Feeding Disorders in Children

 

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A feeding disorder is identified when a child is unable or refuses to eat or drink a sufficient quantity or variety of food to maintain proper nutrition.

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It is important to distinguish between a feeding problem

that is the result of an inability to eat versus one that is the result of refusal.

A child child who is refu refusing sing to eat eat is believ believed ed to have learne learnedd the behaviors that allow him/her to avoid or attempt to

control the feeding situation, and the problem is therefore therefore said to be non-organic.

 A child child who isis physicall physicallyy

unable to eat, unable eat, on on the other  hand, may may be suffering from neuromuscular, skeletal or  metabolic abnormalities.

 These probl problems ems are said to to be be

organic and theref organic therefore ore require the attention of a physician physician to appropriately address and treat the medically related difficulties.

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Feeding skill: stages and timing skills

0-3m

3-6m

7-11m

12-24m

Feeding

sucks

Sucks/bites Munches

Chews

Liquid

Purees

Chopped

Table

Speech

Coos

Babbles

Syllables

Words

Fine motor otor

Finger ngerss

Reach eachees

Tran ransfer sferss

Re Relleas eases

Turns/sits

Stands

Walk5s

(motor) Texture (sensory)

Gross motor Lifts head

 

 Appropriate food provided   Food introduced into the oral cavity

 Suck or mastication prepare bolus  Bolus passes into the pharynx

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  Respiration ceases  Elevation of the larynx , glottic closure  Opening of upper esophageal sphincter   Pharyngeal peristalsis with clearance of the pharynx   Respiration resumes

 Esophageal peristalsis  Opening of lower esophageal sphincter 

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 Receptive relaxation allows storage of the food  into the stomach  Titurbation and controlled emptying of nutrients into the small intestine  Intestinal digestion and absorption of nutrients.

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 M ajor ajor

Diagnostic Diagnos tic Categories Associated with Feeding  and Swallowing Disorders in Infants and Children Neurologic 

Encephalopathies

(e.g., cerebral cerebra l palsy, palsy, perinatal pe rinatal asphyxia)

 Traumatic Traumatic brain injury inju ry  Neoplasms  Mental retardation  Developmental delay Anatomic 

and Structural

Congenitall (e.g., tracheoesophageal fistula, cleft palate) Congenita

 Acquired 12

 

Genetic 

Chromosomal (e.g., Down syndrome)

 Syndromic (e.g., Pierre Robin sequence, sequen ce, Treacher Treacher Collins syndrome)  Inborn errors of metabolism Secondary to Systemic Illness

Respiratory (e.g., chronic lung disease, bronch b y opulmonary dysplasia). 

Gastrointestinal (e.g., GI dysmotility dysmotility,, constipation)  Congenital cardiac anomalies Psychosocial and Behavioral  Oral deprivation Secondary to Resolved Medical Condition  Iatrogenic

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 Dyspha Dysphagia gia and fee feedin ding g proble problem ms are cla class ssifi ified ed according to which phase of swallowing is affected.  Ora Orall moto motorr dysfun dysfunctio ction n in chi childr ldren en is is seen seen mos mostt commonly in those with neurodevelopment disorders .  These These chi childr ldren en will will exh exhibi ibitt poor poor lin lingua guall and and labial labial coordination.  Th This is will will res result ult in in loss loss of of food food and a poor poor seal seal for  for  sucking or removing food from a spoon.

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 These These chil childre dren n may may also also have dif diffic ficult ulty y with with coordin coordinati ation on of sucking, swallowing and breathing.  Child Children ren with with phary pharynge ngeal al dysp dysphag hagia ia may may demons demonstra trate te the the symptoms of oral dysphagia, along with coughing, gagging and choking with foods and liquids.  Howe Howeve ver, r, th thee sign signss of of phar pharyn ynge geal al dy dysp spha hagi giaa may may be be subtle. In this situation, the children may suffer from recurrent upper respiratory infections infections or have a history of   pneumonia.  The mo most st com commo mon n sign signss and and symp symptom tomss of of feedin feeding g disorders and dysphagia are coughing or choking while eating, or the sensation of food sticking in the throat or  chest.

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normally ally dev develo elopin ping g chil childre dren n 0-1 0-1 year year..  25% in norm  50 50% % of of hosp hospita itali lise sed d infa infant ntss for for FTT FTT 

80%

neurologically impaired

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A child with a feeding disorder may experience one or more of the following:

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W eight for age consistently below the 3rd  or 5th percentile  Progressive decrease in weight to below the 3rd  or 5th percentile more than two major  ma jor  W eight crosses more  percentiles downward. W eight < 80% of ideal weight for  height.  Decrease in expected rate of gr g rowth based on the child's pr p reviously defined   growth  growt h curve, irrespective of whether  wh ether  below the 3rd  percentile

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he ight or height heigh t for age Weight for height falls below the 10th percentile

Child experiences three consecutive months of weight loss is diagnosed dehydration  or Child malnutrition, whichwith results in emergency treatment

Child has NG tube with no increase in the percent of calories obtained via oral feeding for for 3 consecutive months

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 Patient Demograp Demographics: hics:  Mean Age: 3 years (39 months)  Gender: 68% male, 32% female  Developmental level:  53% Developmental Delays  47% Typical Cognitive Development

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Patient Demographics Medical Diagnosis

Mean Percentage

Autism

10%

Developmental Delay Cerebral Palsy

53% 7%

Prematurity

30%

Oral Motor Dysfunction

29%

GERD

58%

FTT

59%

Other-Medical

60%

No

Diagnosis

5%

 

 Slow feedings characterized by long meal time.Typically time.Typica lly longer than 30-40 minutes.  Change in feeding patterns or new problems with feeding.  Breathing interruptions interruptions or stoppage during feeding.  ³Gurgly/wet´ vocal quality before and after  swallows.  Unable to coordinate sucking and swallowing.  Significant drooling or oral weakness observed. re current pneumonia .  History of recurrent

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 Irritability or behavior problems during meals.  Unexplained food refusal .  Sleepiness during feedings.  Failure to gain weight over 2-3 months.  Diagnosis of a disorder associated with feeding and swallowing difficulties. Does not achieve age appropriate feeding  behaviors   Not spoon feeding by 9 months   Not chewing table food by 1 8 months   Not

cup drinking by 24 months

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Feeding Disorders  Etiologies

 Medical  Oral Motor   sensory  Behavioral 26

 

PR EMATURITY

 

R EFLUX DISEASE

 

Swallowing and feeding disorders in children and infants are complex and may have multiple causes. Underlying medical that may causeand dysphagia may include,  but are not limited to conditions (Palmer,, 2000; (Palmer Rudolph Link, 2002):  N eurological eurological

disorders

 intracranial hemorrhage

 myasthenia gravis  cerebral palsy  meningitis  encephalopathy

 Disorders affecting suck-swallow-br suck-swallow-breathing eathing coor coo rdination  choanal atresia

 tachypnea

cardiac disease bronchopulmonary dysplasia

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Connective tissue disease  polymy p olymyositis ositis  muscular dystrophy

 Iatrogenic  Iatr ogenic causes cau ses  surgical resection  radiation fibrosis  medications

 Anatomic or congenital abnormalities  cleft lip and/or palate

 abnormalities of the tongue .

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Structural lesions  thyromegaly

 cervical hypero hyperostosis stosis  congenital web  Zenker¶ Zenker ¶s diverticulum  ingestion of caustic material  neoplasm

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 Weak suck   Choking or gagging during meals  Tongue thrusting or inability to lateralize the tongue

 Wet vocal sounds during or after meals  Preferences for smooth or creamy textures

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Common Oral-Motor Feeding Difficulties  Associated with Down Syndrome Weak lip seal on nipple (fluid loss) Tongue protrusion/thrust Delayed chewing (secondary to delayed dentition and or prolonged tongue thrust) Diff Difficulty iculty with texture transition

Diff Difficulty iculty with thin liquids l iquids (increased fluid loss and coughing) 33

 

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Nutritional

Risk Factors for Children with Developmental Disabilities

Oral-Motor Feeding Difficulties       D

iscoordination of suck swal swallow abnormalities (cleftlow lip/palate; dentition)       Poor oral containment (food/fluid loss)       Tone abnormalities (hypo/hypertonic)        Altered oral sensory response (hypo/hyperresponsive)       Structural

Delayed      

oral motor skill development

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Oral- M otor  otor W eaknesses eaknesses Difficulty with oral strength and coordination required for eating.

 Open Mouth Posture  Frequent drooling  Una nab ble to bi bite thr thro ough

 Poo oorr li lip p mov ovem emen entt (c (can an¶t ¶t  pucker / spread)  Tongue Thrusting

foods  Weak chewing  Poor bolus formation  Una nab ble to cl clos osee li lips on on spoon

 Retracted tongue  Poo oorr tong tongue ue la late tera rali liza zati tion on  Coughing / Ch Choking during meals

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 Wh Wher eree do th they ey co com me fro from m?  ± Pr Prem emat atur urit ity y  ± Ch Chro roni nicc ill illne ness ss  ± Mult Multiple iple medical medical inter interventi ventions ons/me /medic dicatio ations ns  ± Und Underl erlyi ying ng neu neuro ro issue issuess

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Sensory Integration Dysfunction  Th Thee se sens nsor ory y sy syst stem em co cons nsis ists ts of of::  Pr Propr oprio ioce cept ptio ion n ± bod body y aw aware arene ness ss  Ve Vest stiibu bula larr ± ba bala lanc ncee  Tactile ± touch  Gustatory ± tas astte  Olfact ctor ory y ± smell  Vision  Auditory ± hea earring  The CNS rece receive ivess all all of these these ty types pes of of input input,, inte interpr rprets ets them, and organizes a response  Sen Sensor sory y Inte Integrat gration ion Dy Dysfu sfuncti nction on occur occurss when when the bra brain in does not efficiently process sensory stimuli coming from the body or the environment.

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Impact pact on on Feeding Sensory Im  Childr Children en wit with h tactile tactile hy hypers persens ensiti itivit vity y are are averse averse to smoot smooth, h, wet, slimy textures on their hands, face, body and/or in their mouth.  Childr Children en wit with h tacti tactile le hy hypose posensi nsitiv tivity ity have red reduced uced sensations of foods in the oral cavity and thus pocket p ocket or  lose control of them which can lead to gagging or choking. cho king.  Uppe Upperr body body stre strengt ngth h and coor coordi dinat natio ion n supp suppor orts ts and and is required for mouth strength and coordination. 40

 

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 Oral Oral mot motor or wea weakn knes esse sess lead ch child ildre ren n to experience eating as difficult and/or scary and thus children do not develop a sense of  trust that they are capable of handling food.  Sens Sensor ory y dysf dysfun uncti ction on lea leads ds child childre ren n to experience eating as scary when the child is  presented with aversive textures.

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 Childr Children en wit with h oraloral-mo motor tor wea weakne kness sses es are most most capable of eating smooth, pureed textures (pudding, yogurt, apple sauce) and are less able to eat crunchy or solid foods.  Howeve However, r, chi childr ldren en with with sen sensor sory y dysf dysfunc unctio tion n are are highly averse to smooth foods and are most comfortable with crunchy or solid foods.  Most Most child children ren wit with h feedi feeding ng prob problem lemss have have bot both h oral motor weaknesses and sensory deficits. 43

 

Avoidance voidance of eating is initially an adaptive adap tive A  behavior as it allows the child to avoid an activity that is painful, difficult, scary and potentially dangerous. Poor oral control and/or sensory aversion may lead to gagging which reinforces fear and promotes further refusal. The child will use a variety of behaviors beha viors to avoid  placement of food into his/her mouth. Parents often accidentally reward avoidance  behaviors by responding with positive attention (playing, smiling, bargaining) or by removing the

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food.  

Pushing food

away hrowing food T hrowing T urning urning away Crying  Saying ´No!µ R

efusing to open mouth Expelling foods from mouth g Gagging/Vomiting

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Steps for Diagnosis and Treatment of  Pediatric Feeding and Swallowing Problems

Å Define problem feeding and swallowing Å Identify etiology(ies) Å Determine appropriate diagnostic tests Å Plan approach to patient/family Å Teach about problem, implement treatment Å Monitor progress Å Evaluate progress (outcomes focused)

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 Evaluation of dysphagia and feeding  disorders 

P erforming erforming

a history and physical 

 Objectives of the history should shou ld include:  Ide Identi ntifyi fying ng tthe he anatom anatomic ic regio region n involv involved ed and and obtain obtaining ing clues to the etiology of the condition.  This ma may y includ includee info inform rmati ation on regar regardin ding g the onse onset, t, duration and severity, presence of regurgitation, the  perceived level of obstruction and presence of pain or  hoarseness, hoarsenes s, and presence of other disorders.

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  During the physical examination: examination: 

The pat patien ientt shoul should d be be obse observe rved d duri during ng the the act of swa swallllow owing ing..

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A cli clinic nical al dy dysph sphag agia ia eval evalua uatio tion n is is usu usuall ally y comp comple leted ted by a speech-language pathologist.

 The ex exam amina inatio tion n will will inclu include de asses assessme sment nt of pos postur ture, e, positioning,, patient motivation, oral structure positioning s tructure and function, efficiency of oral intake and clinical signs s igns of safety. 

In inf infant ants, s, the the ora oral-m l-moto otorr asses assessme sment nt inc inclu ludes des eva evalu luati ation on of  reflexive rooting and non-nutritive sucking ( Darrow and Harley, 1998).

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Infa In fant nts s and and chil childr dren en may may req requi uire re add addit itio iona nall assessm assessmen ents ts,, since growth, development, and changes in medical condition may affect the swallowing process.

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Diagnostic

testing that may be employed includes

 E sophagoscopy  sophagoscopy : This test may be used to rule out neoplasm,

particularly in patients who complain of thoracic dysphagia or odynophagia.

 E sophageal sophageal

manometry m anometry and pH probe studies: These tests may be used when a motility disorder or gastric esophageal reflux disease is suspected.

 E lectromyography: lectromyography: This

test is indicated in patients with motor unit disorder  such as polymyositis, myasthenia gravis, or amyotrophic lateral sclerosis

 F ibroptic ibroptic



endoscopic examination of swallowing ( FEE  FEE S): S): This test is performed with a transnasal laryngoscope to assess pharyngeal swallowing. This test may be helpful when a VF SS (videofluorographic SS (videofluorographic swallowing study) is not feasible

 U ltrasound ltrasound imaging:

This testing has been used to a limited l imited extent on infants to assess the oral phase of swallowing. The technique is limited to infants, since teeth will interfere with the sound signal. This method will permit studying of infants during breast-feeding, since contrast media is not

required.

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Videofluorographic

swallowing study swallowing

Is the gold standard for evaluating the mechanism of swallowing. VFSS is also referred to as modified barium swallow. swallow. study, the patient will eat and drink d rink foods mixed with During this study,  barium while radiographic images are observed on a video monitor  and recorded on videotape.

This testpathologist. is ideally performed jointly by a physician and a speech language

The study will demonstrate anatomic structures, the motions of  o f  these structures, and passage of the food through the oral cavity, cavity,  pharynx and esophagus .

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Videofluorographic

swallowing study swallowing study

This test may also be used to test the effecti effectiveness veness of compensatory maneuvers maneuvers that are used to improve swallowing. This test cannot be performed on infants and children who are unable to swallow. In addition, infants and children with oral aversion and some feeding disorders may not ingest a suff sufficient icient amount of barium to provide a meaningful study.

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Interdisciplinary Approach  Interdisciplinary team evaluation: Medicine Medici ne ± Rule out physical physical causes causes of feeding feeding   problem

  Nutrition ± Evaluate adequacy of current intake  Social Work ± Evaluate family stressors Therapy ± Evaluate oral motor   Speech/Occupational status and safety

 Psy Psychology chology ± Assess contributi contribution on of environment environmental al factors

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 the the cau causes ses of ma many ny of of the the di disor sorde ders rs resul resultin ting g in feeding disorders or dysphagia may not be amenable to pharmacological therapy or surgery as a result of  behavioral contributors to impairment.  In the these se case cases, s, a ref referr erral al to a prof professi ession onal, al, such such as a speech pathologist, pathologist, or feeding clinic is appropriate.  A chi child ld may may con contin tinue ue with with sig signs ns an and d symp symptom toms s of a feeding disorder even after correction of an underlying abnormality due to a learned aversion to feeding. In these cases, behavior therapy may be considered.

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 P rerequisites rerequisites

for oral feeding attempts for infants an  young children include

 Cardi Cardiopul opulmon monary ary stabi stability lity  Alert , calm state  In young infants, demonstration demonstration of rooting responses and adequate non-nutritive sucking  Appetite or observable interest in eating

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 Feeding therapy for infants and children may include the following strategies   Position and posture changes: Trunk and head control are closely related to development of oral-motor skills. In particular, children with cerebral palsy and accompanying motor deficits frequently have poor  head control and poor trunk stability. Position changes need to be monitored closely for  adjustments over time.

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 Feeding therapy for infants and children may include the following strategies  Changes in food and liquid attributes: attributes: These attributes may include, but are not limited to: volume, consistency, temperature and taste.  Oral-motor and swallow therapies: These procedures are focused on developmental stages with goals to increase the range of textures children can handle in their diets. Oral-motor treatment can include direct exercises of the oral mechanism.

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 Feeding therapy for infants and children may include the following strategies 

P acing acing



C hanging hanging

of feedings: Pacing is a technique that regulates the time interval between bites or swallows. This may minimize the risk of aspiration. Some children may need a longer time to swallow. of utensils: The food bolus size can be controlled through spoons of different shapes and sizes. Occupational therapists may recommend adaptive equipment and utensils.

  Esophageal phase swallow disorders are generally not amenable to oral-motor and swallow therapy. Positioning changes, changes in food characteristics and timing may make a difference.

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 Feeding therapy for infants and children may include the following strategies  Specia Specializ lized ed fe feedi eding ng tec techni hnique quess that that are are used used for  for  feeding infants with cleft lip and/or palate have been developed to overcome the lack of negative pressure developed during sucking; these strategies may include:  cross-cutting fissured nipples

 squeezing a soft bottle to help with the flow of  milk   pumping breast to deliver breast milk via bottle

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W

hen a patient unable toby achieve alimentation andishydration mouth,adequate enteral feedings through a nasogastric tube or a percutaneous endoscopic gastrostomy may be necessary.

The presence of a feeding tube is not a contraindication of therapy. Removal of the feeding tube may be a goal of therapy.

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Tips to prevent feeding problems from developing or persisting

 Present a wide range of foods before the child reaches 15 to 18  months of age 

Present preferred as well as non-preferred foods

 Stick to a consistent schedule; sche dule; keep meals, naptime, and bedtime at same times daily

unh ealthy foods less  Make healthy foods readily available and unhealthy available  Model healthy eating behaviors and discuss good g ood eating habits

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Tips to prevent feeding problems from developing or persisting  Teach your child to communicate about his/her hunger by relating food to appetite  Reinforce good mealtime behaviors (avoid praising amount of food fo od eaten)  DO NOT reinforce inappropriate behavior with toys or attention  Try to maintain enough time and energy for meals  Develop a few simple rules and follow them, don¶t start what you

can¶t finish

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