Understanding and approaching feeding disorders in children with autism
Pediatric feeding disorders are common in children with autism, and medical issues associated with these disorders could be overlooked due to underlying behavioral, communication and sensory challenges, according to a presentation at the International Pediatric Feeding Disorder Conference.
Feeding Matters — an advocacy organization for pediatric feeding disorders (PFDs) — defines PFD as “impaired oral intake that is not age-appropriate, and is associated with medical, nutritional, feeding skill, and/or psychosocial dysfunction.”
“Dysfunction in one domain can impact the child’s ability or the family system’s ability to be functional in another area. It’s all intertwined,” said Bethany Kortsha, MA, OTR/L, a pediatric occupational therapist and pediatric feeding specialist.
Kortsha said the incidence rate of feeding disorders in children with autism varies, with one study identifying atypical eating behaviors and feeding problems in 70.4% of children with autism vs. 4.8% of typical children.
“Feeding difficulties is something that’s consistently impacting the majority of kids on the autism spectrum,” she said.
The medical aspect of PFD includes impaired structure of function of the gastrointestinal, cardiorespiratory and neurodevelopmental systems, which makes children with autism more prone to feeding difficulties, Kortsha said.
In addition, studies have shown that many gastrointestinal difficulties are common in children with autism, including chronic abdominal pain, constipation, chronic diarrhea and gastroesophageal reflux disease.
“Oftentimes, these underlying medical or gastrointestinal difficulties get missed because of the child’s underlying communications, sensory processing or behavioral challenges,” Kortsha said. “What happens is parents and caregivers misattribute some of the signs or symptoms that they might otherwise pick up on with a child that’s typically developing, because they just pass things off or account it to the fact the child has autism, so they’re more likely to be angry or aggressive or agitated or refuse foods.”
To ensure that underlying medical difficulties are not missed, physicians should help families observe the child’s behavior and identify patterns and symptoms that could point to a medical issue, she said.
Nutritional issues within PFD include malnutrition, overnutrition, micronutrient deficiency or toxicity and dehydration. Among children with autism, the most common nutritional challenge is restricted dietary variety, with fruits and vegetables often being the least consumed foods.
Studies have found significant deficiencies in vitamin intake stemming from decreased food or vegetable consumption and revealed children with autism had lower intakes of zinc, calcium and fiber. These deficiencies have been shown to lead to other problems, with macronutrient deficiencies causing issues with attention, learning, motor skills and function, and fiber deficiencies linked to constipation problems.
Addressing these deficiencies is important in all children, but “especially when we have a child that is set up for some developmental difficulties because of their neurodevelopmental diagnosis,” Kortsha said. “Those vitamin and mineral deficiencies are going to play a role in impacting their global behavior.”
Therefore, identifying deficiencies and developing a plan to improve nutrition intake, as well as their overall appetite and interest in eating are essential.
Feeding skill deficits
Feeding skills deficits in PFD include impairments in oral and pharyngeal sensory-motor functioning and altered oral experiences such as injury, neurological deficit and limited feeding experience. In her presentation, Kortsha said many experts in the field feel this definition should also consider a child’s entire body and skill sets that play a role in feeding.
An important consideration in pediatric feeding deficits are sensory systems, the role they play in feeding and learning how to eat a new food. Studies of children with autism have shown that they have impairments in how they process and experience sensations, which can affect the way they learn and eat new foods and cause them to limit their intake to foods they are familiar with, Kortsha said.
Postural stability, or the ability to maintain an upright posture, is another skill set needed for feeding. Kortsha said children with autism who have difficulty maintaining their posture often focus their motor skills on keeping themselves upright, rather than the fine and oral motor movements like those needed for feeding, chewing and swallowing, which makes feeding more difficult.
Research has shown children with autism have identified motor deficits and motor planning difficulties and issues with apraxia. In children with autism, these praxis difficulties can “negatively impact the way that they explore food, approach learning about new food, being able to move their body in a way to manipulate the food,” Kortsha said.
The psychosocial domain of PFD includes psychosocial disorders, developmental factors, social and environmental factors, and mental and behavioral health issues in children, their caretakers or both.
Kortsha said caretakers approach feeding the same way in children with autism as they would a typical feeder — often because a child did not yet receive a diagnosis of autism — and are not making appropriate modifications for the child’s skill deficits, including the portion size, the types of food and how they engage with the child.
This leads to a mismatch between the demands of the task and the child’s skills, and the child does not typically have the language capabilities to communicate this mismatch because they are too young or have difficulty communicating. Therefore, they use vocalizations, posture and “problem behaviors” like throwing food and running away during mealtimes to communicate this mismatch.
“Children start to develop learned avoidance behaviors or learned feeding aversions because even before the food was presented, they’re coming to the table in ‘fight or flight,’ expecting for their nervous system to be assaulted from a sensory perspective,” Kortsha said.
Additionally, children’s food preferences often reflect their sensory-motor skills, and health care professionals and parents should monitor these preferences to determine their skill deficits and determine approaches to address them.
“Hopefully, this gives you a better understanding of how to look at a child with autism’s foundational skill deficits, and relate it back to their behavioral challenges during mealtimes, and it gives you a lens to really be thinking about the fact that the child’s behavior during a mealtime is essentially a communication of what’s working for them from a skill standpoint,” Kortsha concluded. – by Erin Michael
Kortsha B. Pediatric feeding disorders and autism: It’s about more than compliance. Presented at: International Pediatric Feeding Disorder Conference; Jan. 24-25, 2020; online.
Disclosure: Kortsha reports being a speaker for Toomey and Associates Inc., and receiving an honorarium from Feeding Matters for a CE session at the 2020 International Pediatric Feeding Disorder Conference.