Feeding Disorders In Children

Hanan Fathy Ass.lecture Pediatric Nephrology 2008 1

 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 who is refusing to eat is believed to have learned the behaviors that allow him/her to avoid or attempt to control the feeding situation, and the problem is therefore said to be non-organic.  A child who is physically unable to eat, on the other hand, may be suffering from neuromuscular, skeletal or metabolic abnormalities.  These problems are said to be organic and 3 therefore require the attention of a physician to

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Feeding skill: stages and timing skills

0-3m

3-6m

Feeding (motor)

sucks

Sucks/bites Munches

Chews

Texture (sensory)

Liquid

Purees

Chopped

Table

Speech

Coos

Babbles

Syllables

Words

Fine motor

Fingers

Reaches

Transfers

Releases

Turns/sits

Stands

Walks

Gross motor Lifts head

7-11m

12-24m

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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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Major Diagnostic Categories Associated with Feeding and Swallowing Disorders in Infants and Children Neurologic •

Encephalopathies (e.g., cerebral palsy, perinatal asphyxia)

• Traumatic brain injury • Neoplasms • Mental retardation • Developmental delay Anatomic and Structural Congenital (e.g., tracheoesophageal fistula, cleft palate) •

• Acquired

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Genetic •

Chromosomal (e.g., Down syndrome)

• Syndromic (e.g., Pierre Robin sequence, 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, constipation) • Congenital cardiac anomalies Psychosocial and Behavioral • Oral deprivation Secondary to Resolved Medical Condition • Iatrogenic

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• Dysphagia and feeding problems are classified according to which phase of swallowing is affected. • Oral motor dysfunction in children is seen most commonly in those with neurodevelopment disorders . • These children will exhibit poor lingual and labial coordination. • This will result in loss of food and a poor seal for sucking or removing food from a spoon. 14

• These children may also have difficulty with coordination of sucking, swallowing and breathing. • Children with pharyngeal dysphagia may demonstrate the symptoms of oral dysphagia, along with coughing, gagging and choking with foods and liquids. • However, the signs of pharyngeal dysphagia may be subtle. In this situation, the children may suffer from recurrent upper respiratory infections or have a history of pneumonia. • The most common signs and symptoms of feeding disorders and dysphagia are coughing or choking while eating, or the sensation of food sticking in the throat or chest. 15

• 25% in normally developing children 0-1 year. • 50% of hospitalised infants for 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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Weight for age consistently below the 3rd or 5th percentile Progressive decrease in weight to below the 3rd or 5th percentile Weight crosses more than two major percentiles downward. Weight < 80% of ideal weight for height. Decrease in expected rate of growth based on the child's previously defined growth curve, irrespective of whether below the 3rd percentile

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Weight for height or height for age falls below the 10th percentile Child experiences three consecutive months of weight loss Child is diagnosed with dehydration or malnutrition, which results in emergency treatment Child has NG tube with no increase in the percent of calories obtained via oral feeding for 3 consecutive months

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• Patient Demographics:

• 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 Autism Developmental Delay Cerebral Palsy Prematurity Oral Motor Dysfunction GERD FTT Other-Medical No Diagnosis

Mean Percentage 10% 53% 7% 30% 29% 58% 59% 60% 5%

Slow feedings characterized by long meal time.Typically longer than 30-40 minutes. Change in feeding patterns or new problems with feeding. Breathing interruptions or stoppage during feeding. “Gurgly/wet” vocal quality before and after swallows. Unable to coordinate sucking and swallowing. Significant drooling or oral weakness observed. History of recurrent pneumonia . 24

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 18 months  Not cup drinking by 24 months 25

Feeding Disorders

 Etiologies • Medical • Oral Motor • sensory • Behavioral 26

PREMATURITY

REFLUX DISEASE

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

Neurological disorders • intracranial

hemorrhage

• myasthenia gravis • cerebral palsy • meningitis • encephalopathy

Disorders affecting suck-swallow-breathing coordination • choanal

atresia

• tachypnea

cardiac disease bronchopulmonary dysplasia

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Connective tissue disease • polymyositis • muscular dystrophy

Iatrogenic causes • 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 hyperostosis • congenital web • 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) Difficulty with texture transition Difficulty with thin liquids (increased fluid loss and coughing) 33

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Nutritional Risk Factors for Children with Developmental Disabilities Oral-Motor Feeding Difficulties

 Discoordination of suck swallow  Structural abnormalities (cleft lip/palate; dentition)  Poor oral containment (food/fluid loss)  Tone abnormalities (hypo/hypertonic)  Altered oral sensory response (hypo/hyper-responsive)  Delayed oral motor skill development 35

Oral-Motor Weaknesses Difficulty with oral strength and coordination required for eating.

• Open Mouth Posture • Frequent drooling • Unable to bite through foods • Weak chewing • Poor bolus formation • Unable to close lips on spoon

• Poor lip movement (can’t pucker / spread) • Tongue Thrusting • Retracted tongue • Poor tongue lateralization • Coughing / Choking during meals 36

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• Where do they come from? – – – –

Prematurity Chronic illness Multiple medical interventions/medications Underlying neuro issues

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Sensory Integration Dysfunction • The sensory system consists of: • Proprioception – body awareness • Vestibular – balance • Tactile – touch • Gustatory – taste • Olfactory – smell • Vision • Auditory – hearing • The CNS receives all of these types of input, interprets them, and organizes a response • Sensory Integration Dysfunction occurs when the brain does not efficiently process sensory stimuli coming from the body or the environment.

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Sensory Impact on Feeding • Children with tactile hypersensitivity are averse to smooth, wet, slimy textures on their hands, face, body and/or in their mouth. • Children with tactile hyposensitivity have reduced sensations of foods in the oral cavity and thus pocket or lose control of them which can lead to gagging or choking. • Upper body strength and coordination supports and is required for mouth strength and coordination. 40

Feeding Sensory Red Flags • Prefers to drink water • Gags easily • May only smell or lick foods • Wipes mouth/tongue • May bite and chew without swallowing foods • Stuffs mouth • Eats only crunchy foods • Wants hands/face cleaned immediately

• Negative response to touch of wet, slimy, or sticky substances • Feeds/eats best when sleepy or distracted • Does not tolerate others touching or putting things in his/her mouth • Mouths only certain items • Separates & expels pieces in mixed consistency food 41

• Oral motor weaknesses lead children 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. • Sensory dysfunction leads children to experience eating as scary when the child is presented with aversive textures.

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• Children with oral-motor weaknesses are most capable of eating smooth, pureed textures (pudding, yogurt, apple sauce) and are less able to eat crunchy or solid foods. • However, children with sensory dysfunction are highly averse to smooth foods and are most comfortable with crunchy or solid foods. • Most children with feeding problems have both oral motor weaknesses and sensory deficits. 43

•Avoidance of eating is initially an adaptive 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 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 food.

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•Pushing food away •Throwing food •Turning away •Crying • Saying “No!” •Refusing to open mouth •Expelling foods from mouth •Gagging/Vomiting 45

Steps for Diagnosis and Treatment of Pediatric Feeding and Swallowing Problems

Define problem feeding and swallowing Identify etiology(ies) Determine appropriate diagnostic tests Plan approach to patient/family Teach about problem, implement treatment Monitor progress Evaluate progress (outcomes focused) 46

Evaluation of dysphagia and feeding disorders • Performing a history and physical • Objectives of the history should include: • Identifying the anatomic region involved and obtaining clues to the etiology of the condition. • This may include information regarding the onset, duration and severity, presence of regurgitation, the perceived level of obstruction and presence of pain or hoarseness, and presence of other disorders. 47

• During the physical examination: •

The patient should be observed during the act of swallowing.

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A clinical dysphagia evaluation is usually completed by a speech-language pathologist.

• The examination will include assessment of posture, positioning, patient motivation, oral structure and function, efficiency of oral intake and clinical signs of safety. •

In infants, the oral-motor assessment includes evaluation of reflexive rooting and non-nutritive sucking (Darrow and Harley, 1998).

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Infants and children may require additional assessments, since growth, development, and changes in medical condition may affect the swallowing process. 48

Diagnostic testing that may be employed includes  Esophagoscopy: This test may be used to rule out neoplasm,

particularly in patients who complain of thoracic dysphagia or odynophagia.

 Esophageal manometry and pH probe studies: These tests may be used when a motility disorder or gastric esophageal reflux disease is suspected.  Electromyography: This test is indicated in patients with motor unit disorder such as polymyositis, myasthenia gravis, or amyotrophic lateral sclerosis  Fibroptic endoscopic examination of swallowing (FEES): This test is performed with a transnasal laryngoscope to assess pharyngeal swallowing.  This test may be helpful when a VFSS (videofluorographic swallowing study) is not feasible  Ultrasound imaging: This testing has been used to a limited 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. 49

Videofluorographic swallowing study Is the gold standard for evaluating the mechanism of swallowing. VFSS is also referred to as modified barium swallow. During this study, the patient will eat and drink foods mixed with barium while radiographic images are observed on a video monitor and recorded on videotape. This test is ideally performed jointly by a physician and a speechlanguage pathologist. The study will demonstrate anatomic structures, the motions of these structures, and passage of the food through the oral cavity, pharynx and esophagus . 50

Videofluorographic swallowing study This test may also be used to test the effectiveness of compensatory 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 sufficient amount of barium to provide a meaningful study.

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Interdisciplinary Approach  Interdisciplinary team evaluation: • Medicine – Rule out physical causes of feeding • • • •

problem Nutrition – Evaluate adequacy of current intake Social Work – Evaluate family stressors Speech/Occupational Therapy – Evaluate oral motor status and safety Psychology – Assess contribution of environmental factors 53

• the causes of many of the disorders resulting in feeding disorders or dysphagia may not be amenable to pharmacological therapy or surgery as a result of behavioral contributors to impairment. • In these cases, a referral to a professional, such as a speech pathologist, or feeding clinic is appropriate. • A child may continue with signs and symptoms 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. 54

Prerequisites for oral feeding attempts for infants and young children include

• Cardiopulmonary stability • Alert , calm state • In young infants, 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: 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 • Pacing 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. • Changing 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. 58

Feeding therapy for infants and children may include the following strategies • Specialized feeding techniques that are used 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 59

When a patient is unable to achieve adequate alimentation and hydration by mouth, 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; keep meals, naptime, and bedtime at same times daily

 Make healthy foods readily available and unhealthy foods less available

 Model healthy eating behaviors and discuss good eating habits 63

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 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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