May 2025 Issue
Nutrition in Early Intervention
By Alexandria Hardy, RDN, LDN
Today’s Dietitian
Vol. 27 No. 5 P. 22
The Role of the Special Instructor Nutritionist
Early intervention (EI) is an incredibly rewarding yet little-known field in the world of nutrition and dietetics. EI programs serve children with developmental delays and disabilities. There are many disciplines and providers who work in EI, including RDs. EI nutrition services aim to support optimal growth and development in infants, toddlers, and children in these populations by assessing individual nutritional needs, creating personalized feeding plans, and educating caregivers on feeding practices.
What Is EI?
The purpose of EI is to provide a variety of services to families with children from birth to age 5. The focus of this article will be on EI services for infants and toddlers with disabilities, including as it relates to the Individuals with Disabilities Education Act Part C.1 EI services are provided in every state and territory of the United States, though specific services and providers can differ.2 For example, in Pennsylvania the EI program is administered through a collaboration between the Departments of Education and Human Services under the Office of Child Development and Early Learning.
Many families begin with services through pediatrician or self-referrals. EI can help babies and toddlers develop crucial skills and meet developmental milestones. The domains that EI typically serve include physical, cognitive, communication, social/emotional, and self-help. The types of providers that work in EI vary, but often include occupational, physical, music, and speech therapists; social workers; special instructors; and dietitians. The primary role of the EI provider is to support and guide families, caregivers, and early childhood education (ECE) professionals such as day care providers in fostering a child’s development. This is done by pairing goals with currently existing routines and building in natural opportunities for practice throughout the day.
How Is EI Different Than Private Practice or Outpatient Services?
EI sessions can be held in the caregiver’s home, childcare facility, or any other place the child goes within the context of their regular routine. For example, some EI providers conduct sessions in person at the library or playground, while others provide primarily virtual services to families. The most common location for EI services is the home, where families can share their day-to-day routines, struggles, and wins; this also importantly allows the EI providers to interact with the child within their natural environment and routines.
EI providers coach families and ECE professionals to identify and address family priorities for a child’s learning. Together, they develop an individualized plan that builds on existing strengths, integrates learning into daily routines, and creates new opportunities for growth using effective intervention strategies. One of the ways this differs from other types of coaching, consulting, or education is that EI focuses on empowering families as active team members. They are encouraged to share insights about their child, ask questions about their child’s development, and set session targets and goals. This type of collaboration allows caregivers and EI providers to set goals that work for their child in a setting that is safe and familiar, ultimately allowing for a higher likelihood of meeting their goals.
The Role of Nutrition in EI
Dietitians who work in EI are identified as special instructor nutritionists. RDs typically start a consultation by taking a nutrition history from the caregiver with a focus on anthropometric and biochemical data, as well as asking about any current or past feeding issues, habits, and preferences. One difference between an EI consult and a clinical consult is that assessments are done without access to a medical record and instead rely on recall from caregivers. The RD is typically assigned a specific number of sessions with each family based on the need determined in the initial EI evaluation. This can vary, but typically looks like weekly, biweekly, or monthly nutrition sessions with the child and caregivers.
During these sessions, RDs often focus on creating and managing feeding plans based on assessments to meet nutritional needs while connecting individuals with community resources to support their nutrition goals. Practically speaking, this looks like assessing growth, diet, and nutrient needs to ensure a child is getting the right nutrition, addressing feeding or GI concerns, managing tube feeding if needed, and connecting families with local resources and support.3 This can be helpful, as many of the medically complex infants and toddlers receiving EI services do not have regular access to a dietitian at their pediatrician visits and feeding clinics, and through EI can regularly receive quality nutrition advice at no cost to them.
Carly Kessler, MPH, RDN, LDN, of Step By Step Pediatric Therapy Inc, says, “The families I work with in EI really appreciate the frequency in which they can visit a dietitian free of charge. Nutrition visits can vary from weekly to monthly, but the frequent follow up allows the RD to build a relationship with the family and to better understand their weekly routine and daily challenges. Strategies and nutrition recommendations can then be tailored specifically for the family while taking the time to understand the whole picture and what the changes would look like for the family. Many families may still follow up with a clinical RD at pediatric hospitals; however, these visits are often once every four to six months.”
Who Receives Services?
Dietitians may provide ongoing EI services for children who:
• have difficulty gaining weight or experience unexplained weight changes;
• have constipation, diarrhea, or other gastrointestinal concerns;
• rely on high-calorie supplements instead of solids;
• struggle with feeding behaviors (eg, picky eating, reliance on a bottle past 12 months);
• or need support for conditions like reflux, swallowing difficulties, or sensory-based food restrictions.
EI RDs may also help families implement recommendations from feeding or growth clinics.4 Common patients include children with cystic fibrosis, cerebral palsy, and autism spectrum disorder.
A review published in Advances in Nutrition found that 10 sessions of nutrition education to low-income families corresponded with a significant decrease in poor nutrition status.5 They found that successful interventions required behavior change strategies that empowered parents, caregivers, and communities to establish healthy feeding practices. Though EI services are available to all families regardless of income status, this is a positive indication of the power of nutrition services in early life.
Danielle Zold, RD, LDN, CLC, CGN, owner of Nourished Pediatrics, LLC, shared a time when her EI experience made a significant difference for a family. She recalls, “I realized a 3-year-old child had drastically fallen off their growth chart, was only drinking juice and eating applesauce pouches, and was in desperate need of a g-tube and radical feeding interventions. I was able to connect with the PCP who realized he had fallen through the cracks, and we were able to get him fed within a week of me “sounding the alarm.” He is now thriving and meeting more milestones now that he is getting the nutrition he needs!”
Service Delivery in EI Nutrition
Whether a dietitian is part of an EI agency or an independent contractor, they receive families via referrals. All services are provided to the families at no cost, thanks to national, state, and community resources.6
Depending on the referral, the dietitian may meet with the family for a single consult or ongoing services. At the initial visit, an individual assessment is conducted and the RD and caregivers work together to write a goal and targets based on the outcome provided in the child’s Individualized Family Service Plan. For example, an outcome may be to help the child meet their nutritional needs through food and drink. The family and RD will use that broad statement to create a more specific family plan to work on between sessions. This typically includes what (the target), how (clear strategies), when and where (routines and locations), who (which caregivers) and what success will look like for the family. Taking the above outcome, an EI RD may decide the target is to offer three new foods, and the strategy is to purchase three new foods at the grocery and prepare them at home. This can be practiced when the child sits in the highchair for snacks and meals (routines and location) by the family and babysitter. In this example, success for the family looks like the child interacting with the three new foods using their five senses.
Implementing Nutrition Strategies in Routine-Based Intervention
Another common referral in EI is for toddlers who have low solid food intake but higher than recommended milk, Pediasure, or formula intake. When Leah Porche, RDN, LDN, an EI dietitian and independent Early Steps provider, has one of these referrals, her intervention generally starts by playing detective. “I will suggest finding the time of day where the bottle or cup is least impactful to their routine, ie, not taking away their comfort first thing in the morning or just before bed, so usually around snack times, and reduce or delay it. In most cases we will see increased intake at the very next meal. I always suggest parents pay attention to how the child responds. If it is very upsetting, this may not be the right intervention for this child. If they do not seem to be eating more at the next meal, offer the bottle or cup after they have eaten. This is a great example of why EI is so important. I can suggest a strategy and within the week or the month I get to check in and see if it’s helping or if we need to come up with something else.” That immediate feedback, paired with caregiver observations and reflections, can help children meet their nutrition goals quickly as well as allows RDs to offer multiple strategies to discover what works best for each individual family.
Challenges and Gaps in EI Nutrition Services
One of the biggest barriers in EI nutrition work is twofold: there are simply too few RDs nationwide who work in this unique role, and of the ones that do, they are often underutilized. Porche cites the biggest challenge she has faced to be one of value. She says, “Similar to most nutrition professionals, I don’t feel our value is well understood or properly recognized. I think it will take RDs advocating our services to these families and programs, showing the positive impact we can have, and educating the field about the necessity of our place on the team. I would advocate for every family in EI to get the minimum of a one-time nutrition assessment with the potential for follow-up services if warranted.”
Advocacy at multiple levels (alongside the rest of the EI team and with families) is key to growing this incredible free service and is supported by an article in the Infant, Child, and Adolescent Nutrition journal.1 Baranoski et al emphasize that nutrition services play a crucial role in EI, ensuring that children receive the necessary support for optimal growth and development. Federal and state regulations guide EI programs, but inconsistencies at the state level can lead to varying interpretations of a dietitian’s role on the EI team. Without clear guidelines, important nutrition services may be undervalued or overlooked, despite their critical impact on a child’s health. Advocacy is essential to educate stakeholders about the expertise of RDs and to safeguard nutrition services from policy changes that could negatively affect children in EI programs.
RDs Who Are Interested in EI
For any dietitian interested in working in EI, there are different educational and practical skillsets required. Porche recommends advanced training in cultural competency and neurodiversity, as nutrition education takes place within the home and routines of the family. “We are going into people’s homes, being invited into the depths of their lives. We are often helping during very stressful times. It is so important to have compassion, understanding, and respect to do this job well. Also, interviewing skills and patience are key. It can take some families time to open up and share, or they may not realize a detail is important until it comes up.” She encourages RDs to be open to learning from the families they work with, and to utilize all available resources to learn from. “We need to be learning about the most marginalized groups, usually those that aren’t the focus of research or typical dietetic training. It’s vital that we help without harming. If we don’t have lived experience with oppression, disability, medical complexity, etc, it can be really easy to say or do things with good intentions but that ultimately cause harm.”
From an educational standpoint, board certification as a Specialist in Pediatric Nutrition through the Commission on Dietetic Registration provides a solid foundation. Zold recommends dietitians undergo feeding training to better understand oral-motor and sensory challenges; some EI RDs become pediatric feeding therapists. Kessler cites previous neonatal or pediatric clinical experience as a must, as many EI children have spent time in the neonatal ICU. Other excellent resources include the Division of Responsibility in Feeding by the Ellyn Satter Institute and many of the free networking groups on social media.7
In Conclusion
Dietitians play an important role as part of the EI team. Whether they are educating families on food allergies, helping them implement the Division of Responsibilities in Feeding, or aiding in the transition from tube feeds, nutrition services are a critical part of EI. An adequate nutrition status allows children to meet age-appropriate developmental milestones while providing critical education to their parents and caregivers.5 RDs who currently work in the field are excellent resources and well placed for dietetic interns or other RDs interested in pediatrics, particularly those who prefer a nontraditional clinical setting. As with most RD roles, advocacy is crucial to illustrate the importance of nutrition and the positive effect of nutrition education in early life.
— Alexandria Hardy, RDN, LDN, is an early intervention nutrition therapist, and the owner of Pennsylvania Nutrition Services, an insurance-based private practice located in Lancaster, Pennsylvania.
References
1. Baranoski C, Grutza T, Hagen GL, Humphrey J, Kedzierski C, Schrock K. Nutrition practice in the early intervention system Illinois. Infant Child Adolesc Nutr. 2011;3(3):133-139.
2. Early intervention and special education services for children. USAGov website. https://www.usa.gov/special-education. Updated November 19, 2024. Accessed February 17, 2025.
3. What are nutrition services in early intervention? TEIS Early Intervention website. https://teis-ei.com/blog/nutrition-services-early-intervention/. Accessed January 12, 2025.
4. Thomas Jefferson University. Philadelphia Infant Toddler Early Intervention Nutrition Practice Guidelines. https://jeffline.jefferson.edu/cfsrp/tlc/cultural_pdfs/Transdisciplinary-Nutrition Practice Guidelines (June_2014).pdf. Published June 2014. Accessed January 27, 2025.
5. Hurley KM, Yousafzai AK, Lopez-Boo F. Early child development and nutrition: a review of the benefits and challenges of implementing integrated interventions. Adv Nutr. 2016;7(2):357-363.
6. McCarty J, Havens L. Bottom line: who pays the bill for early intervention services? The ASHA Leader Archive. 2013;18(2):26-27.
7. Ellyn Satter Institute. Ellyn Satter’s Division of Responsibility in Feeding. https://www.ellynsatterinstitute.org/wp-content/uploads/2015/08/ELLYN-SATTER’S-DIVISION-OF-RESPONSIBILITY-IN-FEEDING.pdf. Published 2015. Accessed January 2, 2025.