CVI Mealtime Strategies

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As soon as I received my daughter’s Cortical Visual Impairment (CVI) diagnosis in 2018, I began researching, reading, and brainstorming ways to help her begin using her vision throughout her daily routines (you can check out my introductory CVI reading recommendations here). 

The very first adaptation I can recall implementing was the mealtime strategy of placing a shiny, red gift bow on the handle of Rosalie’s spoon (I think I got this idea from reading the Little Bear Sees book?). At the time, Rosalie was 7 months old and her mealtimes consisted largely of being fed purees on a spoon. Prior to my learning about CVI, she never seemed to open her mouth in anticipation of the spoon; rather, she would open her mouth only after I gently touched the spoon to her lips. In hindsight, it’s pretty obvious that she didn’t see the spoon coming! 

Fast forward to placing a red, shiny bow on her spoon…and voila! Rosalie began opening her mouth as I brought the spoon towards her. That first easy adaptation literally changed our lives – and reminds me that even the simplest changes can be made to provide my daughter access to the visual world.

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Our CVI mealtime strategies have evolved numerous times throughout the past 2+ years, so today I’m sharing some of what has worked for us. Perhaps it will spark new ideas for your own mealtimes!

After placing the bow on the spoon, I began thinking about additional CVI characteristics that could be impacting meals.

“Attention to light” was easily addressed by ensuring Rosalie sits with her back to the kitchen windows. Overhead and natural lighting were never distracting for her, but someone more greatly impacted by lighting could possibly benefit from adjusting the lighting (dimming lights, closing blinds/shades/curtains) and/or shining a flashlight or finger light on a visual target.

“Complexity” was a big factor to consider with meals, and is something I’m still constantly addressing nowadays. One strategy I’ve sometimes used to minimize visual complexity is placing a background behind the food on the high chair tray or table. This blocks out the array of what’s on the table and/or in the distance and helps draw the visual attention to the food.

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Complexity is also addressed by minimizing the array on the tray/table (not placing too many foods or utensils at one time) and paying attention to the sensory (mostly auditory) environment. We intentionally keep distracting background noise off and I have been known to remind some rowdy big brothers once or twice (give or take a thousand) to use indoor voices – and sometimes instruct them to play the “quiet game” so Rosalie can focus on eating. 😉

“Preferred visual fields” were addressed by blocking out visual distractions (with a background) in the direction Rosalie would most often look towards. In the early days, this also meant that I positioned myself on Rosalie’s right in order to help her notice the spoon more quickly (latency). As functional vision progressed, I began intentionally feeding her while I sat on her left side – which was an appropriate challenge (for her) that encouraged her to look towards and use her often (at the time) neglected left visual field.

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“Color” is another CVI characteristic that needs to be addressed in the earlier phases of CVI and can still be very successfully utilized well into Phase III. In the beginning, I began addressing color in two ways:

  1. consistently using a bright, solid red spoon ONLY and
  2. considering the color contrast at play.

Gradually, I introduced a second spoon color (yellow), then a third (blue), until eventually it didn’t matter what color the spoon was in order for Rosalie to visually attend to it. Someone that has a clear color preference and/or is still in the earliest phases of CVI would likely benefit from consistent use of the same solid color for plates, bowls, cups, or utensils at every meal.

Rosalie was too young for plates and bowls, so anything she ate or used was placed directly on a high chair tray. If I planned to feed her a dark food, it would visually disappear on her black tray – so I would put the top (cream-colored) tray back on.

Here’s an example:

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In this first photo, the bar in an orange wrapper and bright-colored spoons stand out against the black background of the high chair tray. But look what happens as soon as the bar is unwrapped:

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The dark-colored bar is much more challenging to visually find on a dark background.

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After placing the cream-colored top tray back on the high chair, everything is clearly visible due to the more drastic color contrast.

As Rosalie’s functional vision continued to improve, I relied less on visually blocking out the rest of the table and simply focused more on keeping the table area immediately in front of her uncluttered. This allowed her to start paying attention (visually) to the rest of the family a little more, although distance-viewing (due to complexity) was still a challenge.

Occasionally I will bring back the black background in order to visually introduce something new or teach a specific food-related concept/item.

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You can see in this photo there is nothing on the high chair tray except a red bowl, yellow spoon, and a Talktools Honey Bear Cup (a wonderful cup for children learning how to sip through a straw and/or that need help developing some oral motor skills). Here I placed a black background (by turning an inexpensive black bin on its side) in front of the high chair in order to eliminate background distractions. This helped whenever I introduced a new item. Here’s something you might have overheard when Rosalie began eating food out of bowls:

“This is a bowl. It is round and it can hold things inside. This bowl is red. It is smooth and hard. Here are the round sides – and here is the smooth bottom. Here is your yellow spoon, with its long handle for holding and a round scoop for food. I’m going to put the spoon inside the bowl. Do you see the yellow spoon inside the red bowl? Now I took the spoon out of the bowl. Next, I’m going to put some food inside the bowl. Here is a box of Cheerios. I’m opening the box and the loud, crinkly bag. The Cheerios are inside the bag; now I’m going to pour them in the bowl. Do you hear that sound? I poured the Cheerios in the bowl. Now they are inside the red bowl. We can reach inside and pick them up.”

The above conversation would be paired with appropriate pauses to accommodate visual latency – and to allow Rosalie to look at and touch everything before moving on.

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Additionally, I could use the black background to showcase a new food item, like the bag of peanut puffs featuring familiar Elmo’s picture (seen above). Generally speaking, I tend to dislike the commercial use of characters on food items geared towards children – but in this case I love that Elmo is on this bag! Rosalie recognizes Elmo in 2D and not only loves to look at his picture, but she especially enjoys holding the bag and listening to the crinkle sound it makes. The familiar picture of Elmo actually motivated her to try this new food (always an exciting, important “inchstone” over here).

Note: an orange flashlight and small finger light are seen next to the “Elmo bag.” Shining these lights are not part of a strategy that I need to use, but can be very helpful to some individuals – and can still be fun or useful even for kids in late Phase II or Phase III CVI.

Rosalie has a brain condition (hydrocephalus), which causes babies to be born with larger (heavier) heads, which translates to delayed gross motor skills – like not being able to sit upright in a high chair at a typical age.  This means I have always had to consider the physical complexity of a task as part of the CVI characteristic of “complexity” during meals.

A child with CVI that cannot sit upright independently needs to be supported in order to maximize their functional vision while seated. This is because a child with CVI will not be able to access their vision as well if they are simultaneously working in a physically challenging position. To eliminate this barrier to visual access, we used a supportive high chair well beyond age two. 

Almost a year after Rosalie began sitting independently, we gradually introduced a booster chair. I waited a long time because we were constantly working on improving functional vision, improving motor skills, and dealing with feeding delays, dietary limitations, and more. It was a big step to begin using a chair that provides FAR LESS physical support – and we had to do it gradually (part of a meal, one meal a day, two meals a day, and finally all three meals) in order to build up the familiarity (novelty) and stamina. 

The booster chair also presented new visual challenges – because suddenly Rosalie was using the tabletop alongside the rest of the family!

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I imagined the large tabletop might be visually overwhelming compared to having her own private high chair tray, which I addressed by introducing solid-colored placemats! This is an important usage of “color” that visually defines her eating area. Because Rosalie is still refining her motor skills, I needed placemats that would not slide around; I love this Munchkin silicone set.

For tableware, I intentionally use bright colors, but don’t stick to just one. However, I still constantly think about the color CONTRAST. For example, if we’re using the blue placemat I do NOT use the blue plate or blue fork. It makes for some very colorful combinations. 😉

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Nowadays I continue addressing “novelty” just as I do when we are on-the-go in public places: with a familiar, beloved toy.

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As you can see, Cookie Monster (or a select handful of other favorite toys) joins us for many meals. This is sort of a CVI + feeding therapy strategy that works for us, but isn’t necessarily something I recommend for children that don’t have feeding issues (because I’m a believer in not starting things you don’t need that might become a habit or create unnecessary dependency).

In our case, a familiar toy during meals acts as a visual anchor, a vehicle for transitioning from cause-and-effect to pretend play (the dolls get hungry and we feed them, of course), and sometimes minimizes visual complexity by blocking out the rest of the table.

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Can we briefly talk about how much I love these Munchkin plates? They have no-slip bottoms, so even when I opt to forego a silicone placemat they don’t slide around the table.

And check out how Rosalie’s blue octopus toy (pictured above) conveniently blocks out the visual clutter of the rest of the food! An added bonus is that a favorite toy can provide entertainment while I run around preparing plates for my other kids. 😉

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A couple months ago I shared this photo (below) on social media, which depicts what I call “CVI-friendly” snack time.

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I shared that I was strategically accommodating at least 5 of the 10 CVI characteristics and encouraged followers to guess which ones. The official answer is:

  1. Color: bright blue placemat, hot pink plate, red Elmo doll
  2. Complexity: nothing else is on the table, only 2 foods on the plate
  3. Novelty: familiar Elmo doll serves as a visual anchor
  4. Light: her back is to the window/natural light source
  5. Visual field preference: objects are placed where I know she will easily find them

In summary, I do my best to accommodate any/all relevant CVI characteristics at any given meal. On really good (well-rested) days I push the envelope, intentionally using as few accommodations I can get away with in order to give Rosalie the opportunity to use her vision with added (but appropriate to her CVI Range Score) challenges. On other days, I provide more visual supports and/or physical supports that allow Rosalie to better access her vision without putting forth as much effort. 

After all, we all have our tired days. And while those days might look like me drinking extra coffee, for my daughter with CVI it could mean reverting to the tried and true help of a supportive high chair. It’s all about what works with any given activity or goal each day.

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Confession: Meal time is actually the most frustrating time of day for me as Rosalie’s mom right now – not because of functional vision, but because of other medical issues. I’m sharing this personal admission with the hope that everyone reading will please give yourselves some grace.

Incorporating vision strategies and finding the right balance of supports for various other concerns is always evolving for us. And while improving functional vision is a top priority for me in everything we do, EATING is our number one goal during mealtime forever and always. At the end of the day, it’s more important to me what kinds of calories and nutrition Rosalie gets during meals than how many times she independently uses her vision and motor skills to feed herself at two years old.

So, if you aren’t incorporating extensive CVI strategies into your mealtimes because you’re more focused on surviving food allergies, overcoming a “failure to thrive” diagnosis, addressing oral motor deficiencies or delays, or any other medical concerns: please don’t be discouraged! I see you (figuratively) and you’re doing great.

If you have a great mealtime strategy that works for you, please consider leaving it in the comments for other readers to find below!

3 thoughts on “CVI Mealtime Strategies

  1. Hi Stephanie!
    I’ve been reading you for a year now, love your practical tips! Our daughters are just a year apart so it’s been really nice to follow your steps 😉 A question about the self-feeding, what did you start with? Mine has never tried to self feed anything, but I wonder if it’s a visual or motor issue, as opposed to Rosalie, she never had any trouble seeing the spoon, whatever the color, so I didn’t use the bow trick. She would grab her bowls and play with them, but then no attempts to put her hand to her mouth. Oh and she has chewing issues, so she’s not comfortable yet with cheeerios and melts, even if it’s me feeding them. Thanks!
    Yari

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    1. Hi Yari! Thanks for following along and for reaching out! We began self-feeding skills with crunchy foods that are easy to hold. First, Baby Mum Mums which are dissolvable rice crackers that are big ovals. Then, things like veggie straws and pretzel sticks. Basically we stuck to longer items that are easy to hold and gradually moved to smaller things like Cheerios. I still spoon feed her, but she can hold a spoon and does like to feed herself a bite or two before I do the rest. And once she showed interest in holding the spoon with food on it, I introduced her to the fork. She does not yet stab food with the fork, but she can feed herself the whole time if I pre-load each bite onto the fork for her. Hope that helps! Let me know if you have follow-up questions. 🙂

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    2. P.S. In addition to the foods I mentioned, what helped Rosalie is a LOT of narration, slow demonstration, repetition, and knowing body parts. So I can say things like. “I am holding a veggie straw in my hand. I am going to put this veggie straw in my mouth.” Then she would watch, then I demonstrate, and tell her I’m going to put one in HER mouth. Then I encourage her to try and do it herself. And repeat. 😉

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