-assist way (one hand leads, the other supports).
• Reach and grasp: Your child must be able to reach and grab cutlery or their cup and maintain their grasp whilst they move it to their mouths.
• Visual perception: Children must be able to see where their food and drink is in front of them and process this in relation to their hands, and also be able to identify different objects
• Sensory development: Your child must be able to respond to different sensations, textures, and smells e.g. different foods and drinks.
• Body awareness: Children must have an awareness of their own body, and where it is in space. They must be aware of the two sides of their body and an understanding of their midline (middle of their body) and be able to cross it effectively (left to right and vice versa) to pick up items and move them to their mouths.
• Proprioception {pro-pri-o-cep-tion}: Your child must have the ability to judge the force they are using to cut up food items, balance food items on cutlery, or pick up a cup with liquid in it.

Where to begin?

Sharing a meal is an important part of family life, but for children who have difficulties with their coordination it can cause anxieties, embarrassment and sometimes leave a big mess to clean up.

Feeding is a complex activity which involves various textures and smells, and is often the source of frustration for both parents and children. Some children find eating with a knife and fork so difficult that they refuse and eat with their fingers. Others avoid the table completely, or only eat a limited amount of food.

The following tips might help to improve your child’s difficulties with eating and drinking, not just in the house, but also when eating elsewhere and hopefully minimise avoidance behaviours your child may use.

Seating

Good seating and sitting position can make all the difference to helping your child with their eating and drinking skills. A seat that is too big can make it harder for your child to maintain their stability as their feet will not reach the floor. Equally, a chair that is too small can be uncomfortable, especially if it means your child isn’t high enough to reach the table or more importantly their food properly!

Using cutlery requires your child to use both hands together. This is made easier if your child is sat at a good height at the table, with support under their feet, which gives them a stable base.

Helpful tips:

• Make sure that your child has their feet flat on the floor or put a box under their feet if they cannot reach the floor.
• If the chair is too low for the table, think about a cushion or a book for them to sit on to raise them to the correct height to access the table.
• Non-slip matting can be placed on the seat so your child does not slip down into a slumped position and reduces them moving around in their seat as they eat, which can become an unnecessary distraction. (Non-slip matting can be bought in most home stores or online.)
• If there is more than one child at home, think about a smaller table and chairs for them both to share.

Cutlery and Plates

The secret to cutlery is the grip. Cutlery that has an obvious place on them for your child to place their index fingers can help your child to use the correct grasp, and is also helpful when turning the knife blade and the fork prongs.

Helpful tips:

• Tommee Tippee range of cutlery can be used for small hands
• Caring Cutlery can be used for older children. (Ask for purchase details from your child’s OT.)
• Initially place the cutlery into your child’s hand. If your child is struggling with two pieces of cutlery, start off with just one.
• If your child has difficulty bringing the food to their mouth, start with a spoon and a bowl. Don’t overload the spoon as this makes it harder for your child to be successful.
• Once your child is confident with this then replace the spoon with a fork. Practice stabbing different sizes and textures of food making sure that the plate is directly in front of your child.
• If the dish is moving away from your child, try using a non-slip mat underneath it.
• Practice with the knife by first using playdough. Ask your child to roll out a sausage shape. Ask them to hold it on the table with one hand to secure it then cut it with a knife. Always supervise your child when they are doing this activity. As your child’s confidence grows, reintroduce the fork to secure the playdough instead of their hand.
• Check that your child is holding the cutlery properly. The grip does not have to perfect at first, but it must be effective e.g. the knife and fork the correct way up. A picture card showing how to hold the cutlery can be helpful.
• Encourage your child to stab their food with a fork so that the curved edge is facing down. They can then use this as a guide for the knife to follow to help them cut their food.
• Finally, introduce different texture foods to stab and cut.
• A deep lipped plate or a plate guard can help food to stop slipping off the plate.
• Cutlery handle length is important. The longer the handle, the harder it is to control so choose cutlery that is appropriate for your child’s age (and hand size).
• Whilst novelty cutlery is fun, some are not balanced and easily tip off the plate making it harder for your child to use them.
• Thick handles allow more control. If you are unable to buy this type of cutlery, you can thicken up regular cutlery by adding some padding around it such as pipe lagging cut to size.
• Encourage your child to take their time, and think about each stage of the process. A picture card on the table next to them can be a good prompt for them to check.
• Expect some untidy cutting and tearing of food to at first.
• If your child will accept some physical help:
  • Stand behind them and help the hand holding the fork to stay still. Your child can then move their own hand with the knife forwards and backwards.
  • Stand behind them and help the hand holding the knife to move forwards and backwards. Your child can use their other hand to hold the fork still.
• To increase the pressure being used, encourage your child to place their first finger (pointy finger) on top of the cutlery, rather than wrapping their whole hand around the handle. Before your child picks up their cutlery, ask them ‘Are your pointy fingers ready?’ as a prompt for hand position. You may need to demonstrate this to them the first few attempts.
• Do not expect your child to practice more than one or two cuts at each meal. It is important that mealtimes do not become times to be dreaded.
• Use as few words as possible and leave time between your comments to allow your child to process the information and make any changes or movements if needed.
• Introducing a reward chart can be a helpful motivator for children to use their cutlery if they are reluctant to try.

Food

Different foods are easier than others to scoop with a spoon or stab with a fork. Think about food choices. Often children insist on eating the same thing every day because the texture of the food is bearable when they eat – and there are no surprises.

Helpful tips:

• Before planning your meals, watch what your child prefers. Is it soft and gooey, or rough and chewy? Are there any textures that your child avoids?
• Your child may find some tastes and textures unpleasant in their mouths. Foods that are chewy, like gum, or chewy sweets, lollipops or foods you suck on, and cold foods like ice-lollies, can help to lower sensitivity. These should be given in moderation.
• Simple foods like sausages can be cut beforehand into bite-size pieces so your child can stab them with a fork.
• Food like spaghetti or pasta can be very slippery and difficult to control.
• Peas and beans are also difficult to balance on the fork, requiring a lot of patience. Using a ‘spork’ may be helpful to try with these food items.
• Hard cheese and apples cut up are easier for the beginner to stab, and a long thick block of cheese is easier to cut.
• At the start, make the activity easy with easy food – this will keep your child’s interest and motivate them to enjoy their food.

Eating out

Restaurants, dinner at school or staying over with a friend can be tough for a child who is aware of difficulties with cutlery.

Helpful tips:

• Picnic or pack lunches can avoid embarrassment and can be really fun.
• Restaurants with floor-fixed chairs will make it more difficult for your child to sit comfortably
• Restaurants where it is acceptable to eat with your fingers may lower anxiety
• If your child uses specialised cutlery at home, take it with you, if your child is happy with this.
• Having wet wipes or tissues with you in case of any spillages means you can clear it up quickly yourself without fuss, and continue to eat
• Sit beside your child to help them concentrate
• If possible, don’t sit near the door or window, as this can be a distraction.
• For the same reasons, choose a quiet restaurant rather than somewhere busy
• Don’t be in a rush – enjoy your meal!
• If your child is staying over with a friend, explain to that child’s parents what your child’s needs are.

Pouring and drinking

Sometimes pouring a drink is too difficult for a child with coordination difficulties or reduced body awareness. This is because it can be difficult to judge the force needed to move liquid from one container to another, without spilling it!

Helpful tips:

• Think about seating – is their seating balance good?
• Is the cup too big for their hand to reach around?
• Is the bottle too big to reach around? Is it too heavy, or slippery?
• Check your child’s hands are not slippery.
• Try practicing with different sized jugs and cups in the bath. Using water play, your child will learn how heavy the jug is before it is too difficult for them to lift and control and if they spill any, it won’t make a mess in the bath.
• In a restaurant or outing, think about using a straw.
• Don’t allow your child to fill the cup to the top a quarter of the way is enough. Having a marker on the outside of the cup can be a good prompt for your child to check how much they need to pour in.
• Playing with sand or rice and pouring from one container to another is a good way to practice.

Additional things to remember

• Practice, practice, practice! Any opportunity for your child to try using cutlery – even handling it by setting the table at meal times will help.
• Have fun and be patient with yourself and your child. This is a chance to teach your child an independence skill for life!

Activity Suggestions

There are lots of activities and games that you can play with your child which will help them to practice the skills needed to be successful with eating and drinking. Fun = motivation for your child, and they won’t know that they are working on developing skills for eating and drinking!

Below are some suggestions for you try:

• Using a dustpan and brush – emphasise keeping the dustpan still and moving the brush
• Cutting paper or card with scissors – start with easy patterns and progress to more complicated ones. Always supervise your child when they are using scissors.
• Playdough and clay – use tools to model shapes and create artwork, or use as a means to practice with knife and fork. Play pretend café’s or restaurants with your child and ask them to make a menu with different food items, take it in turns to be the chef and the customer.
• Cooking and baking – holding a mixing bowl whilst stirring the contents, or spooning the ingredients into another bowl.
• Colouring – emphasise holding the paper steady with one hand whilst the other hand does the colouring.
• Opening screw top jars and bottles.
• Construction toys – e.g. Meccano, K’nex, and LEGO. Make sure your child holds one piece still whilst moving a connecting piece
• Play games with your child lying on their tummy – this will strengthen their back and core which is essential for good sitting balance
• Ask your child to sit on an exercise ball and shift their weight from side to side to develop their core and pelvic stability.
• Animal walks and yoga poses are great fun for your child to develop strength and stability.
• Any activities that require your child to kneel, squat or sit to stand are helpful.
• Have fun with food – use cheese blocks to make towers or cut up vegetables to make vegetable monster faces!

Contact the team

If you require any further advice on the information provided in this booklet, please do not hesitate to contact the Children’s Occupational Therapy team in your area.

North Sefton Children’s Community Occupational Therapy
Hoghton Street Clinic
52 Hoghton Street
Southport
PR9 0PN
Tel: 01704 395895
(Areas covered – L37, PR8, PR9)

South Sefton Children’s Community Occupational Therapy
2nd Floor
Sefton Carers Centre
27-37 South Road
Waterloo
L22 5PE
Tel: 0151 252 5836
(Areas covered – L20, L21, L22, L23, L30, L31, L38, Sefton parts of L10)

This leaflet only gives general information. You must always discuss the individual treatment of your child with the appropriate member of staff. Do not rely on this leaflet alone for information about your child’s treatment.

This information can be made available in other languages and formats if requested.

PIAG: 336