Patient Care: Pediatric Feeding Services

Maria Coxon, OTD, OTR/L, CLC, works with children ages 0-18 and their families on strategies to improve feeding outcomes

by Michele Berhorst • October 16, 2023

Maria Coxon, OTD, OTR/L, CLC, uses a colorful children’s book to help an infant develop reaching skills.

“The best-case scenario is that after, a couple of weeks or months, a child that wouldn’t eat anything is now eating everything,” says Maria Coxon, OTD, OTR/L, CLC, an occupational therapist in OT Services’ newest service line: Pediatric Feeding Services.

It is estimated that pediatric feeding disorders affect more than one in 37 children under age 5 in the United States each year.* Children take part in meals and snacks multiple times a day and in a variety of settings like home, day care and school. Coxon works with children ages 0-18 and their families on strategies to improve feeding and provide a positive mealtime experience for all: “Part of the reason I'm so passionate about feeding is because there's so much personal and cultural value assigned to mealtime. It shouldn’t be stressful or a battle of wills.”

Coxon knew as a first-year OT student that she wanted to focus on feeding. “I did my observation hours at The Children's Institute of Pittsburgh, where they had an intensive outpatient feeding program. I fell in love with it immediately,” Coxon recalls. She earned her master’s degree in occupational therapy in 2018 and her post-professional doctoral degree in occupational therapy in 2019 from Boston University. Coxon completed her Level II fieldwork at Rady Children’s Hospital-San Diego in Calif., where she specialized in feeding and worked for two years following graduation.

In infants, Coxon often sees difficulties with breast feeding or bottle feeding and latching, especially with premature infants. “They tend to be less efficient and must work harder to eat. I show parents what to look for if a baby is struggling to eat and develop gentle strategies to set them up for success,” says Coxon, who typically sees infants in the home setting. “If I can observe the feeding, I can see, for example, if the nipple flow is too fast for them and help make an adjustment. There are several devices and environmental adaptations that can help infants feed.”

Transitioning to purees or solid foods (6 to 18 months old) can be a difficult time, and Coxon uses a hands-on approach to help parents get their child to eat. “We work on supportive strategies to introduce new foods, textures and tastes in a positive way. Parents join the sessions with me at the table or by the highchair so there won’t be an issue when I’m not there.”

Coxon uses play to encourage food acceptance and break down the steps of eating. “The goal is to get children comfortable being around food they’re not sure about by touching it, bringing it to their mouth and eventually trying it. We're making silly faces with food, using food to paint or moving toys through a plate of food. This gives them a ‘toolbox’ of skills to react to a new food that doesn’t involve crying, running away or even hiding. Children can think: ‘I don’t know what this is, but I can use my fork to push it around as Ms. Maria says. I can smell it before I try and take a bite.’”

Medical diagnoses like autism, attention-deficit/hyperactivity disorder or Down syndrome can bring rigidity and contribute to selective eating. “I look for any skill deficits that may be impacting chewing or swallowing in addition to sensory concerns,” Coxon says. “For example, lower muscle tone in some children with Down syndrome can affect their ability to chew or swallow because it takes longer to build that strength and endurance.”

Feeding issues can continue into the teen years, often stemming from childhood experiences. Techniques they have used to avoid foods may no longer work in adult settings. “As they mature, teens start to realize how much of their social life revolves around food. They tell their parents or providers, ‘I want to go to prom and be able to eat the dinner served,’ or ‘I'm going to college, what do I do about meals?’’’ Coxon explains. “Their treatment tends to be self-advocacy and learning strategies for when they are in situations where food they aren’t sure about is offered such as how to respectfully ask questions, take a bite, advocate for themselves at a restaurant, or request a substitute. For example, if they don’t like garlic flavor, how can they politely ask for a different seasoning instead?”

Managing expectations is another way Coxon helps her young clients learn to eat new foods. “It can take trying a food 10 to 20 separate times before deciding if they like it. Palates do change, and if they tried it once a long time ago – it may taste different now that they are older,” Coxon says. “Reframing how they think about food can help them open up to new experiences.”

Coxon will be sharing her clinical interests with doctoral students this fall in the newly formed Maternal Health Collective, a directed scholarship lab run by both faculty and clinicians. The overarching goal of the collective is to work toward improved perinatal outcomes for parents with a focus on co-occupational engagement; mental, physical, emotional, and spiritual participation; health; and well-being. Coxon will mentor students interested in infant feeding, breastfeeding, neonatal intensive care unit (NICU) transition and new parent support.

“It will be an expansion of our existing NICU-Transition Services (often referred to as Baby Bridge), which provide support to infants and their families after they go home from the NICU and until other therapy services like early intervention can begin,” Coxon says. “There will be an arm that focuses specifically on breastfeeding and lactation. Students will not only accompany me on home visits, but also help support program and service development for infants and their families in the community. I hope I can instill the same passion for feeding that I had when I was a first-year student in my lab mentees.”