Management of Pediatric Feeding Disorder

Version	Summary	Created by	Modification	Content Size	Created at	Operation
1		Rajmohan Dharmaraj	--	1982	2023-03-03 02:31:33	\|
2	format correct	Catherine Yang	Meta information modification	1982	2023-03-03 02:46:09	\|

This entry is adapted from the peer-reviewed paper 10.3390/gidisord5010008

Pediatric feeding disorder (PFD) is defined as impaired oral intake that is not age appropriate and is associated with at least one dysfunctional domain: medical; nutritional; feeding skills; and psychosocial Feeding difficulties take time to resolve and are best managed in progressive phases. A series of short-term goals are typically developed that can lead to complex interdisciplinary coordination of care. Using a stepwise treatment approach to PFD is important because, even though feeding problems are relatively common—occurring in up to 45% of children in the general population—the condition is severe enough to warrant intensive intervention in about 10%. A stepwise approach ensures that feeding problems are not overlooked or treated inappropriately.

feeding disorder children management

1. Stepwise Approach to PFD

In the initial phase, a comprehensive history and physical examination, including a review of growth parameters and a dietary assessment, should help identify red flag symptoms and signs in each domain that require prompt attention and need for an in-depth investigation or interdisciplinary management ^[1]. Dysphagia, odynophagia, aspiration, severe malnutrition, and frank nutrient deficiencies need immediate attention. In addition to identifying red flags, it is important to screen the child’s oral-motor development, stabilize nutrient intake, and address aversive parental feeding practices ^[2] (Table 1). Signs related to oral-motor dysfunction, such as excessive drooling, poor postural control, abnormal muscle tone, excessive gagging or choking, failure to advance through textures, difficulty managing food in the mouth, or difficulty with feeding milestones will require referral for an oral-motor evaluation ^[3]. Nutrient stabilization includes supplemental calories for growth failure, multi-nutrient supplementation for limited dietary variety, and single-nutrient supplementation for documented deficiency ^[4]^[5]. Reviewing basic feeding guidelines (Table 1) should be part of anticipatory guidance for all children and should help discourage aversive feeding practices ^[6].

Table 1. Initial Management of Pediatric Feeding Disorder.

Identify Red Flags	Evaluate for Signs of Oral Motor Dysfunction	Stabilize Nutrient Intake	Review Basic Feeding Guidelines
Aspiration Dysphagia Pain with feeding Vomiting and diarrhea Developmental delay Chronic cardio- respiratory symptoms Growth failure Nutrient deficiencies Force-feeding	Excessive drooling Poor postural control Abnormal muscle tone Excessive gagging or choking Failure to advance textures Difficulty with feeding milestones Difficulty managing food or liquid in mouth	Supplemental calories for growth failure Multi-nutrient supplementation for limited dietary variety Single nutrient supplementation for deficiency	Avoid mealtime distractions Maintain pleasant, neutral attitude while feeding Limit meal duration Provide 4–6 meals/snacks a day with water in between Serve age-appropriate foods Systematically offer new foods (8–15 times) Encourage self-feeding Tolerate age-appropriate mess

Note. Adapted with permission from Milano, K.; Chatoor, I.; Kerzner, B. A Functional Approach to Feeding Difficulties in Children. Curr. Gastroenterol. Rep. 2019, 21, 51 ^[2].

In the next phase, if feeding problems do not improve within a few weeks after the initial evaluation, more specific interventions tailored to the child’s eating behavior and parental feeding style are necessary. Common eating behaviors in children include limited appetite, food selectivity, and fear of feeding ^[7]^[8]. Rumination and pica are less common but may also impact oral intake. Some children may have more than one eating behavior, and the contribution of each to feeding dysfunction should be assessed. Interventions for limited appetite focus on hunger inducement coupled with nutritional supplementation and behavioral therapy. Pharmacological treatment with appetite stimulants (e.g., cyproheptadine and megestrol acetate) is commonly used to improve appetite and weight gain and appears to be safe and effective ^[9]. Targeted interventions for food selectivity include frequent exposure to new foods, parental modeling with subtle encouragement, sensory integration, and/or behavioral therapy. Fear of feeding can be addressed by developing strategies to reduce feeding-related anxiety, including changing the mealtime environment, using alternative feeding equipment, and giving anxiolytic medications. In addition, understanding the influence of parental feeding style on the child’s eating behavior is helpful in developing a therapeutic strategy ^[10]^[11]^[12].

2. Interdisciplinary Management

Referral to specialized care should be considered when feeding problems are complex or difficult to resolve. Many major medical centers have outpatient interdisciplinary teams that focus on feeding problems. The team approach can benefit a family by avoiding duplication of services and allowing feeding issues to be addressed by one team that can identify subsequent therapies that might be necessary. Studies have found overall reductions in tube feeding, increases in oral intake, improvements in eating behavior, and reductions in parental stress as a result of interdisciplinary intervention ^[13].

Interdisciplinary feeding teams that focus on pediatric patients often include medical, nursing, nutritional, and social services. Core members of the team usually include a speech–language pathologist or an occupational therapist, a behavioral psychologist, a gastroenterologist, and a developmental pediatrician. The role of the speech–language pathologist includes assessing oral-motor function by performing a clinical swallowing evaluation with or without an instrumental exam (e.g., a videofluoroscopic swallow study or a fiberoptic endoscopic evaluation of swallowing). The speech–language pathologist also takes an active role in treatment to facilitate the development of oral sensorimotor skills. The role of the dietitian includes assessing caloric intake, providing a nutritional plan, and managing enteral feedings. The role of the behavioral psychologist is to provide a behavioral perspective on PFD, assess for comorbid behavioral or psychiatric conditions, and provide behavioral interventions. The role of the gastroenterologist is to assess and treat GI conditions associated with PFD, such as gastroesophageal reflux disease (GERD), severe constipation, and eosinophilic esophagitis, and coordinate care between team members. A developmental physician will further assess and treat developmental and behavioral problems, including attention deficit/hyperactivity disorder (ADHD), autism spectrum disorder, and caregiver–child conflict. Each member of the interdisciplinary team provides initial assessments, and then a unified treatment plan is devised. Hospitalization may be necessary in some cases to confirm the diagnosis, perform specific laboratory tests, monitor weight, provide optimum nutritional intake, and observe caregiver–child interactions.

3. Interventions for Dysphagia

Oral-motor skills usually improve over time; however, they can be promoted in a more organized and efficient manner with therapy. Speech–language pathologists and occupational therapists are most often involved in applying therapeutic interventions, such as the modification of bolus size, specialized nipples and bottles, thickened liquids, proper positioning and posture, oral-motor and desensitization exercises, and the alteration of food texture, temperature, and/or presentation. However, the evidence base for these interventions is limited ^[14]^[15]. The prognosis depends on the etiology of the dysphagia and the potential for developmental progress.

Thickening feedings is one of the primary interventions to treat dysphagia. However, there is limited efficacy data to support thickening feedings despite the fact that it is frequently used. A systematic review of 22 studies on the effects of thickened feedings on swallowing physiology and pulmonary health outcomes reported mixed findings. There was no significant increase in the rate of adverse effects from the use of thickened feedings ^[16]. However, adverse events have been reported with the use of thickened feedings in preterm and newborn infants ^[17]. In May 2011, the U.S. Food and Drug Administration issued a report on 15 preterm infants who developed necrotizing enterocolitis (NEC) after the use of a thickening agent ^[18]. Currently, no clear etiology by which thickeners lead to NEC has been established; however, it is suspected that the fact that the GI tract in preterm infants may not have a fully developed mucosal barrier could be a factor.

There are a few alternatives to the thickening formula that allow continued oral feedings apart from nasogastric feeding, which bypasses the oral cavity and esophagus. Slow-flow nipples can limit the speed rate of bottle-feed delivery to a safe level as compared to standard-flow nipples. Studies of nipple flow rates have shown that the measured flow rates are extremely variable and are not consistent from nipple to nipple within the same type ^[19]^[20]. Another approach has involved using a side-lying position for feedings rather than the normal cradle position; however, only a few small studies have been conducted on this approach with mixed results ^[21]^[22]^[23]^[24]. Transcutaneous neuromuscular electrical stimulation is a new therapeutic approach for dysphagia in children, involving external electrical stimulation of the peripheral motor nerves of the anterior throat to activate the pharyngeal muscles involved in swallowing.

4. Behavioral Treatment

There is strong evidence supporting the use of behavioral interventions in the treatment of PFD ^[25]^[26]. Behavioral feeding therapy is appropriate when the child’s medical, oral-motor, and nutritional status have stabilized but feeding difficulties continue. Behavioral treatment generally has five goals: (1) increasing desirable mealtime behaviors; (2) decreasing undesirable mealtime behaviors; (3) optimizing pleasurable caregiver–child interactions at mealtimes; (4) decreasing caregiver stress; and (5) making progress in developmentally appropriate intake (e.g., moving from purées and smooth foods to chewable solids) ^[27]. Behavior management techniques are designed to strengthen desirable behaviors and weaken undesirable/maladaptive behaviors. Behavioral treatment plans can be implemented in various settings, such as outpatient, partial day, and inpatient facilities. Treatment should be initiated via the least intrusive approach, which is generally in the outpatient setting.

5. Dietary Interventions

Nutritional support is begun as soon as a child is identified as being at risk and should aim to establish a balanced and healthy diet. Methods of nutritional support include oral supplementation, increasing the formula’s caloric density, enteral feedings (nasogastric or jejunal), and parenteral nutrition. Risk factors necessitating dietary intervention include the present nutritional status, underlying medical conditions, anticipated therapy, current caloric intake, and past medical history. Oral supplementation is recommended as the initial step for patients who can consume sufficient energy and nutrients safely, either with specific supplements or by increasing the caloric density of the formula. If the caloric density of the formula is increased, care must be taken to provide adequate free water to avoid dehydration and electrolyte imbalances.

Patients who cannot consume sufficient energy and nutrients by mouth require enteral (i.e., tube) feedings. Enteral feedings can be delivered via nasogastric tube or gastrostomy tube (g-tube). Nasogastric feedings are simple to administer and allow normal digestive processes and hormonal responses. If gastric feedings are required for longer than six weeks, a g-tube placement is preferred. Percutaneous endoscopic gastrostomy and laparoscopic gastrostomy have largely supplanted open laparotomy for the placement of g-tubes. Gastric feedings can be administered as an intermittent bolus or continuously. Intermittent bolus feedings are preferred since they align more closely with normal physiologic activity. Transpyloric or jejunal feedings are indicated in patients with significant gastroesophageal reflux, impaired gag reflux, gastric motor abnormalities, or intractable vomiting. Jejunal feedings are generally administered continuously for a specified period to meet caloric needs. Parenteral nutrition should be initiated only when the child’s caloric needs cannot be met through oral or enteral feedings. Although beneficial for optimal physical development, feeding tubes may negatively impact the development of oral feeding skills by limiting the child’s hunger drive and may increase the risk of the child developing an oral aversion to taking food by mouth. To reduce the risk of developing oral aversion, it is recommended that oral feeds should precede supplemental tube feeds when it is safe to do so, and oral sensory and motor therapy should be performed along with nutritional adjustments.

Transitioning from enteral feedings to oral feeds requires attention to establishing adequate hunger cues and feeding and oral-motor skills, maximizing caregiver interactions, and often, providing behavioral therapy. Children who have received chronic tube feedings often miss critical transition periods for eating, such as beginning solid foods. Subsequently, these children demonstrate a significant oral aversion to eating, especially textured foods. Transitioning from enteral feedings to oral feeds should be a slow and gradual process. First, patients on continuous feedings are slowly transitioned to bolus feedings. Next, food by mouth is offered before each daytime bolus feeding to simulate a mealtime schedule. As the child consumes more calories by mouth, the tube feedings can be decreased accordingly. This process will be more successful if performed in conjunction with oral sensory treatment and close monitoring by the interdisciplinary team. Currently, there are multiple approaches to the tube-transitioning process, including intensive inpatient and outpatient hospital-based programs. Considerations when selecting a transitioning approach include underlying medical conditions, the developmental feeding skill level, the child’s temperament, the duration and method of enteral feeding, and family psychosocial dynamics. Children who receive no feeds, fluids, or flushes through their g-tube for 6–12 months are candidates to have the device removed. Premature removal may increase the child’s risk for complications, such as malnutrition.

References

Kerzner, B.; Milano, K.; MacLean, W.C.; Berall, G.; Stuart, S.; Chatoor, I. A practical approach to classifying and managing feeding difficulties. Pediatrics 2015, 135, 344–345.
Milano, K.; Chatoor, I.; Kerzner, B. A Functional Approach to Feeding Difficulties in Children. Curr. Gastroenterol. Rep. 2019, 21, 51.
Kleinert, J.O. Pediatric feeding disorders and severe developmental disabilities. Semin. Speech Lang. 2017, 38, 116–125.
Hojsak, I.; Bronsky, J.; Campoy, C.; Domellö, F.M.; Embleton, N.; Mis Fidler, N.; Hulst, J.; Indrio, F.; Lapillonne, A.; Mølgaard, C.; et al. Young child formula: A position paper by the ESPGHAN committee on nutrition. J. Pediatr. Gast. Nutr. 2018, 66, 177–185.
Golden, M.H. Evolution of nutritional management of acute malnutrition. Indian Pediatr. 2010, 47, 667–678.
Finnane, J.M.; Jansen, E.; Mallan, K.M.; Daniels, L.A. Mealtime structure and responsive feeding practices are associated with less food fussiness and more food enjoyment in children. J. Nutr. Educ. Behav. 2017, 49, 11–18.
American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders (DSM 5®); American Psychiatric Association: Washington, DC, USA, 2013; pp. 557–586.
Chatoor, I. Diagnosis and Treatment of Feeding Disorders in Infants, Toddlers, and Young Children; Zero to Three: Washington, DC, USA, 2009.
Sant’Anna, A.M.; Hammes, P.S.; Porporino, M.; Martel, C.; Zygmuntowicz, C.; Ramsay, M. Use of cyproheptadine in young children with feeding difficulties and poor growth in a pediatric feeding program. J. Pediatr. Gastroenterol. Nutr. 2014, 59, 674–678.
Benjasuwantep, B.; Chaithirayanon, S.; Eiamudomkan, M. Feeding problems in healthy young children: Prevalence, related factors and feeding practices. Pediatr. Rep. 2013, 5, 38.
Byrne, R.; Jansen, E.; Daniels, L. Perceived fussy eating in Australian children at 14 months of age and subsequent use of maternal feeding practices at 2 years. Int. J. Behav. Nutr. Phys. Act. 2017, 14, 123.
Hughes, S.O.; Power, T.G.; Fisher, J.O.; Mueller, S.; Nicklas, T.A. Revisiting a neglected construct: Parenting styles in a child-feeding context. Appetite 2005, 44, 83–92.
Sharp, W.G.; Volkert, V.M.; Scahill, L.; McCracken, C.E.; McElhanon, B. A systematic review and meta-analysis of intensive multidisciplinary intervention for pediatric feeding disorders: How standard is the standard of care? J. Pediatr. 2017, 181, 116–124.
Miller, C.K. Aspiration and swallowing dysfunction in pediatric patients. Infant. Child Adolesc. Nutr. 2011, 3, 336–343.
Morgan, A.T.; Dodrill, P.; Ward, E.C. Interventions for oropharyngeal dysphagia in children with neurological impairment. Cochrane Database Syst. Rev. 2012, 10, CD009456.
Gosa, M.M.; Schooling, T.; Coleman, J. Thickened liquids as a treatment for children with dysphagia and associated adverse effects. Infant. Child Adolesc. Nutr. 2011, 3, 344–350.
Clarke, P.; Robinson, M.J. Thickening milk feedings may cause necrotising enterocolitis. Arch. Dis. Child. Fetal Neonatal Ed. 2004, 89, F280.
Abrams, S.A. Be cautious in using thickening agents for preemies. AAP News 2011, 32, 23.
Pados, B.F.; Park, J.; Thoyre, S.M.; Estrem, H.; Nix, W.B. Milk flow rates from bottle nipples used after hospital discharge. MCN Am. J. Matern. Child Nurs. 2016, 41, 237–243.
Jackman, K.T. Go with the flow: Choosing a feeding system for infants in the neonatal intensive care unit and beyond based on flow performance. Newborn Infant Nurs. Rev. 2013, 13, 31–34.
Clark, L.; Kennedy, G.; Pring, T.; Hird, M.I. Improving bottle feeding in preterm infants: Investigating the elevated side-lying position. Infant 2007, 3, 354–358.
Thoyre, S.M.; Holditch-Davis, D.; Schwartz, T.A.; Melendez Roman, C.R.; Nix, W.B. Coregulated approach to feeding preterm infants with lung disease. Nurs. Res. 2012, 61, 242–251.
Park, J.; Thoyre, S.M.; Knafl, G.J.; Hodges, E.A.; Nix, W.B. Efficacy of semielevated side-lying positioning during bottle-feeding of very preterm infants. J. Perinat. Neonat. Nurs. 2014, 28, 69–79.
Dawson, J.A.; Myers, L.R.; Moorhead, A.; Jacobs, S.E.; Ong, K.; Salo, F.; Murray, S.; Donath, S.; Davis, P.G. A randomised trial of two techniques for bottle feeding preterm infants. J. Paediatr. Child Health 2013, 49, 462–466.
Babbitt, R.L.; Hoch, T.A.; Coe, D.A. Behavioral feeding disorders. In Disorders of Feeding and Swallowing in Infants and Children; Tuchman, D.N., Walters, R.S., Eds.; Singular: San Diego, CA, USA, 1994; pp. 77–95.
Kerwin, M.E. Pediatric feeding problems: A behavior analytic approach to assessment and treatment. Behav. Anal. Today 2003, 4, 162–175.
Silverman, A.H. Behavioral Management of Feeding Disorders of Childhood. Ann. Nutr. Metab. 2015, 66, 33–42.

© Text is available under the terms and conditions of the Creative Commons Attribution (CC BY) license; additional terms may apply. By using this site, you agree to the Terms and Conditions and Privacy Policy.

Upload a video for this entry

Information

Subjects: Gastroenterology & Hepatology

Contributors MDPI registered users' name will be linked to their SciProfiles pages. To register with us, please refer to https://encyclopedia.pub/register :

Rajmohan Dharmaraj

Rasha Elmaoued

Razan Alkhouri

Pankaj Vohra

Ricardo O. Castillo

View Times: 251

Update Date: 03 Mar 2023

Table of Contents

Video Upload Options

Confirm