When would you consider speech/eating/oral therapy? Update post 6

[Buzzer Beater]

I've posted before about dd's oral issues and so far we have just kept on keeping on... nursing tons and ignoring our ped's less than enthusiasm at bf after a year... but what now? When should I be concerned?

DD is 15 months and has had oral quirks and delays from day one. She has had a terrible latch, late tongue thrust, delayed solids and interest in any foods. She still eats little, some days less than half a cup in 24 hours. (She does nurse round the clock tho and although her latch has remained shallow and painful she seems efficient at least.) Her weight gain has slowed over the months to the point she is now dropping on her curve, from the 20th to under the 10th percentile, no big deal I think. She just doesn't care to eat much still and chewing/biting food seems to be too much trouble for her. Ped suggested Pediasure which I find a little odd since I'm ummm breastfeeding!!  She's also not talking much. She understands a ton of stuff, comprehension is not the problem... she tries a lot of words, but they all sound the same. "Boo" is moon, boob, boom, shampoo, you get the idea, she's trying. She only uses b, n, m, d.

So I've got questions for you if you have a babe of similar age or remember what your babe was doing at the same age. (Our ped has repeatedly suggested oral therapies and we have resisted... but I don't have much to go by.)

How much did they eat during the day, and how many times did they nurse?

How many consonants did they have?

Would love a pep talk before I go for a check up tomorrow, mostly for dd's weight. Thanks.

[crunchy_mommy]

Wow, I'd have been thrilled if DS ate a half-cup of food at that age!! He didn't eat even close to that much until well after 18mos and only around 2yo did he finally start eating what I consider to be 'normal' amounts for a toddler. We did not do any feeding therapy, I just kept nursing him constantly and he did just fine and now is an amazing eater (will eat pretty much anything!) He probably would have eaten much more, much sooner, had we done feeding therapy, but it wasn't a big concern for us because he was growing fine (albeit slowly, though that's normal for the second year & BF babies tend to drop on the charts after the 1yr mark) and I was willing to keep nursing as much as he needed.

It doesn't sound like she's behind on words, I thought they were just supposed to have 2 or 3 words by 18mos? So it seems like she's already ahead on that... and it's normal for them to struggle with lots of sounds, as long as they are approximating some words & getting the point across, I don't think it matters that most of the words still sound the same. I can't compare DS because he was very verbal very early -- maybe that's why I felt comfortable not doing any kind of oral therapy though, because the muscles in his mouth seemed just fine... but even he had a lot of pronunciation issues early on.

So anyway, nothing you've said rings any alarm bells to me (though I'm no expert!) but I do want to say, an Early Intervention evaluation is free, easy and painless, so you could just get the eval and see what they say... it won't hurt, and if they agree she would benefit from oral therapy, you can get it started early, and if not, you (and your pedi!) can just relax.

[Buzzer Beater]

crunchy m how often were you nursing then, and I'm assuming all night too?

[crunchy_mommy]

Yikes don't use us as a gauge, DS was an 'extreme nurser' lol. He nursed 1-3 times an hour, both day and night, easily 30++ times a day.

[Terrilein]

my dd was only eating one meal a day at 18 months, too. 1/2 cup sounds about right to me. She nursed the rest of the time and around the clock. Her interest in did eventually increase by 2 years, but she's still not much of an eater altogether. Still, she's a healthy big 10 year old.

[Buzzer Beater]

Argh well just got back from the ped and she has actually lost weight, so is now in about the 2nd percentile. We are going to do EI at the request of the ped and to (hopefully) make ourselves feel better. I really really don't want her on pediasure or some toddler formula, but if she continues to lose I'm not sure what's up with our bf relationship. I feel like I nurse her all the time. And I just don't know what to do to get her to eat...

bumming here a bit, any btdt? Food tricks/tips/help?

[crunchy_mommy]

Which charts did they plot her on? The CDC or the WHO ones? Make sure that percentile is based on the WHO charts.

Since she actually lost weight (I assume you mean she dropped ounces), I would want to make sure there were no allergies or absorption issues. I'd also want to make sure she's taking in adequate milk when she nurses. Not eating table food shouldn't cause her to lose weight unless something else is going on there.

[Buzzer Beater]

Yes she has dropped several ounces. The ped uses the CDC chart and looking at her records she has gone from about the 25th percentile at 9 months to the second at 15 months. I'm not sure what the corresponding numbers are on the WHO chart but it's a drop off her own curve just the same. I wish I could be sure she is getting enough milk when she nurses- well obviously she's not. We'll do the EI (we have to wait for a clinic with specialists from another city), and we have an appt with a GI specialist in Oct in lieu of a pediatric nutritionist which we don't have in our state I'm told. The GI guy comes from Colorado to a city 2 hours from us.  It is stunning to me she could plateau in her weight, let alone lose it!

[APToddlerMama]

Originally Posted by crunchy_mommy 

It doesn't sound like she's behind on words, I thought they were just supposed to have 2 or 3 words by 18mos?

10 words by 18 months is the cut off EI typically uses for qualifying for speech therapy.  That is about a 25% delay.  One word plus mama and dada by 12 months.  OP-- I would not be worried about her speech at all, but I am glad to hear you are doing the EI evaluation for sensory/oral/motor.  What is making you feel hesitant about it?  Having worked in EI and interpreted for the speech therapists pretty frequently on the side, I've sat through a lot of feeding apts with speech therapists.  Seeing a SLP for feeding issues is typically not an unpleasant experience for kids at all.  EI works pretty hard usually to make evaluations and therapy fun.  They come to your home, sit down on the floor, talk to you, and typically don't push kids outside of their comfort zones.  The EI model is really to work with parents so that they can work with their own kids throughout the week on whatever is going on. They are really getting away from a direct therapy model, so it is much less them "doing" things to your kids, and much more them teaching you what you can do.  You are always present the entire time.   It has been a while, but outside of evaluation, they may use things like vibrating toys, flavored toys, chewy things, etc. to work on some of the issues a child with feeding difficulties may be having.  My son also spent a year and a half in EI, so we were the receipient of services too.  We had a few therapists who I wasn't thrilled with, so I fired them and we got ones I liked who were really helpful.  Hopefully that makes you feel better.  I would not hesitate to have your DD evaluated.  If there is something going on, it is MUCH better to deal with it early on...much easier to treat, and kids tend to me much more open to treatment.  I won't go into any stories about families who waited, but it was typically much much more difficult on them and their kids.  Good luck with the eval.  I hope it goes well.  You have nothing to lose. 

[Buzzer Beater]

Thanks APTM... I'm not worried about the number of words she understands or uses. I do wonder how many consonants she should have by this age, as she hasn't gained any since 9 or 10 months. Do you know what's normal?

[crunchy_mommy]

Well a lot of kids plateau with weight gain somewhere in that age range -- they are generally much more active etc. (learning to walk burns up lots of calories!!) Also, the CDC charts are not based on BF babies (who do gain more slowly than non-BF babies, and the difference is notable right around the 1yr mark on the CDC charts). I would plot her on the WHO charts, because that will show more accurately what the normal curve is for her height/age/etc. She hasn't fallen off her own curve, but a curve based on non-BF babies, if that makes sense. However, I'd still be concerned that she's actually losing weight (a few ounces wouldn't send me into panic mode, but a pound or more might!!) and would monitor closely.

I also want to second what APToddlerMama said about EI. DS is in EI for sensory issues & social/emotional delays and he loves his therapists -- LOVES them... Always asks when they are going to come, a lot of his pretend play revolves around them, he even cried hysterically when he heard us call them to reschedule his appointment once. He rarely even talks to anyone outside the family, so this is saying a lot that he's so attached to them.

[SeattleRain]

I'll be the voice of dissent. I don't really think that's normal. Specifically, it seems like the not venturing to eat food at all at 15 months sounds concerning. I'm sure there are children who don't eat at all and prefer to nurse at this age, but I'd say that's an anomaly. I don't think it's a problem that she's nursing, or even the quantity of the nursing, but the fact that she seems to have an aversion to food would bother me.

I've been down the path of the losing weight baby when DS was 6-9mos and had reflux that wasn't being controlled enough. It's really frustrating. Once my son started eating table food and not purees (around 9 months) and got the reflux under control, he started gaining weight like a champ and is now back on  his curve and a healthy 20lbs at 14mos. He never filled out or gained well on formula alone (we only FF), as it sounds like your daughter is not gaining well on nursing alone. It seems like at 15 months something should be looked at.

My son has NO words at 14 months, so we're a little concerned about speech. We recently had a hearing test (perfect) and were referred to EI for a speech eval. When I was at the hearing appointment, they said that I only had 4 more months to get him "in the system" for him to be serviced until 3. So it seems like you need to get the eval by 18 months, but that was the first I ever heard of that. I'm talking it over with my ped in a week or two and seeing if we should wait it out, but I'd confirm when the cut-off is.

[crunchy_mommy]

Originally Posted by SeattleRain 

When I was at the hearing appointment, they said that I only had 4 more months to get him "in the system" for him to be serviced until 3. So it seems like you need to get the eval by 18 months, but that was the first I ever heard of that. I'm talking it over with my ped in a week or two and seeing if we should wait it out, but I'd confirm when the cut-off is.

I wonder if this is a regional thing. I know around here that you can do the eval any time up to age 3 (though obviously past 2.5 or so it probably wouldn't be worth it since they'd age out soon). We had DS's eval sometime after he turned 2 (maybe 26mos??).

SeattleRain, according to the Denver Developmental Milestones chart, if I read it correctly, most (75% of) kids have 1 word by about 14mos, 3 words by 16mos, and 6 words by 21mos.

OP, the one thing that stands out to me is that in your first post, you said she's had oral quirks since day 1. That says a lot. We know our kids best. Even if I couldn't pinpoint specific issues that sound like a big deal to anyone else, I've always known DS had sensory issues and that's what prompted us to do the EI eval. Sure, lots of kids probably do some of the things that DS does, and they don't have sensory issues, but DS's issues are quite obvious to me & most people who are close to him and the little things were all part of a bigger issue. So just because your concerns might not sound super worrisome to all of us, doesn't mean they aren't valid concerns... and the particular combination of concerns you have certainly merit further investigation.

[Buzzer Beater]

crunchy mommy she drops on the WHO charts considerably too- from around 40 to around 17 or so? It's hard to tell from this paper but we do track her on WHO at home.

SeattleRain we went through reflux as well and it sucked. She's just been off medication for about 2 weeks now. Ya know it's not that she doesn't eat ANY food, she does like fruits and certain ones she'll eat a number of. But she doesn't accept most of what we eat, or at least won't like anything more than once (she does seem willing to try things at least once, doesn't balk at new stuff). For instance she really grooved on guacamole but now she won't eat it. Same with cheese. She won't eat eggs, won't drink any kind of milk, no oatmeal, no chicken, sweet potato, toast, you get the idea. She will eat black beans also, and curried lentils. At least she did. It wouldn't surprise me if she refused them next time I make them. What does your guy like to eat? BTW were you in the June '10 ddc and went late? I was in there and went early, your UN is sooo familiar.

[mckittre]

Don't know what's normal, but my son (been between 5th and 10th percentile for a long time, but always a pretty good eater, now a 2.5 yr old jabberbox) didn't really have any more consonants at that age.  In addition to your list, I think he could say an "s" sound as in "ice."  And he also used a limited array of sounds to try and make a lot of different words in combination with signs, etc...

[SeattleRain]

Originally Posted by Buzzer Beater 

crunchy mommy she drops on the WHO charts considerably too- from around 40 to around 17 or so? It's hard to tell from this paper but we do track her on WHO at home.

SeattleRain we went through reflux as well and it sucked. She's just been off medication for about 2 weeks now. Ya know it's not that she doesn't eat ANY food, she does like fruits and certain ones she'll eat a number of. But she doesn't accept most of what we eat, or at least won't like anything more than once (she does seem willing to try things at least once, doesn't balk at new stuff). For instance she really grooved on guacamole but now she won't eat it. Same with cheese. She won't eat eggs, won't drink any kind of milk, no oatmeal, no chicken, sweet potato, toast, you get the idea. She will eat black beans also, and curried lentils. At least she did. It wouldn't surprise me if she refused them next time I make them. What does your guy like to eat? BTW were you in the June '10 ddc and went late? I was in there and went early, your UN is sooo familiar.

Yeah, I was in the June DDC. I ended up over 2 weeks late so our babes are probably a month apart.

I don't know if you're aware of this but babies with reflux can have a higher chance of having oral issues and speech delays and feeding problems.  I think there are a few theories on why this is the case. Some say it has to do with being in pain during feeding as an infant and associating food with pain. Some say that perhaps their throats are actually damaged from the reflux and it takes time to heal and in the meantime can burn the back of their throat. I've heard that because reflux indicates an immature/underdeveloped GI tract it may indicate other immature/underdeveloped areas. I'm not really an expert, but I know there's a connection. Maybe this is why your ped is being more aggressive about her oral problems. I know my ped is being a little more aggressive about Daniel's speech problems because he has the added reflux issue.

Daniel is a great eater these days. He was late to getting teeth, and I think that was part of his resistance to texture or table food. Now he has 6 teeth and eats lots of things. His favorite foods are chicken, eggs, yogurt, black beans, and tubes of fruits/veg like the Ella's Kitchen foods. He would literally eat cheese all day long, but it makes him constipated so I have to restrict how much dairy he gets. He's been into blueberry waffles from Trader Joes lately for breakfast. I theorize that he associated the bottle with the pain of reflux and that's why he used to refuse feedings when he was younger, but we had him on a good dose of meds when he started solids so he doesn't associate the food with pain. It's possible that your DD has the opposite problem, as some babies with reflux hate nursing/feeding (mine) and some want to nurse all the time because the pain isn't there while they're nursing (yours maybe).

In any case, I'd get it checked out. But I tend to be more interventionist in general and less relaxed about things, which sometimes means I overreact to things. But it also means that I've caught things early that might have gone on for too long if I hadn't been so proactive.

[ElliesMomma]

just dropping in/crashing...

... but wanted to point out that giving pediasure does NOT have to sabotage your breastfeeding relationship! just like when you introduce food, always NURSE FIRST. when the baby is done nursing, offer the food (and if she won't take any, offer some pediasure). then, in a little while, nurse again. nurse, nurse, nurse. but after every nursing, offer some food, then some pediasure.

there is nothing inherently bad about pediasure in the case of a baby who is losing weight. your baby needs to be gaining for important brain functions, to build bone mass, to grow!!

also, if you still have pain while nursing, 15 months in, there is a problem with the latch for sure. and it cannot be very efficient nursing.

if i were you, i'd up my intake of oatmeal, maybe try some fenugreek. and redouble efforts to improve the latch. take a nursing "vacation" and park it in bed with her for the weekend. be topless so she can have constant access. do you nurse side-lying? best position to work on latch, IMO.

you say she understands everything? explain it to her -- when she latches and it hurts say, "honey the way you are attaching your mouth to my breast hurts. can you pull off for a second and try again -- try to get it in your mouth up to here (or whatever)"

hope this helps a bit. 

[APToddlerMama]

Originally Posted by Buzzer Beater 

Thanks APTM... I'm not worried about the number of words she understands or uses. I do wonder how many consonants she should have by this age, as she hasn't gained any since 9 or 10 months. Do you know what's normal?

It has been a long time since I have worked in EI and my own son who had a speech delay is 3.5 now, so off the top of my head, I can't think of exactly what she should have.  I know a T sound should typically be there but can't think of what other sounds.  The SLP who sees her will tell you, though I doubt they'll see any need for speech therapy for speech purposes.  Sorry I can't be more help! 

Originally Posted by crunchy_mommy 

I wonder if this is a regional thing. I know around here that you can do the eval any time up to age 3 (though obviously past 2.5 or so it probably wouldn't be worth it since they'd age out soon). We had DS's eval sometime after he turned 2 (maybe 26mos??).

SeattleRain, according to the Denver Developmental Milestones chart, if I read it correctly, most (75% of) kids have 1 word by about 14mos, 3 words by 16mos, and 6 words by 21mos.

That must be regional or even more likely, a mistake... EI is a federally funded program with (unless things have changed since I worked for them) a requirement to service children from birth to three.  EI has 45 days to start services after referral, so the EI program I was in took referrals for kids up to 33 months.  After that, we referred to school which is what we had to do anyhow 90 days before the third birthday.

The Denver is notorious for under-identifying kids with speech issues. It tends to find kids with fairly typical motor and social emotional skills "suspect" more than it should as well.  It is really just a screeening tool, not a good evaluation tool.   

[bananabee]

My baby girl, 14.5 mos, isn't eating much either, and I'm a little concerned. All she wants is cheerios and grapes, half of which she just wants to play with and end up on the floor. I've had to reduce how much I feed the dog to compensate. I can get her to eat cheese, bread, and tortillas sometimes, too, and yogurts. I'm sure I'll win mom of the year for this, but the only way I get her to sit and eat is if I put on a movie and kind of ignore her. We're down to nursing once before bed, once in bed, and once in the morning. I am so drained of energy at this point, I really need to stop BF. I can barely function and need to go back on my medications. I feel like I'm getting depressed and need to go back on meds for that, too. I need more energy so I can put more into cooking healthy foods for her and make eating more fun. 

[Buzzer Beater]

Originally Posted by ElliesMomma 

also, if you still have pain while nursing, 15 months in, there is a problem with the latch for sure. and it cannot be very efficient nursing.

Thanks for your thoughts ElliesMomma. I'm going to revisit the Pediasure thing with my dh tonight... and the latch thing, yeah. I've seen 5 or 6 different lactation counselors since dd was born and I can't get her to take more than the nipple. Even now when I try to work with her on it she will just refuse to eat rather than relatch. It's very frustrating.

If anyone is interested I found a really cool link on speech development and acquisition... I think I'm not so worried about the speech at this point and will just focus on the food issues. http://www.speech-language-therapy.com/ASHA03McLeodBleile.pdf