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Complex Feeding

Due to the COVID-19 pandemic, Complex Feeding is currently offering virtual clinic visits. In-person clinic visits may be scheduled if needed.
About us
If community feeding supports are available

We offer outpatient-based consultative services or short-term nutrition counseling and feeding therapy to eligible children with complex feeding and nutrition needs that have not responded to ongoing treatment or are difficult to manage by local community supports. When appropriate, we may also offer medical management.

If community feeding supports are not available

We offer outpatient-based ongoing nutrition counseling and feeding therapy to eligible children with complex feeding and nutrition needs. When appropriate, we may also offer medical management.

Physician: Dr Vishal Avinashi

Dietitian: Soleina Karamali, RD (on maternity leave)

Dietitian: Alessia Vaz, RD (temporary)

Occupational therapist: Rochelle Stokes, OT, MSc.RS, IBCLC

Social worker: Kathryn Urquhart, MSW, RSW

Nurse: (vacant)

Clerk: Anita Terjesen

Coordinator: Debby S Martins

Medical director: Dr Linda Casey

You need a referral from a doctor, a nurse practitioner or a community feeding therapist to use this service. When appropriate, we may redirect referrals to another service to best meet your child's needs; we will inform the referring provider.

 

The Complex Feeding clinic is a tertiary service. When they are available, children must access local community supports before a referral to Complex Feeding can be made. Some exceptions may be considered; referring providers may contact the Complex Feeding team to discuss the child's feeding history and needs.

 

Complex Feeding can accept referrals for consultation, short-term management or ongoing management for the following issues:


  • Children who are or have the potential to be orally fed and who require support from both an occupational therapist and a dietitian for the following feeding and nutrition issues:
    • Poor growth, oral / bottle aversion, oral-motor skill deficits, weaning enteral nutrition, transition from enteral nutrition to oral intake, and prevention of enteral nutrition.
    • The Complex Feeding physician may be involved if additional diagnostic testing, medication and/or procedures are required.

At this time, Complex Feeding is unable to accept the following referrals:


  • Children who do not have the potential to be orally fed
  • Children who have not yet accessed local community supports (when they are available)
  • Children whose local community supports do not require support from Complex Feeding
  • Children whose feeding difficulties are predominantly related to sensory issues, including but not limited to: autism spectrum disorder or sensory processing disorder
  • Children whose feeding difficulties are predominantly related to mental health issues, including but not limited to: ARFID, eating disorders, anxiety, trauma / PTSD
  • Self-referrals 
  • Wilms AL, Cowie HK, Stokes RH, Browes A, Avinashi V, Zwicker JG. Transitioning to oral feeding: A family-centered, hunger-based tube weaning program. November 2021 (in submission). 

  • Stokes RH, Browes A, Avinashi V. 2018. Evaluation of an Outpatient Tube Transition Program. Canadian Association for Occupational Therapy Conference, 21 June 2018, Vancouver, BC.

  • Parsons H, Stokes RH, Martins DS, Boyle A. 2011. The Pediatric Patient with Nutritional and Feeding Challenges. Children's Health Today, BC Pediatric Society, 21 Sep 2011, Vancouver, BC.

Phone: (604) 875-2345

Paging: (604) 875-2161

Toll Free: 1-888-300-3088

Fax: (604) 875-3244


Do you have questions about Complex Feeding?

Contact Debby S Martins, program coordinator, by email or by phone at (604) 875-2345, local 5886.


Our program

  • Empower you to care for your child at home. We will be there to support you.
  • Enable your child to live a full life, despite their medical needs
  • Optimize your child's health, development and well-being
  • Increase your child's intake of food and promote a healthy relationship with food
  • Prevent, decrease or end your child's need for tube feeds

Planning your visit will help you get the most out of your appointment. 

 

What to bring
  • Your child's BC Medical Card
  • A list of your child's medication
  • Any questions or concerns that you would like to discuss
Parking

Parking at BCCH can be difficult, especially during midweek clinic days. Give yourself plenty of time to find parking and walk across the large campus. You may wish to take advantage of the FREE valet parking service. This service is located by the TACC building main entrance (near Emergency).

 

If you are running late or are having trouble with parking, please contact the program secretary at (604) 875-2345, local 7464.

Clinic visits are typically an hour long. We are a multidisciplinary clinic, so you will see a dietitian and an occupational therapist at the same time. Depending on your child and family's needs, you may also see a doctor, a nurse or a social worker.

 

We will ask about your child's medical history, growth history, feeding and nutrition history, mealtime routines and behavior at mealtimes. We will discuss your goals and concerns, and we will answer your questions. The occupational therapist may ask to see your child eating. If we are seeing you in person, we may ask you to bring food from home. The doctor may examine your child. We might adjust your child's care plan to support growth, to help with support their feeding, to help manage symptoms, or if any issues come up. We will discuss these changes with you.

 

If your child needs additional investigations, we may refer them to the appropriate service or diagnostic studies.

  • Our clinic is located on the second floor of the BCCH Ambulatory Care Building. Follow the yellow ribbon on the floor to Area 10 – Gastroenterology, Hepatology and Nutrition.
  • Check in with the Complex Feeding and Nutrition clerk. The clerk will ask you to wait in the waiting room or direct you to an assigned room. They will notify the team that you have arrived for your clinic visit.
  • The nurse or the dietitian will measure your child's height and weight. They may also measure your child's head circumference, temperature and blood pressure.
  • You will meet with the team for your clinic visit. Depending on your child and family's needs, your clinic visit may include a discussion with the team, a medical examination, a feeding observation and a private discussion with the social worker. If needed, we may ask you to take your child for bloodwork or we may refer them for additional testing.
  • After your clinic visit, schedule your follow-up appointment with the Complex Feeding and Nutrition clerk. If the clerk is not at the front desk, they will contact you to schedule your follow-up appointment.

We do our best to follow your scheduled appointment time, but some clinic visits may go longer than expected. Please have a plan for family members at home if this should happen or for keeping your child entertained if you should have to wait.

Depending on your child's needs, we may do some clinic visits virtually. However, in-person feeding assessments are very important and we may ask you to come for an in-person clinic visit.

 

  • Please weigh your child before your clinic visit.
  • Log into your clinic visit using the Zoom link provided by the Complex Feeding and Nutrition clerk. You will be asked to wait in a virtual meeting room. We will let you into the meeting at your scheduled appointment time.
  • You will meet with the team for your clinic visit. Depending on your child and family's needs, your clinic visit may include a discussion with the team, a feeding observation and a private discussion with the social worker. If your child needs a medical examination by a physician, we may ask you to come for an in-person clinic visit. If needed, we may ask you to take your child for bloodwork or we may refer them for additional testing.
  • After your clinic visit, the Complex Feeding and Nutrition clerk will contact you to schedule your follow-up appointment.

We do our best to follow your scheduled appointment time, but some clinic visits may go longer than expected. We will notify you if we are expecting to be delayed.

We will schedule follow-ups according to your child's needs. 


Resources
Community feeding supports

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

 
Feeding

Reference: Adapted with permission from copyrighted material of Dr. Kay Toomey (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 #1 priority

FALSE: Eating is actually the body's #3 priority, with breathing being #1 and postural stability ("not falling on your head") being #2. If either breathing or postural stability is compromised, eating may be resisted.


Eating is instinctive

FALSE: Eating is only instinctive for the first 4 to 6 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 behaviors around 6 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 6 nerves to coordinate). Finally, eating is the ONLY task we do that requires simultaneous coordination of all 8 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 learning to eat process. 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 4 to 6% 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 and so, they refuse to do it. In addition, children with medical issues may not have had the opportunity to learn to respond appropriately to hunger.
 

Feeding issues are either behavioral or organic (physical)

FALSE: Most children with feeding issues have a combination of organic and behavioral problems. Children who start with an organic problem that affects eating (ex: reflux) quickly learn that eating is painful or unpleasant, and behaviors to avoid eating will start to surface. Children who start with behavioral or environmental problems that affect eating (ex: 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.

Picky eating versus Problem feeding

Reference: Adapted with permission from copyrighted material of Dr. Kay Toomey (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 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

Books

Webinars and workshops

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

Pain with feeding is often suspected in babies who develop a feeding aversion, but 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

Difficulties with sucking may be suspected if the baby has never bottle-fed well. 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 their 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. Examples of non-nutritive oral stimulation include:

 

  • 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 color
    • 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. They may be referred 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, a series of x-ray images are taken 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 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

    Books and articles

    Webinars and workshops

     

    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

     

    Related resources

    Websites

    Books and articles

    Nutrition

    growth chart.pngMonitoring 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. 


    Growth charts are used 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 3 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, one-time measurements can be used to screen for health or nutrition issues. However, they don't give enough information to assess growth and can be misleading. When they are 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. Their growth can be monitored 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.

    Are HBTF safe for my child?

    HBTF may be safe for your child if:


    • They are at least 6 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

    HBTF require more times 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.


    HBTF require more resources to prepare.

    If your child's current formula is covered, it is true that 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.


    HBTF have a higher risk of food-borne illness.

    Following good food safety practices decreases the risk of food borne illnesses:

    1. Clean your hands, your workspace, your tools and your food well.
    2. Cook foods to the correct temperature.
    3. Store your HBTF in the refrigerator or in the freezer.

    HBTF have a higher risk of nutritionally inadequate diet.

    Dietitians can help you develop a HBTF recipe template that is nutritionally adequate for your child.


    HBTF have a higher risk of clogging the feeding tube.

    HBTF 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, HBTF have many potential benefits:


    • They provide enhanced nutritional variety
    • They can be tailored to your child's specific nutritional needs
    • They can be tailored to your family's personal, cultural or religious values around food
    • They may improve feeding tolerance and decrease gastrointestinal discomfort
    • They may help facilitate the transition to an oral diet
    • They 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, they may continue to receive a HBTF if it is medically safe to do so. We are not able to prepare HBTF, 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, an appropriate commercial formula will be offered.

     

    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

    Handouts

    Books


    Awareness and support


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