How many times have parents told their children's pediatrician about their children's feeding habits? These are some of the common complaints we have received:
* A 3-year-old who "doesn't chew anything. We have to give him just baby food."
* "He chews meat, but he just spits it out."
* "We tried the cup, but the milk just runs out the side. We just give him the bottle."
* "He eats whatever we eat. I just put everything in the blender."
* "Mashed potatoes or farina are easiest for him, so that's what he eats for every meal."
Growth may not be a reliable indicator of feeding skills. Normal growth does not indicate how children are being fed, nor what feeding skills they are using, only that reasonably adequate nutrition is probably being provided. Sidebar 1 (see page 480) and Sidebar 2 (see page 481) list the normal developmental sequence for feeding and the sequence for introduction of foods and textures. Questions about the textures of foods offered are just as important as those about which foods are offered. Caregivers may think that the child has age-appropriate feeding skills, not realizing that tolerance of age-appropriate textures is equally important to feeding.
Tolerance of textures, however, can only occur when all oral structures are working together properly.
FUNCTIONS OF THE ORAL STRUCTURES
The functions of the oral structures are explained in Sidebar 3 (see page 482). The oral structures are interdependent. If one structure fails to carry out its role, another will attempt to compensate for this loss. As this structure compensates, it sets off a negative chain reaction, almost like a domino effect, resulting in very inefficient feeding.
Bottle drinking is an example of this interdependency. Suckling is observed in utero as early as 15 to 18 weeks' gestation. In order to extract liquids from a bottle, negative pressure and a tightly-sealed space must be created. The larger the space, the greater the sucking power. The tongue helps create the seal in the mouth and works with the lower lip in the front of the mouth and with the soft palate in the back of the mouth. If a child has a poor lip seal, the tongue must make the seal alone, resulting in tongue smacking sounds and a loss of liquid.
The lips and the cheeks are also very dependent on one another. Low tone in the cheeks usually indicates low tone in the lips with resulting inability to create space in the oral cavity, causing the jaw to then drop down widely to create more space. This, in turn, results in poor lip seal and ultimately a loss of liquid.
Figure 1. Proper feeding positioning for drinking: neck elongated but not hyperextended, jaw supported to facilitate a proper seal around cup.
CRITERIA FOR REFERRAL FOR A FEEDING EVALUATION AND/OR INTERVENTION
The following are several important factors that warrant referral for a feeding evaluation:
* Failure to meet normal feeding milestones;
* Swallowing dysfunction; and
* Children fed by nasogastric tube or gastrostomy tube.
Failure to meet normal feeding milestones. When normal feeding milestones are not being met, further evaluation to rule out feeding problems is indicated. Feeding difficulties in children with developmental diagnoses have been well documented,1,2 and inquiring about feeding skills should be a routine part of the developmental assessment to ensure proper energy and nutrient intake. Tolerating age-appropriate foods is not the same as competence with age-appropriate textures. It is common, for example, for caregivers to puree table foods to the consistency of pudding or even a thick liquid and add them to a bottle for suckling (with the nipple holes enlarged to accommodate a viscous liquid), or to serve them with a spoon.
Presence of swallowing dysfunction. Any child with swallowing dysfunction should be considered for a feeding evaluation and video fluoroscopy of the swallowing mechanism. Medical clearance, by either the primary or referring pediatrician or after obtaining a swallow study, should be given before oral feeding intervention begins. However, note that a clinical assessment of aspiration may be accurate only 50% to 60% of the time.3 Children with central nervous system (CNS) impairments are especially at risk for swallowing dysfunction.4 Some signs that may signal aspiration include the following:
* Coughing and choking during feeding. This can also signal poor coordination of breathing and swallowing. Even without coughing and choking however, there can be "silent aspiration."
* History of frequent respiratory infections or a history of aspiration pneumonia.
* Multiple swallows: when a child needs to swallow several times after each spoonful, there may be residue in the pharynx after the swallow.
* Noisy breathing: when the child produces gargling sounds during breathing, especially during eating, this may signal swallowing dysfunction.
All tube-fed children. Any children fed by nasogastric or gastrostomy tube should be referred for a feeding evaluation and subsequent feeding therapy. Whenever a child is tube fed, especially during the first year of life when crucial feeding skills are acquired, feeding therapy helps preserve learned feeding skills and helps prevent skill regression. A "critical period" of feeding skill acquisition has long been described as a physiological phenomenon that occurs between 6 and 7 months.5 Upon referral for feeding therapy, the physician may be asked to give clearance for the level of feeding intervention. The goal for most children is oral feeding milestones that are consistent with their developmental level. The feeding of appropriate textures, with appropriate challenges, can occur during therapy. Feeding may be contraindicated, however, if there is dysphagia, swallowing problems, absence of a gag reflex, suspicion of food aspiration, or a history of aspiration pneumonia. Such feeding contraindications should be documented by the referring physician. Even when oral feeding is not indicated, however, oral motor stimulation and the practicing of non-nutritive suckling and non-nutritive chewing, biting, and teething can be critical to helping maintain oral motor skills.
One challenging aspect of feeding therapy in tube-fed children, especially those who have spent a large portion of infancy being tube fed, is their loss of connection between oral feeding and satiety. The children can sense hunger and satiety, but they don't know that the purpose of oral feeding is how to achieve satiety, because their pathway to satiety bypasses the oral route.
Distinguishing feeding skill problems from feeding behavior problems. This distinction is often blurred, and a referral to a behavior-oriented feeding therapist or nutritionist may be helpful in making this distinction, such as when a child eats normal table foods but spits some foods out (as is often the case with meat). Referral to a speech/language pathologist is appropriate for difficulties with the oral phase of swallowing. Failure to meet milestones for physical development may also raise concern about feeding skills. A physical or occupational therapy evaluation should be considered, for example, along with an assessment of feeding skills, if a child is unable to sit independently.
DIAGNOSES OFTEN ASSOCIATED WITH FEEDING PROBLEMS
Some diagnoses are red flags that should cause a heightened awareness of possible feeding problems. Among these conditions are the following:
* Central nervous system disorders;
* Genetic disorders;
* Increased or decreased sensitivity; and
* Swallowing problems.
For children with a central nervous system disorder, inquiring about feeding skills is especially critical,6 both to obtain a baseline indication of nutrient intake and feeding skills and to monitor any status changes. In cerebral palsy, for example, or anytime there may be hyper- or hypotonicity, feeding difficulties can negatively impact macroand micronutrient intake.7 Hypertonicity around the upper lip, for instance, may prevent the child from being able to efficiently and effectively use the upper lip to strip food from the spoon. Hypotonicity can also limit adequate intake because the child lacks the ability to effectively manipulate food in the mouth, form a bolus, and swallow effectively.
Some genetic disorders also predispose children to hypotonicity. Ironically, children with Prader-Willi syndrome usually have a history of poor feeding during the first year of life, often to the point where they are undernourished and need tube feeding.8 Children with Down syndrome may have similar low muscle tone and be poor feeders and slow to acquire feeding skills.
Children with increased or decreased sensitivity are also at increased risk for feeding disorders. When there is limited sensory input, there is little motivation to move oral-motor structures. On the contrary, when a child is hypersensitive, the slightest advancement in texture is likely to be met with refusal. Sometimes this hypersensitivity is because of limited exposure to new textures. A 3-year-old who has never had anything in his mouth more textured than strained peaches will shudder the first time a Cheerio is crumbled into his mouth. Children with autism may or may not have true feeding skill disorders, but their refusal of certain textures and foods can mimic a feeding disorder.
Swallowing problems are a subclass of feeding disorders, because they can exist even when chewing skills are somewhat intact. Part of appropriate chewing is the ability to form a bolus and bring it to the rear of the mouth, where the gag reflex and subsequent esophageal peristalsis take over to complete the swallowing process. If a child has a gag reflex that is delayed or even absent, feeding is interrupted. Under these circumstances, the child may not even be a candidate for oral feeding. Confirmation of the swallowing dysfunction should be obtained from a swallowing study with videofluoroscopy before clearance is given for feeding intervention.
It is possible, of course, for children to be able to exist by taking only pureed foods, but this is not developmentally appropriate and can be nutritionally limiting. Children who depend on liquids for most of their calories and nutrition may risk poor growth, because solid foods are often far more energy dense than liquids. A cup (8 ounces) of whole milk, for example, is 150 calories, while a 1.5 ounces of cheese has about 160 calories and only about one-sixteenth the volume.
Finally, even when a feeding problem has an organic etiology, the child is at risk for adding behavioral components to the feeding disorder unless the underlying organic issues are addressed quickly. The home feeding environment, consistency of caregivers, and concomitant psychosocial issues can affect feeding skills and impede progress.9
The Feeding Team
Feeding is such a complex process, involving all the senses and numerous organs, CNS pathways, and thought systems, that an interdisciplinary approach is recommended. This process usually involves the expertise of a speech pathologist, a nutritionist, occupational and physical therapists, as well as the pediatrician, and often a dentist and gastroenterologist. Caretakers also provide a critical role, because they need to learn the skills to be practiced with the child in the home environment.
Before feeding intervention can begin, a medical and nutritional history should be taken. Included in this history are the following:
* A developmental diagnosis, if any;
* History of aspiration and/or reflux;
* Surgical history, if any;
* Results of any video fluoroscopy tests or other swallowing studies; and
* Psychosocial history and information on family dynamics.
Assessment of Feeding Skills
This can be done by a qualified speech pathologist, nutritionist, or occupational therapist and should include information on the following:
* Information on the feeding environment, consistency of caregivers, and position of the child during feeding;
* Observation of feeding skills of the child (the use of a bottle for drinking, competence with cup drinking, chewing skills, and tolerated textures);
* Dietary pattern and feeding schedule;
* Assessment for oral hyper- or hyposensitivity; and
* Baseline observation of the caregiver's feeding style.
Even when proper textures are presented, the child is willing to eat, and the caregiver is trained and competent, proper positioning during feeding is essential for feeding success. Optimal alignment of the head, neck, trunk, and extremities is required for effective feeding skills to be expressed. An example of proper positioning of the head for drinking is shown in Figure 1 (see page 479).
STRATEGIES TO ENHANCE SUCCESSFUL INTERVENTION
In order to ensure the most effective feeding intervention, certain components are necessary, and every effort should be made to include the following:
* Interdisciplinary approach - At minimum, the team should include a speech therapist, occupational therapist, and nutritionist. Other specialists can be consulted as needed, and the referring pediatrician should be kept informed of the child's progress.
* Utilize appropriate adaptive feeding equipment on a daily basis.
* Explain ground rules to caregivers, including required attendance and practice at home and frequency of visits.
* Set realistic goals - appropriate goals take into account feeding and speech/communication needs along with the child's developmental level and a realistic rate of progress.
* Expect setbacks. They are inevitable, especially if children receive ongoing intervention. After a serious illness, regression of feeding skills is common, even expected. Some regression of skills can even occur after a cold or
Feeding problems are common in children with special healthcare needs, and inquiring about feeding skills should be a routine part of the developmental assessment. Failure to meet normal feeding milestones, the presence of swallowing problems, and the presence or history of placement of a nasogastric or gastrostomy tube are all reasons to refer a child for a feeding evaluation. An interdisciplinary approach that includes the pediatrician along with a feeding team that includes a speech pathologist, occupational therapist, feeding-oriented nutritionist, and often others, should be taken to diagnose and manage feeding disorders in such children as early as possible for the best prognosis.
However, caregivers also play a critical role in intervention, and effective management of feeding disorders should always be seen as a partnership between the caregiver and the interdisciplinary team. The additional benefit is the feeling of competence by the caregiver who is properly trained in the feeding of his/her special needs child. Providing caregivers with proper training as well as realistic goals, regular instruction for home practice, and the expectation for periodic setbacks, can help the child and the caregiver reap the most benefit from feeding intervention.
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