Shulamis’s Yossi also defied the he’ll-eat-when-he’s-hungry platitude, although Shulamis didn’t realize this until his six-month checkup. Even though Yossi refused bottles and baby food, he was still nursing, so she didn’t realize how few calories he was consuming. One glance at the numbers on the scale showed that his weight had dropped alarmingly. Shulamis finally understood why her playful baby, who used to love his baby mirror and colorful rattles, couldn’t sustain the energy to engage for long.

Besides the stressful mealtimes she endured with Yossi as she struggled to transition him to solids, Shulamis’s other children were reacting to the tension at home. One daughter became withdrawn, while her older son’s rebbi complained of wild, uncontrolled outbursts in school. When Shulamis realized how much Yossi’s issues were affecting her family, she asked for further testing.

After testing ruled out several underlying medical conditions, such as reflux or allergies, as well as any common genetic issue or congenital issue, like kidney or heart problems, both Meir and Yossi received the same verdict from their respective pediatricians — a diagnosis of Failure to Thrive.

A Failure to Thrive Diagnosis

When babies and young toddlers fail to gain weight properly, when their weight-for-height percentile falls below the 3rd to 5th percentile, or when a child’s weight curve drops two percentile points for no apparent reason, they might have the letters FTT — Failure to Thrive —assigned to the condition.

“The reasons for a lack of nutrition are many, and aren’t usually anyone’s fault,” says Dr. Dov Shapiro, a pediatrician with decades of experience working at Associated Pediatric Partners in Northbrook, Illinois. According to the National Institutes of Health, between 20 and 50 percent of neurotypical children have some form of feeding difficulties, even though it usually isn’t severe enough to merit a FTT diagnosis. “Failure to Thrive is a serious diagnosis,” Dr. Shapiro adds.

Dr. Shapiro says that he works hard to head off feeding-related FTT diagnosis. “It’s important to catch little problems before they become big problems,” he says. Talking about Baby’s weight gain and feeding habits is one of the most important parts of any checkup, and parents should be proactive if they have any questions.

As the first line of defense, “When I identify a child during a visit who is at risk of FTT, it requires a lot of time to get to the bottom of the issue and help the parents turn the problem around,” Dr. Shapiro says. “After work hours, on my drive back home, I frequently call parents for feeding-related issues so we can speak at length.” Early warning signs such as a sustained dip in a baby’s weight gain will propel him to share tips and tricks with parents. If those don’t work, he’ll recommend more urgent intervention.

Sometimes a feeding issue requires a simple fix, like when Dr. Shapiro advises first-time parents to use bottle nipples with a faster flow (when appropriate) so their baby can drink without expending so much effort, or tips on transitioning to solids. Sometimes the problem goes deeper.

According to Dr. Wahad Zaidi, MD, a gastroenterologist at Memorial Hospital in South Bend, Indiana, issues leading to feeding disorders can range from allergies or reflux to dysphagia (swallowing issues) and esophagitis (when the esophagus is irritated by food and acid flowing upward).

Chaya’s everyday caseload as a feeding therapist brings her children with difficulties in chewing and swallowing, as well as those with food aversions and sensory sensitivities.

To determine the exact reason behind a baby’s feeding issue, doctors will order myriads of tests. Feeding therapists first ensure that children chew properly, and sometimes also schedule a swallow study, where babies first ingest barium, which makes certain parts of the body show up clearly on X-rays, and then eat various foods while being scanned. This gives therapists and radiologists a front-row seat into how Baby chews and swallows (or spits everything out onto the floor). ENTs inspect children’s mouths for issues of the palate or throat, and gastroenterologists perform endoscopies in search of intestinal problems. No doctor wants to miss an obvious medical issue.

“But sometimes, there are no concrete answers,” says Chaya Rosmarin. “Babies and toddlers can fail to thrive or have serious feeding problems, and the medical team may not find the reason. And we often need to go with that.”

Lifting the Burden

Feeding therapy is the art of lifting the burden of feeding from both parents and children, figuring out strategies to facilitate improved oral feeding.

In layman’s terms, feeding therapists get kids to eat.

According to Chaya, children who often refuse meals, eat a significantly limited variety of food, refuse varied textures, don’t chew their food, or are struggling to suck a bottle, may need feeding therapy. Another red flag is mealtimes that are longer than a high school play. Parents shouldn’t need to ‘get’ children to choke down a maximum of three bites at every meal. Feeding should be intrinsically motivating.

For Chaya, a phone consultation begins the process.

“Fifty percent of the time, a phone consult helps parents,” she says. One baby refused to drink water, even in a bottle, until she suggested the mother use water from a cooler. The baby liked the taste better. She advised the mother of a congested, suddenly-unwilling-to-eat baby in a new apartment to have the basement checked for mold (there was). However, “It’s not always so easy,” she admits. A good feeding therapist is essentially a problem solver, trying to figure out why tiny, often nonverbal human beings are refusing, or having difficulty with, a basic skill that can’t wait until later to develop.

If the phone consultation is inconclusive, parents bring their children to Chaya’s office, where she watches them eat (or refuse) various foods, and discusses the child’s eating habits in intense detail. These details help her figure out what type of issues to focus on.

Does the child have difficulty chewing, sucking, or swallowing? Little Leah can’t figure out how to drink from a straw? Then Chaya will target oral-motor skills — the how-tos of eating. If Avi can’t bear the feeling of applesauce on his fingers, Shaya refuses the Shabbos cholent, or Blumi spits out anything remotely resembling a vegetable, then Chaya focuses on sensory issues, where the texture or taste of food is hard for children to handle. And when Chaya meets children like Meir and Yossi, who take no pleasure in food and throw tantrums over a sprinkling of Cheerios, she needs to find ways to turn food from a battleground into a pleasurable experience.

Chaya has many tools in her arsenal (patience prominent among them), and she shares a few of her techniques.

“I sometimes have to start with something sweet,” she says. While conventional wisdom advises parents to introduce vegetables first, Chaya encourages her clients to start solids with pureed fruits or, in extreme cases, sugar water. Sometimes, children need a little sweetness to jumpstart their desire for food, though she’s found that those who have reached the stage of needing a feeding tube to get nutrition into them often prefer savory food.

Next, she works on texture. Does the baby or toddler like mushy food or hard food? One child simply didn’t like the feeling of sticky food on his hand, but was happy to eat with a spoon. Some babies love food that has crunch, but is also quick to dissolve, like veggie straws, onion rings, or Bamba. Sometimes it’s the placement of the food in a child’s mouth that’s key — Chaya had to put each morsel in an exact spot on one baby’s gums to get her to eat. One kid’s magic moment was a chocolate graham cracker, another hungry baby gobbled up regular food — apparently, he was tired of the baby puree his mother was offering.

If children still resist, a lengthy process of accustoming children to different foods will begin, accompanied by a skilled nutritionist’s input.

Chaya deals with cases like Meir’s every day. “I see kids cry when I place food on their tray. For them, food is scary,” she explains. A child whose eating problems are more severe often associates food with battles, parents trying to force-feed, and unpleasantness. She works patiently with these children, coaxing them back into the wonderful world of food.

And sometimes, the answer is outside of Chaya’s field of expertise.

One particularly memorable toddler looked chubby but was completely malnourished — all he ate were bottles of milk and bland oatmeal. By the time he was three, several specialists had given up on figuring out his issue. Chaya examined the toddler and sent him to a trusted ENT, where he was diagnosed with huge tonsils. After an operation to remove them and a swift recovery, he developed a normal appetite.

“I have to figure out what will work for each child,” says Chaya. “I try to think — what would I want if I was struggling like this child?”

Chaya notes that many of the mothers who come to her practice are consumed with guilt over their child’s feeding difficulty. “It’s important for mothers to know that when a child has a severe feeding issue or FTT, it’s not a normal parent’s fault. And I’m not just saying that to make anyone feel good,” Chaya says.

But while life with a feeding disorder can be torturous, it’s important for mothers to know that feeding therapy can give pint-size eaters and their parents the correct tools for a smooth feeding experience, restoring food to its threefold purpose of pleasure, social interaction, and survival.

“In my practice, I’ve seen that when we give children the ability to eat and don’t hover (too much!) most of the time, children eventually work through their issues,” says Dr. Zaidi.

Take the Cake

Both Meir and Yossi needed feeding therapists who were patient and creative in helping them overcome their aversions to food.

“She was incredible,” Eliana says about Meir’s feeding therapist. Meir hated food, so first, he needed to get comfortable. In the initial weeks of therapy, if Meir would touch the food on his tray, he’d receive a toy as a reward. Then, he was encouraged to play with his food, holding it, examining it, crushing it, or throwing it. The first foods he ate were cookies and crackers — neutral textures that weren’t too mushy or messy. “Meir’s therapist played games with him. She put a dab of food on his cheek and didn’t even mention the word ‘eat’ for a few weeks! When he worked his way up to actually tasting food like applesauce, she’d put some on a spoon and play ‘Clean the Spoon’ with him.”

It was slow progress — some sessions were better than others — but over half a year, Meir began to display interest in food.

When Yossi refused his mother’s best efforts to feed him, she asked their feeding therapist for tips to try at home.

“Use pickle juice,” the therapist told her. For some reason, kids who are less interested in food sometimes need stronger flavors to make them eat. Salty pickle juice is a real flavor booster, and dipping crackers or small pieces of chicken into the brine can make the most uninterested child smack his lips.

“I thought she was crazy, but I tried it — and it worked,” Yossi’s mother admits.

Yossi’s feeding therapists helped him strengthen his chewing ability, giving him strips of toast or chewy rubber toys to bite down on. With lots of encouragement, he began to overcome his dislike of mushy textures, and fun games turned eating into something positive. Soon he was tentatively trying a variety of foods. Within a year, Yossi was sitting in his highchair at the supper table, calmly feeding himself bite-sized pieces of schnitzel — sometimes more, sometimes less.

Each bite a sweet taste of victory.

Gastronomic Gains

Sometimes even the most dedicated parents and expert feeding therapists need a stronger tool to help the FTT child on the road to fabulous feeding — the gastrostomy tube, or as it’s colloquially known, the g-tube.

This small, flexible tube is inserted into the stomach through a minimally invasive procedure, and the opening is “closed” with a “button.” The “button” can be opened to deliver fluid, food, or medication directly into the stomach.

“It’s important to know that most kids with FTT don’t end up needing a gastro tube,” emphasizes gastroenterologist Dr. Wahad Zaidi. “We see it occasionally, but not often. And parents should remember that for typical children, the tube is a temporary measure to help them thrive while they sort out their eating.” Chaya adds that g-tubes are plan B (therapy being plan A), but that sometimes it’s necessary to make sure a child is healthy while he learns how to eat orally.

Both Meir and Yossi, two toddlers diagnosed with FTT, needed g-tubes since they couldn’t take in enough calories to grow properly for months after beginning feeding therapy.

“Putting in the g-tube was a very, very hard decision,” admits Shulamis, Yossi’s mother. “The g-tube can seem scary, and I dealt with a lot of horrified reactions from friends and family who didn’t understand why a merely ‘picky’ kid needed surgery. Some of them still don’t get it, and I hope they never will.”

Eliana had a more practical approach. “Meir needed it, so we did it.”

Feeding therapist Chaya Rosmarin, ClinScD-SLP, explains that parents should never feel guilty for taking the g-tube route. In the beginning, there’s an adjustment period where parents and the gastroenterologist figure out the proper formula type and amount to deliver through the g-tube, but when the kinks are worked out, the g-tube can be a blessing — a safe, hassle-free way to ensure children take in enough calories each day. Specialized feeding therapy, in conjunction with a skilled nutritionist, is used to wean children off their g-tubes as their ability and desire to eat grows stronger.

“G-tube kids need to relearn the hunger/satiation cycle, and keep their oral eating habits strong,” Chaya says. She recently spent three months training a g-tube baby to drink from a bottle by herself and enjoy a varied menu of foods. “I love this kind of transformation,” she says.

G-tubes, as Dr. Zaidi stresses, are not usually forever. Meir, now a strapping yeshivah bochur, has long shed his g-tube. Four years in, Yossi still uses his g-tube for an occasional feeding supplement, but he’s slowly growing out of it.

“I usually use it when he’s sick. Last week, Yossi wasn’t feeling well, and he refused to eat. I gave him a feeding through the g-tube, and he perked up. By the next day, his fever was down, and he was begging to go to school and his rebbi.”

Shulamis admits that she’s waiting for the day when Yossi’s g-tube can be removed. But whenever she gets annoyed, she remembers the time before it was inserted — and she’s grateful.

(Originally featured in Family First, Issue 923)