EATING AND

DRINKING 4
This module covers
the following information:

Eating and drinking

Feeding your child
Helping your child to eat and drink
enough and ‘safely’
1. Environment and hygiene
2. Diet
3. Food textures
4. Positions for feeding
5. Utensils
6. Kind and supportive feeding methods
Practical feeding session
Towards independent eating
Monitoring progress
Sharing emotions and feelings

Important: This is a long module

that can be split over 2-3 sessions.

Module 4: Eating and drinking_June21_Version2 | © LSHTM 55

 EATING AND DRINKING
Materials
Flipchart, pens, jug of water, glasses, dessert spoons, yoghurt and face cloths,
poster 4.01, pictures 4.02, cards 4.03, pictures 4.04a-e, 4.05a-b and 4.06a-b.

For demonstrations: Large rag doll, supportive seat with straps and a tray
if possible, small towels, normal chair, large glass, small plastic beaker, dessert
spoon, strong plastic teaspoon.

Feeding session: Small plastic beakers and plastic teaspoons.

Facilitator Tips:
Eating and drinking are important for the health and growth of all children. Muscle
tone and co-ordination of children with disabilities can be different to other children
and this may change the way that they eat and drink. This creates a risk of food or
drink going down the wrong way, onto the lungs, and a child being unable to eat or
drink enough (risking malnutrition and dehydration).
Some of the advice in this module includes asking caregivers to modify the food
they prepare so that it is easier (and safer) for their child to eat and more nutritious.
It is important to recognise that preparing food that is made especially for their
child can be challenging for many caregivers due to a lack of money and time, or
maybe because they are sharing cooking facilities with many other families. These
barriers, and possible ways round them, need to be discussed.
Identifying local nutrition programmes and knowing what they offer is important,
to help you to clarify how the most vulnerable children and families could be linked
into their services. Some services don’t work with children with malnutrition caused
by disability alone but only those with diarrhoeal disease, for example. During
routine health appointments, the medical team will assess a child’s growth and
body weight. It is important parents understand this is to help them access local
services and support if there are any issues with nutrition that could slow a child’s
development.

Icebreaker
In pairs, take it in turns to feed one another yoghurt using a dessert spoon.
The person being fed should have their head leaning back, then turned to
one side, then flopping forwards.

“How easy or difficult is swallowing in this position? How does it feel?“

Explain
Explain what we will learn together over the next few sessions.

Module 4: Eating and drinking_June21_Version2 | © LSHTM 56

 By the end of module 4, you will:

1. Understand the difficulties your child may have with eating and drinking.

2. Find feeding her easier, more enjoyable, and safer.

3. Know how to help her eat more independently.

4. Know how to give your child a balanced diet and increase her nutritional
intake.

FEEDING YOUR CHILD

Ask
“What does your child eat and drink? Does your child drink out of cups or
bottles?”

“Have you started giving your child solid foods yet? What kinds of food do you
give? (eg. runny, mushy, crunchy, chewy?)”

“What utensils do you use?”

Write a list of the foods that everyone mentions to use later in the food grouping
activity.

Facilitator Tips:
We found that we needed to change the order of these key sections because the
children were ready to eat at the start of the session. It is OK to change the order
of the following sections to feed the children when they are ready. You can do other
activities/discussions with everyone when the children are asleep.

Ask
“What problems do you have feeding your child?”

Explain
The following are common:

Difficulty controlling her head

• Her head is floppy and she can’t keep it upright/

Difficulty controlling her body

• She cannot sit upright by herself.

• It is difficult to hold her body upright when feeding her as she pushes back
and can’t keep still.

Module 4: Eating and drinking_June21_Version2 | © LSHTM 57

 Difficulty controlling her mouth/lips/tongue

• She struggles to close her mouth and food or drink falls out.

• She struggles to chew her food.

• She pushes the food out of her mouth with her tongue.

• She only eats soft food.

Difficulty with food/drink going down properly

• She coughs or chokes when eating/drinking.

• She finds it hard to breathe.

• She vomits her food back up during the meal.

Difficulty eating on her own

• She struggles to hold things and bring them to her mouth.

Mood

• She is often unhappy during mealtimes and won’t eat.

Other problems

• Vomiting after eating due to ‘reflux’.

• Frequent chest infections cause by food and/or drink going down the
wrong way into the lungs.

• Constipation, due to problems with digestion and/or dehydration.

• Parents often feeling very frustrated because feeding is so difficult.

HELPING YOUR CHILD

TO EAT AND DRINK
ENOUGH AND ‘SAFELY’
6. Kind and
supportive
5. Utensils feeding methods

4. Positions
for feeding
3. Food
textures
2. Diet

1. Environment
and hygiene

Module 4: Eating and drinking_June21_Version2 | © LSHTM 58

 Activity 1
There are 6 things to consider in helping your child eat and drink better. We will
learn together about how these steps lead to safe and responsive feeding.

1. Environment and hygiene

2. Diet

3. Food textures

4. Positions for feeding

5. Utensils

6. Kind and supportive feeding methods

1. Environment and hygiene

Ask
“Has anyone got any tips on hygiene?”

For example: don’t use a dirty cloth to clean with because our children are at
a high risk of infection.

Write the list of examples on the flip chart.

Ask
“Where do you choose to feed your child, and why? What is your routine
before you feed your child?”

Discuss that everyone may have different places where they like to feed their
child for different reasons. Cleaning routines should include washing both
your hands and the hands of your child with soap and good water, as well as
the utensils.

Ask
“If your child gets distracted when eating, what is she distracted by?”

Ask what solutions everyone has found to decreasing distractions.

2. Diet
Activity 2
Discuss with a neighbour: “When and why was your child introduced to solid
foods?”

Explain
When a child reaches 6 months, she needs to have solid food as well as
milk in order to grow, even when she has developmental difficulties.

Eating and drinking are important for nutrition and hydration, and so for

Module 4: Eating and drinking_June21_Version2 | © LSHTM 59

 growth and health. Eating and drinking are also important for exercising parts
of the mouth that are helpful for learning to talk.

If your child finds eating and drinking difficult, giving small amounts often will
build up her nutrition.

Ask
“What is a nutritious or ‘balanced’ diet?”

Good eating and drinking helps your child stay healthy, hydrated, develop
and grow.

Explain
Explain that poster 4.02 shows all the food groups that your child needs.

On the flipchart, list what foods you eat the most.

EN
ER
GY
DAIRY G
PRODUCTS

IV
ING
D
OO

FO
D Y B U IL D I N G F

OD
ANIMAL PROTEINS FATS/OILS

FRUITS
LEGUMES
BO

D
O
O

F
E
T IV
PRO TEC

Activity 3
Draw a circle divided into three sections labelled:

• Body building foods

• Protective foods

• Energy giving foods

Show the different local foods and ask everyone to place the food into the
three groups. Also use the list you made earlier of foods that they give their
children. Each child needs a combination of these foods to grow, develop,
and gain weight.

Explain
Children with developmental difficulties need a balanced diet that is especially
high in energy, which comes from fat and oil.

Your child may get tired easily when eating and this will increase the risk of
food going down the wrong way to her lungs. It will also mean that she can’t
eat a large amount of food at one time. She therefore needs small meals
given more often (e.g. 6 small meals instead of 3 bigger meals).

Module 4: Eating and drinking_June21_Version2 | © LSHTM 60

 Children need the equivalent of at least 4 cups of fluid per day. As drinking
can be difficult, your child will need to take sips of fluid throughout the day.
This will help reduce the side-effects of dehydration, such as constipation,
and give her more energy. Constipation is very common in children with
developmental disabilities and can cause them pain and discomfort.

Ask
“How can your family help to increase the amount of water that your child
drinks through the day?”

Avoid adding sugar to your child’s food and drinks. Try to add pureed fruit
instead. If children get used to sugar added to their food, they will not accept
food that is not sweet later on. Also, sugar causes tooth decay and health
problems later.

Changes as your child gets older:

As children grow, they start to breastfeed less and eat more, and begin to
drink water from a cup.

For example:

Children who are less than 9 months old

• Mainly breastfeed.

• Start learning to drink sips of water from a cup.

• Start eating 2-3 small meals (each meal about 2 full tablespoons) a day.

Children 9 and 12-month old infants

• May start breastfeeding less and drink more water.

• Start eating 4-5 meals (each meal about 4 full tablespoons).

Infants over 1 year

• May continue to breastfeed, but take more water from a cup.

• Now need to eat more food (approximately 6 meals a day).

3. Food textures
Activity 4
Show a banana, a biscuit, and other common foods.

Ask
Ask if the food items are:

• Hard or soft?

• One type of texture or more?

• Can they be made into smooth puree?

• How can they be made into puree?

Module 4: Eating and drinking_June21_Version2 | © LSHTM 61

 Liquids: Liquids are runny and can be difficult to control in the mouth.
Liquid runs quickly and can go down the wrong way, into the lungs, if your
child cannot control it well. Liquids should therefore be given very carefully or
thickened by missing something with them.

Solids: When we introduce solids, children must get used to eating food
that’s firmer than milk, and feels different in their mouths. Your child may
have difficulties chewing. This is because she does not have the muscle power
or coordination, so we need to make solid food that is moist and soft so she
can manage it.

We start with smooth food – not too runny, not too solid. As your child starts
to develop better control over her tongue and mouth, you can slowly increase
the thickness of the food. This helps to develop chewing skills and enables
your child to eat food that is richer in nutrition (because it is less liquid).

Children with developmental disability have difficulty controlling food that has
more than one texture, with both hard bits and liquid, such as bean soup.

For example, banana can be pureed by mashing with a spoon. A biscuit can
be moistened with some milk.

It is difficult for children to manage a mix of textures in the mouth at the same
time. All foods that are not puree must be made into smooth puree until your
child is able to chew.

Activity 5
“Knowing what you now know about nutrition and food texture, which of these
are easy or difficult textures to eat?”

• Biscuits

• Ugali or kichuri

• Rice with cabbage or kale strips

• Chappati

• Pumpkin

• Mandazi or samosa

• Mashed avocado

• Mashed beans or dhal

• Stew or fish curry

• Matokeor banana

• Yoghurt

“Why did you give those answers?”

Explain that, in addition to avoiding runny or mixed consistencies, children

with chewing and swallowing difficulties should avoid ‘tricky’ textures (such as

Module 4: Eating and drinking_June21_Version2 | © LSHTM 62

 bitty, crumbly, dry, crispy, chewy, stringy, floppy), as these may cause choking
-prevent your child from breathing- or it may go down the wrong way and
cause a chest infection.

This is the right answer:

Biscuits Ugali or kichuri

(dry, crumbly and not usually (smooth and nutritious)
nutritious)

Rice with cabbage or kale strips Pumpkin

(rice breaks up in the mouth and (smooth and nutritious)
cabbage or kale is floppy)

Chappati Mashed avocado

(chewy) (smooth and nutritious)

Mandazi or samosa Mashed beans or dhal

(crispy, chewy and dry) (smooth and nutritious)

Stew or fish curry Yoghurt

(mixed consistency) (smooth and nutritious)

Matoke or banana
(smooth and nutritious but can be quite chewy - some children might manage
this, some not)

Activity 6
Give everyone a sieve, a spoon, and a bowl. Place some bean / vegetable
soup with liquid into the sieve and show how to crush the bits into a smooth
puree as seen in the pictures below.

Module 4: Eating and drinking_June21_Version2 | © LSHTM 63

 4: Positioning for Feeding
This is a good time to reinforce positions learned in last session.

Head and body: Sitting upright. Head facing forwards and neck long.

Shoulders and arms: Forwards.

Legs: Hips and knees bent at 90°.

Activity 7
In 2 groups, look at the card sets (a+b) showing different positions.

Ask the groups to choose which they think is the best position for feeding from
each set.

Ask
Ask a different person each time to explain one card: “Can you say why you
chose one position rather than the other?”

Explain
Both a child and the caregiver need to be positioned well. Children are held
in a reclined position when they are breastfed. As they get older and their
neck becomes longer, they need to be held more upright to make sure food
doesn’t go down the wrong way onto their lungs. Lying down is not a ‘safe’
way to feed as it causes chest infections, which are dangerous for your child.

Module 4: Eating and drinking_June21_Version2 | © LSHTM 64

 Sitting up also allows children to chew and swallow more easily and to learn
to feed themselves. It also reduces the risk of vomiting.

Activity 8
Sit on a chair in the middle of the group in a poor position.

Ask the group how they would change your position to make it better for
eating. As each person makes a suggestion, ask them to come and correct
your position.

Point out that if you start with the bottom and hips and get them centred and
at the back of the chair, it is easier to position the rest of the body.

Use a doll (or one of the children in the group) and demonstrate how to
position a child for feeding when sitting on a chair or sitting on the floor.

Show pictures 4.04a and b, act out the positions with the rag doll, and
explain how to position well.

Lap feeding:

Feeding your child on your lap is more suitable for younger smaller children.

On a chair, couch or bed:

• Make sure you are comfortable.

• Keep your upper arm against the top of her head and not behind her
neck. Make sure you can see your elbow.

• Hold your child’s bottom firmly between your legs so that she cannot push
back.

Module 4: Eating and drinking_June21_Version2 | © LSHTM 65

 • Support her knees with one leg and her back with the other. Raise the leg
that is supporting her back by putting something under your foot.

• Bring her arms forward and shoulders forward.

On the floor:

• Lean against a wall.

• Put a cushion under your raised knee.

• Make sure your child’s bottom is well between your legs with her hips
bent.

• For a bigger child, or for one who pushes back very strongly, try resting
her bottom on the floor and push her legs towards her chest.

• Place your leg across her feet to hold them flat.

Other ways to help good positioning:

• If your child is sinking down too far between your legs try putting a towel/
blanket underneath her.

• If her back is rounded give her something to lean against.

• Use a supportive chair.

Feeding in a supportive chair (4.04 c-e)

Photo by: CECHE Foundation Photo by: Motivation

It is good to get children used to sitting in a supportive seat as early as

possible. Independent sitting is an important part of developing and being
able to learn about the world around you. At mealtimes, a supportive seat
can help children to learn to eat better and feed themselves more easily. It
also allows the caregiver to concentrate on providing sensitive and supportive
feeding methods, not having to worry about positioning as well.

Supportive seats can be made locally out of low-cost materials. Children

who need full support for sitting will need a seat with a slightly tilted back.
Tilting the seat as well as the backrest will keep a 90 degree angle so that
a child will not slide out. A soft, washable lining will help a child to be more
comfortable. Rolled up towels can be used as padding, to make sure children

Module 4: Eating and drinking_June21_Version2 | © LSHTM 66

 are well supported around hips and body, as well as behind the head and
neck. Also make sure the seat is the right size - a child should be able to sit
with their buttocks against the backrest, or they will slide forward.

Summarise:

• Position your child well before feeding her.

• Good positioning will make feeding easier and safer.

• Make sure her head is not leaning back or flopping sideways, and that
her chin is tucked in so she can swallow safely.

• Playing with your child in these positions will help her get used to them.

5: Utensils
SPOON
Show a small metal spoon, a big metal spoon and a strong plastic teaspoon.

Ask
“Which is better for feeding your child and why?”

Make sure the following points are covered:

• A good quality plastic teaspoon is best, it gives small mouthfuls, which

are easier and safer for your child, and it prevents harm if your child bites
hard onto it.

• Metal is often too hard/sharp for your child’s mouth.

Activity 9
In pairs:

• One person is the caregiver and the other is a child.

• Take the caregivers away from the group so that the ‘children’ cannot
hear what you are telling them.

Module 4: Eating and drinking_June21_Version2 | © LSHTM 67

 • Tell the caregivers that they must feed the ‘child’ very quickly with the
big spoon.

• The caregiver then feeds the ‘child’ with a few big spoons of yoghurt very
quickly.

Explain
A child’s tongue moves forwards and backwards when she drinks from the
breast or bottle. As she gets older, your child has to learn to use different
tongue movements to manage more solid food.

When using a spoon to feed your child:

• Give food from the front and straight.

• Give food at the right pace for your child.

• Place the spoon with the food touching the top lip so that she can feel it
and use her top lip to remove the food from the spoon.

• At first she will suck on the spoon like she did on the breast/bottle but this
will change.

• Your child should bring her jaw up, but if she doesn’t, place your finger
under the jaw and give some support.

Don’t lift the spoon up and drag it against the top gum when taking it out -
keep the spoon straight as you take it out of her mouth.

Remember, some children who are breast or bottlefed may not like to eat
from a spoon or drink from a cup at first. Keep trying and they will get used to
it.

You can encourage your child in independent feeding by putting her hand on
the spoon. You can put your hand over her hand. Together, hand over hand,
you can help your child to learn to feed herself.

CUP
Show a plastic cup and a plastic cup with one side cut away. Pass them
around for participants to try.

Module 4: Eating and drinking_June21_Version2 | © LSHTM 68

 Facilitator Tips:
The cut-out section in the cup allows the cup to be tipped upward without having to
move a child’s neck back in order to finish drinking. Children drink from the side
that is not cut out.

Activity 10
Ask everyone to look up to the ceiling and try and swallow.

“How difficult does it feel? What kinds of cups do you think are better for
giving your child a drink and why?”

Make sure the following points are covered:

• The cup that is not cut away makes your child tip her head back to drink,
making swallowing the liquid harder.

• When using the cut away cup you can see the liquid in the cup and how
much you are giving your child.

• You can also use a short clear cup that you can see through e.g., a
medicine cup.

Explain
A cup is introduced when

• Your baby cannot suck or gets tired on the breast or bottle.

• Your child is 6 months and ready to drink sips of water.

Ask
“What could go/has gone wrong with cup feeding?”

Write up responses and use the list below to ensure all the following

difficulties are discussed:

My child:

• May not wake up enough to drink.

• May not actively swallow.

• May spill liquid from her mouth.

• May cough/choke.

• Might breathe the liquid into the lungs.

• May not control how fast the liquid comes out of the cup.

Module 4: Eating and drinking_June21_Version2 | © LSHTM 69

 Explain
• Your child needs to be alert and able to suck/sip.

• Position your child upright.

• Present the cup at your child’s lips and tilt it a little allowing the liquid to
touch the upper lip then wait. Do not pour liquid into the mouth.

• If your child struggles to close her mouth, help her by placing your finger
under the jaw and lips for support.

• Give single sips and observe the swallow.

BOTTLE FEEDING
Ask
Many parents use bottles to feed their child when they are older.

“Who feeds their child with a bottle? Can you explain why?”

Facilitator Tips:
Many participants are apprehensive about changing the way that they feed their
child, because either it is easier or they find it difficult to feed their child with a
spoon or a cup. This is a good place to gently start this conversation.

• Reinforce the message that the cup will help their child to learn to sip and
swallow well.

• Bottles encourage tongue patterns that babies use.

• This makes it harder for your child to learn to eat food.

• Being fed with a bottle discourages independence and self-feeding.

• Feeding purees through a bottle is unsafe as your child needs to use

more mature tongue movements and be sitting more upright in order to
swallow puree safely.

• The teat of a bottle can easily carry germs and so is less hygienic.

Activity 11
Allow everyone to try out cup feeding.

Observe and advise to ensure correct technique.

6. Understanding how your child eats: kind and

supportive feeding methods
Activity 12
In groups of three, discuss other things that you think are important in helping
your child to eat and drink well.

Module 4: Eating and drinking_June21_Version2 | © LSHTM 70

 “What do your child’s reactions to food and drink tell you?”

Ask the groups to share their ideas.

Ensure that the following points are covered:

• Give small mouthfuls, and one mouthful at a time.

• Give your child plenty of time.

• Provide support to her jaw if she struggles to keep her mouth closed when
there is food inside. This will reduce the amount of food she spills from
her mouth and therefore help her to eat more.

• Talk to her and encourage her to eat and have fun at mealtimes.

• Be gentle. If she cannot finish her food because she is getting tired, stop
and offer her a little more later.

• Watch your child’s reactions to see when she is ready for the next
mouthful. Never force feed. Allow her to be involved eg. touching your
hand/the food/the spoon etc.

• Start with food – finish with a sip of water or milk so that she doesn’t fill up
on liquid before eating.

Summarise that being kind and sensitive protects children from feeding
methods that put their health at risk (eg. force feeding), they make mealtimes
more relaxed and enjoyable for both a child and person feeding them, and
they encourage a child to want to eat more.

PRACTICAL FEEDING
SESSION
Activity 13
Show the ‘Before and After’ clips.

After each ‘before’ clip, ask everyone “What difficulties the children are having
and how you could improve? What is different in the ‘after’ clip?”

Sit in a circle and either give your child a drink or feed her some yoghurt, trying
to follow all the advice. Encourage everyone to help one another.

In Bangladesh the video clips were a good way of encouraging discussion.

You will need to make your own video clips of children demonstrating good
and poor feeding practice –ask parents if they are happy for you to film
their children and explain you will use them to help other parents.

Module 4: Eating and drinking_June21_Version2 | © LSHTM 71

 TOWARDS
INDEPENDENT EATING
Explain
Explain why it’s good:

• You are very busy and may not always have enough time to feed your child.

• Your child will be more interested in eating and less reliant on you.

• Children enjoy feeling independent and react against a feeder that is

‘controlling’.

• Try not to worry about mess, all children make a mess when they are
learning to eat.

“Has anyone tried to do this with their child?”

Explain using a doll:

• Guide her hand to help her.

• Put a banana in her hand and guide it to her mouth. You might be
surprised at how much she manages to feed herself.

• Don’t stop her putting her hand in her food and trying to feed herself.

• Put a wet cloth under the bowl to stop it moving.

• Bend the spoon and put padding on the handle to make it easier to grip
and get into her mouth.

Ask
“What one thing have you learned today that you will now do differently
at home?”

“What one thing will you try to help your child feed herself?”

Module 4: Eating and drinking_June21_Version2 | © LSHTM 72

 MONITORING
PROGRESS
Ask
Think back to session 2 where you looked at stepping stones to help your child
learn:

“What have you learnt today that would help your child practice these?
What are you going to do at home from today’s session to help your child’s
development?”

Take Home Messages:

• Your child may take time to learn to chew and eat solid foods and drink from a
cup. She needs help to learn these skills in the right way.
• She may have difficulties with eating and drinking. These difficulties can result in
malnutrition, dehydration and chest infections. There is a lot that you and your
family can do to help reduce these difficulties.
• If your child frequently vomits during or after meals, it is important that she is
seen by your medical team.
Things you can do:
• Position your child in an upright position, with her chin tucked in slightly.
• Feed her small and frequent meals of a balanced diet, which has extra fat or oil
in it.
• Introduce foods that are smooth and moist. Not too runny, not too solid or
chewy.
• Give your child small spoonfuls of food and small sips of water, slowly, using a
small plastic spoon and small cup.
• Give positive verbal encouragement and do not force feed.
• Teach other family members to feed your child in the same way you do.

Module 4: Eating and drinking_June21_Version2 | © LSHTM 73

 SHARING EMOTIONS
AND FEELINGS
Ask
“How did this session feel? Did it raise any emotions or feelings that you did not
expect? How have you been feeling this week?”

Allow time for discussion and interaction with each other.

Facilitator Tips:
Situations that can be challenging is if answers is unspecific: for example
“everything is ok” or “I am tired”. You can encourage everyone to talk more by
asking “why?” or “what happened” or “how do you feel about that?”

Module 4: Eating and drinking_June21_Version2 | © LSHTM 74