Complex Feeding Patient and Family Resources
Resources for community feeding supports and information on feeding, nutrition and awareness foundations.
Community feeding supports
- BC (all health authorities) (PDF)
- Burnaby (PDF)
- Fraser Valley (PDF)
- North Shore (PDF)
- Vancouver (PDF)
- Vancouver Island (PDF)
- Pediatric feeding service providers (complete list) (PDF)
At this time, Complex Feeding is not able to accept referrals for children whose feeding difficulties are predominantly related to autism spectrum disorder.
Consult the Registry of Autism Service Providers (RASP) for a list of professionals who have the experience and education to offer programs for children on the autism spectrum.
At this time, Complex Feeding & Nutrition is not able to accept referrals for children whose feeding difficulties are predominantly related to mental health issues, such as ARFID.
Consult the Kelty Eating Disorders website for a list of resources who have the experience and education to offer programs for children with ARFID, as well as a Patient and Family Workbook (PDF).
Feeding
Reference: Adapted with permission from copyrighted material of Dr. Kay Toomey's (1990/2021) SOS Approach to Feeding program. The following materials cannot be presented or taught by any other person without direct permission from Dr. Kay Toomey.
Eating is the body's number 1 priority
False: Eating is actually the body's number 3 priority, with breathing being 1 and postural stability ("not falling on your head") being 2. If either breathing or postural stability is compromised, people may resist eating.
Eating is instinctive
False: Eating is only instinctive for the first four to six weeks of life. After that, we use a set of primitive motor reflexes (rooting, sucking, swallowing) to allow us to eat, while we lay down pathways in our brain that evolve into learned behaviours at around six months of age.
Eating is easy
False: Eating is the most complex physical task humans engage in. It is the only task that involves every organ system and that requires all of those systems to work correctly. It also involves every muscle in the body. For example, one swallow takes 26 muscles and six nerves to coordinate. Finally, eating is the ONLY task we do that requires simultaneous coordination of all eight of our sensory systems.
Eating is a 2-step process: 1) sitting down and 2) eating
False: There are 32 steps in the process of learning to eat.
It's not appropriate to touch or play with your food
False: Being messy, touching and playing with food is a normal and important part of the process of learning to eat. It is play with a purpose. It teaches children the 'physics' of the food. They can learn a lot about a food before putting it in their mouth.
Children will not starve themselves - they will eat if they are hungry enough
False: For four to six per cent of children with feeding issues, 'starving' themselves can seem like the better option. Children with feeding issues often find eating so painful or unpleasant that no amount of hunger can overcome it, and so they refuse to do it. Also, children with medical issues may not have had the opportunity to learn to respond appropriately to hunger.
Feeding issues are either behavioural or organic (physical)
False: Most children with feeding issues have a combination of organic and behavioural problems. Children who start with an organic problem that affects eating (e.g. reflux) quickly learn that eating is painful or unpleasant, and behaviours to avoid eating will start to surface. Children who start with behavioural or environmental problems that affect eating (e.g. pressure to eat) will become compromised nutritionally, and organic problems will start to surface.
Children should mind their manners at mealtimes
False: We need to learn the skills to eat before we can learn good manners, especially for children with feeding issues. Mealtimes are an opportunity for parents to model how to eat and to teach the 'physics' of food.
Reference: Adapted with permission from copyrighted material of Dr. Kay Toomey's (1990/2021) SOS Approach to Feeding program. The following materials cannot be presented or taught by any other person without direct permission from Dr. Kay Toomey.
| Picky eater | Problem feeder |
| Decreased range or variety of foods; typically has 30 or more foods in their food range | Restricted range or variety of foods; usually eats less than 20 foods |
| Foods lost due to "burn out" from food jagging are usually eaten again after a 2-week break | Foods lost due to "burn out" from food jagging are not eaten again after a break, resulting in a further decrease in the number of foods eaten |
| Eats at least one food from most nutrition or texture groups (e.g. purees, meltable foods, proteins, fruits) | Refuses entire categories of food textures or nutrition groups (e.g. soft cubes, vegetables, hard mechanicals) |
| Can tolerate new foods on their plate; usually able to touch or taste food (even if reluctantly) | Cries, screams, tantrums, "falls apart" when new foods are presented; complete refusal |
| Frequently eats a different set of foods at a meal than other family members; typically eats at the same time and at the same table as other family members | Almost always eats a different set of foods than their family; often eats at a different time or at a different place than other family members |
| Sometimes reported by parents as a "picky eater" at well-child check-ups | Persistently reported by parents to be a "picky eater" at multiple well-child check-ups |
| Learns to eat new foods in 20 to 25 steps on a Steps to Eating Hierarchy | Requires more than 25 steps to learn to eat new foods |
Picky eating
If you are concerned that your child is a picky eater, the resources below may help. You may also wish to speak with their pediatrician or seek help from a pediatric dietitian, occupational therapist or speech-language pathologist.
Problem feeding
If you are concerned that your child is a problem feeder, don't wait to get help. Speak with their pediatrician and seek help from an experienced feeding therapist.
Resources for caregivers
Websites
- SOS Approach to Feeding: Parents and caregivers
- Kelty Mental Health Resource Centre: Picky Eating
- Ellyn Satter Institute: Picky Eating: Born or made?
Books
- Anxious Eaters, Anxious Mealtimes: Practical and compassionate strategies for mealtime peace. Marsha Dunn Klein, 2019
- Conquer Picky Eating for Teens and Adults: activities and strategies for selective eaters. Jenny McGlothlin and Katja Rowell, 2018
- From Picky to Powerful: The mindset, strategy, and know-how you need to empower your picky eater. Maryann Jacobsen, 2016
- Helping Your Child with Extreme Picky Eating: A step-by-step guide for overcoming selective eating, food aversion, and feeding disorders. Katja Rowell and Jenny McGlothlin, 2015
- Love Me, Feed Me: The adoptive parent's guide to ending the worry about weight, picky eating, power struggles and more. Katja Rowell M.D, 2012
Webinars and workshops
- SOS Approach to Feeding: When Children Won't Eat (and how to help!) - Parent and Caregiver Workshop
Babies who have a bottle aversion are physically capable of taking the bottle, but refuse the bottle or take only small amounts. This can be very distressing for parents.
Possible signs
Babies who have a bottle aversion may:
- Become distressed when they see the bib or the bottle, or when they are placed in a feeding position
- Avoid eye contact when feeding
- Push the nipple out or move the nipple around with their tongue and refuse to drink
- Clamp their mouth shut, push the bottle away, turn their head away or arch their back, even when they seem hungry
- Reluctantly take a few sips when they are very hungry, then pull away, arch their back or start to cry
- Fight being fed until they are too tired to fight or feed only when they are drowsy or asleep
- Accept milk from a syringe, a spoon or a sippy cup or eat solids after refusing the bottle
- Take less milk than expected
- Have poor growth
Possible causes
Pressure to feed is a common cause of bottle aversion.
- Offering the bottle repeatedly
- Distracting your baby
- Jiggling and twisting the bottle
- Getting your baby to suck on a soother, then switching it for the bottle
- Placing the nipple in your baby's mouth against their wishes
- Squeezing milk into your baby's mouth
- Trying to make your baby suck by applying pressure to their cheek or chin
- Not responding to your baby's cues: not allowing the baby to push out the nipple
- Force-feeding or restraining your baby
People often suspect pain with feeding in babies who develop a feeding aversion, but it is generally not a common cause. It is not likely to be the cause of bottle aversion if your baby is happy when you stop feeding them, if your baby is happy between feeds or if your baby feeds well in certain situations. Possible causes of pain with feeding include:
- Acid reflux
- Cow's milk protein allergy or intolerance
- Constipation
- Mouth ulcers
- Thrush
- Teething
If the baby has never bottle-fed well, the problem may be difficulties with sucking. Possible causes of difficulties with sucking include:
- Nipple shape is not suitable for the baby
- Nipple shaft is too long or too short
- Flow rate is too fast or too slow
- Poor positioning
Babies who have had a choking episode or who have experienced medical trauma from procedures involving their face or mouth (such as intubation or NG insertions) may become distressed when offered a bottle.
Babies with a sensory processing disorder may be very sensitive to the feel, taste or smell of breastmilk, formula or bottle nipples.
Treatment
If you suspect your child has a bottle aversion, speak with their pediatrician and seek help from a feeding therapist.
Children who have an oral aversion are physically capable of eating, but refuse to eat or take only small amounts. They have a strong dislike or a fear of anything touching their mouth. This can also lead to a refusal of being touched or an overactive gag reflex. This can be very distressing for parents.
Possible signs
Children who have oral aversion may:
- Become distressed when they see the bib or the bottle/dish, or when they are placed in a feeding position
- Clamp their mouth shut, push the bottle/spoon away, turn their head away or arch their back, even when they seem hungry
- Reluctantly take a few sips or bites when they are very hungry, then pull away, arch their back or start to cry
- Fight being fed until they are too tired to fight
- Skip meals
- Throw food
- Have poor growth
Possible causes
- Pressure to feed or force-feeding are stressful events and often create an unfortunate cycle instead of helping the child
- Negative feeding experiences or environments
- Any condition or sore affecting the mouth, throat or gastrointestinal tract can stop children from eating due to pain with feeding
- Children can develop an oral aversion after a scary choking event
- Swallowing difficulties
- Children who have experienced medical trauma from procedures involving their face or mouth (such as intubation, suction or NG insertions) may become afraid to eat
- Children with a sensory processing disorder may be very sensitive to the feel, taste or smell of foods and drinks
- Breathing difficulties
- Muscle weakness or impairment, or poor motor coordination
- Some medical conditions may be associated with oral aversion: gastroesophageal reflux disease (GERD), congenital diaphragmatic hernia (CDH) or tracheoesophageal fistula (TEF)
Treatment of oral aversion
If you suspect your child has an oral aversion, speak with your pediatrician and seek help from a feeding therapist.
Oral stimulation will help prevent oral aversions, maintain oral-motor skills and maintain the child's ability to process oral sensory input. Oral stimulation should be pleasant and enjoyable. If at any point your child becomes distressed, stop and try again later.
Non-nutritive oral stimulation
Non-nutritive oral stimulation is positive touch to your child's face and mouth, without the use of food. Some examples of non-nutritive oral stimulation are:
- Including your child in the family meal. This allows them to see different foods and experience different smells
- Encouraging your child to explore their hands or different toys with their mouth
- Encouraging your infant to suck on a soother or a pumped breast during tube feeds
- Giving pleasant or loving touches around your child's face and mouth
- Giving firm, but gentle massage on your child's upper body and face
Nutritive oral stimulation
Nutritive oral stimulation provides positive experiences with small amounts of food. Examples of nutritive oral stimulation include:
- Offering tastes of a variety of foods and liquids (if they have a safe swallow)
- Encouraging your infant/toddler to suck on a soother, a spoon or a toy dipped in milk or purees
- Rubbing a small amount of milk or purees on your child's lips or gums
After swallowing, food and liquids should move from the mouth, through the esophagus and into the stomach. However, many children have difficulties with swallowing. This increases the risk of food and liquids going into the lungs instead. This is called "aspiration". If not addressed, repeated aspirations can cause serious infections or lung damage.
Possible signs or symptoms
Aspiration can happen without any obvious signs or symptoms, so you may not be aware that your child is aspirating. This is called "silent aspiration".
Common signs and symptoms of aspiration include:
- During or after eating or drinking:
- Signs of stress or refusal to eat or drink
- Coughing, choking or gagging
- Coughing, choking or gagging with specific textures or tastes
- Wet or hoarse voice quality
- Frequent throat clearing
- Watery eyes or change in facial colour
- Difficult or noisy breathing
- Food or liquid coming out from the nose
- Decreased activity or alertness
- Discomfort when swallowing
- Sensation of food being stuck in your child's throat
- Frequent illness, especially with respiratory illnesses (pneumonia, bronchitis, prolonged cold, etc.)
- Fevers, especially if there are no other signs of illness
- Increased mucous and secretions; your child may sound congested
Speak with us if your child is experiencing any of these signs or symptoms of aspiration. If the Complex Feeding Clinic does not actively follow your child, speak with your doctor or therapist if they are showing any signs or symptoms of aspiration. The doctor may refer them to a swallowing clinic for further assessment.
Possible causes
- Neurological disorders
- Muscle weakness or impairment
- Fatigue
- Poor oral-motor coordination
- Medication side effects
- Gastroesophageal reflux
- Swallowing difficulties
- Anatomical conditions
Health risks
- Pneumonia, respiratory infections
- Airway obstruction, choking
- Malnutrition, failure to thrive
- Dehydration
- Decreased interest in eating
Diagnosis
If your child is showing signs or symptoms of aspiration, our occupational therapist may recommend a "videofluoroscopic swallowing study". During this test, we take a series of X-ray images as food moves from the mouth, through the throat and into the stomach. These images show if there are problems at any stage of swallowing and help us decide how to treat the swallowing difficulty.
If your child needs a videofluoroscopic feeding study, we will give you more information before the test.
Treatment
Your child's treatment will depend on what is causing their swallowing difficulties. This may include modifying the texture or consistency of foods and fluids, using special tools or positions for feeding, surgery to correct anatomical conditions, or medications.
At this time, Complex Feeding is not able to accept referrals for children whose feeding difficulties are predominantly related to autism spectrum disorder. Consult the Registry of Autism Service Providers (RASP) for a list of professionals who have the experience and education to offer programs for children on the autism spectrum.
Resources for caregivers
Websites
- Government of British Columbia: Autism spectrum disorder
- ACT - Autism Community Training
- AutismBC
- Canucks Autism Network
- Pacific Autism Family Network
- POPARD - Provincial Outreach Program for Autism and Related Disorders
Books and articles
- Conquer Picky Eating for Teens and Adults: Activities and strategies for selective eaters. Jenny McGlothlin and Katja Rowell, 2018
- Food Refusal and Avoidant Eating in Children, Including Those with Autism Spectrum Conditions: A practical guide for parents and professionals. Gillian Harris and Elizabeth Shea, 2018
- Helping Your Child with Extreme Picky Eating: A step-by-step guide for overcoming selective eating, food aversion, and feeding disorders. Katja Rowell and Jenny McGlothlin, 2015
- UnlockFood.ca: Autism and Nutrition
Webinars and workshops
- Ellyn Satter Institute: Mealtimes with Your Children with Autism Using the Satter Models
At this time, Complex Feeding and Nutrition is not able to accept referrals for children whose feeding difficulties are predominantly related to mental health issues, such as ARFID. Consult the Kelty Eating Disorders website for a list of resources who have the experience and education to offer programs for children with ARFID, as well as a Patient and Family Workbook (PDF).
Related resources
Websites
Books and articles
- ARFID Avoidant Restrictive Food Intake Disorder: A guide for parents and carers. Rachel Bryant-Waugh, 2019
- Cognitive Behavioral Therapy for Avoidant/Restrictive Food Intake Disorder (CBT-AR): Patient and family workbook (PDF)
- Conquer Picky Eating for Teens and Adults: Activities and strategies for selective eaters. Jenny McGlothlin and Katja Rowell, 2018
- Food Refusal and Avoidant Eating in Children, Including Those with Autism Spectrum Conditions: A practical guide for parents and professionals. Gillian Harris and Elizabeth Shea, 2018
- Helping Your Child with Extreme Picky Eating: A step-by-step guide for overcoming selective eating, food aversion, and feeding disorders. Katja Rowell and Jenny McGlothlin, 2015
Nutrition
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Monitoring a child's growth is an important part of their health care. It helps to confirm that they are growing and developing well, and to identify possible nutritional or health issues early.
We use growth charts to track how a child is growing over time. Since 2010, the World Health Organization growth charts are recommended as the standard charts for all Canadian children. The WHO growth chart is divided into the 3rd, 15th, 50th, 85th and 97th percentiles (set 1) or into the 3rd, 10th, 25th, 50th, 75th, 90th and 97th percentiles (set 2). The percentile number indicates the percentage of children of the same age and sex that are smaller than your child. For example, if your child is on the 15th percentile for height, they are taller than 15% of children their age.
Your child's weight, length/height and head circumference will be measured regularly and recorded on their growth chart. If your child is growing well, they will generally follow the same percentile over time. Which percentile your child follows does not matter. Healthy children come in different shapes and sizes. They may be taller or shorter, heavier or lighter than other children their age. What matters is that your child is growing in a healthy way, even if they are growing along the 3rd percentile or the 97th percentile.
It can be normal for children to slowly change percentiles during the first three years of life and again at puberty. However, if there is a rapid change in your child's growth pattern or if any of their growth lines remains flat, there may be a problem with their health or with their nutrition.
When measured and recorded accurately on your child's growth chart, we can use one-time measurements to screen for health or nutrition issues. However, they don't give enough information to assess growth and can be misleading. When available, two or more measurements over time allow for a more accurate assessment of how your child is growing.
Children with special health care needs
Children with some special health care needs have different growth patterns. We can monitor their growth on the WHO growth charts alone, or in conjunction with specific growth charts that exist for some of these disorders.
Blenderized tube feeds are tube-feeding formula made from real food.
Homemade blenderized tube feeds (HBTF)
Speak with your pediatrician and a dietitian before starting a homemade blenderized tube feed.
Safety of HBTF
HBTF may be safe for your child if:
- They are at least six months old
- Their doctor has confirmed that they are medically stable
- They receive bolus feeds through a G-tube
- Their medical nutrition therapy needs can be met with real food
- You have or can access the equipment and training needed to safely transition to HBTF
Some children who do not meet all these criteria may still benefit from HBTF. Ask your pediatrician or dietitian about it.
Potential risks and disadvantages
More time to prepare
It is generally true that safely preparing and storing a HBTF takes more time and planning than using a commercial formula. We can help you determine if they are safe for your child and we can discuss what is involved with HBTFs. Then, only you can determine if they are feasible and realistic for your family.
More resources to prepare
If your child's current formula is covered, changing to a HBTF will increase your expenses. However, if your child's current formula is not covered, changing to a HBTF may in fact decrease your expenses. Only you can determine if they are feasible and realistic for your family.
Higher risk of food-borne illness
Following good food safety practices decreases the risk of food borne illnesses:
- Clean your hands, your workspace, your tools and your food well
- Cook foods to the correct temperature
- Store your HBTF in the refrigerator or in the freezer
Higher risk of nutritionally inadequate diet
Dietitians can help you develop a HBTF recipe template that is nutritionally adequate for your child.
Higher risk of clogging the feeding tube
HBTFs are generally thicker than commercial formulas, so there is a higher risk of clogging the feeding tube. Using a high-powered blender (such as Vitamix® or Blendtec®) and/or straining your HBTF will help decrease the risk of clogging the feeding tube.
Potential benefits
When prepared adequately, HBTFs have many potential benefits:
- Enhanced nutritional variety
- Can be tailored to your child's specific nutritional needs
- Can be tailored to your family's personal, cultural or religious values around food
- May improve feeding tolerance and decrease gastrointestinal discomfort
- May help facilitate the transition to an oral diet
- Support the parent-child feeding relationship
- If your child's current formula is not covered, changing to a HBTF may decrease your expenses
Hospital admissions
If your child needs to be admitted to BC Children's Hospital (PDF), they may continue to receive a HBTF if it is medically safe to do so. We are not able to prepare HBTFs, so you will be responsible for preparing and providing your child's HBTF for the duration of their stay.
If it is not medically safe for your child to receive a HBTF during their hospital stay, or if you are not able to prepare and provide your child's HBTF, we will offer an appropriate commercial formula.
Emergency planning
Emergencies can happen at any time. If your child is on a HBTF, having a backup plan is prudent for situations where preparing and storing HBTF is not safe or not possible. Options may include:
- Having a supply of jars or pouches of commercial baby food
- Having a supply of commercial food-based formula
Commercial food-based formula
If you are interested in offering your child a food-based formula, but preparing a blenderized tube feed at home is not feasible or realistic for you, speak with your pediatrician or dietitian about using a commercial food-based formula.
Resources for caregivers
Pamphlets
- Homemade Blenderized Formula Readiness Questionnaire (PDF)
- Equipment and Supplies for a Homemade Blenderized Formula (PDF)
- Preparing, Blenderizing and Storing a Homemade Blenderized Tube Feed (PDF)
Books
- Homemade Blended Formula Handbook. Marsha Dunn Klein and Suzanne Evans Morris, 2017