Undernutrition is a major problem in the world and certainly a major contributor to disease and poor growth in vulnerable populations. Prolonged undernutrition affects the physical health as well as the mental and social development of children. In addition, it exacts a heavy cost to their families and society at large. Primary causes of undernutrition are availability of food and the ability or willingness to consume available nutrition. This chapter focuses on feeding disorders as an increasingly common source of undernutrition in young children.
Feeding disorders is a term used to describe children experiencing difficulty in consuming adequate nutrition by mouth (impaired feeding), those who eat too much (hyperphagia), and those who eat inappropriate items (pica). The term is often mistaken for eating disorders such as anorexia and bulimia, but it is unrelated to the risk factors in adolescent bulimia and anorexia nervosa.
Most normally developing children learn to accept and consume a well-balanced, healthful diet to sustain growth and health (1
). They develop the capacity for self-regulation and adapt to various parent and environmental changes. Satter (2
) has expanded this concept and outlined the role of the child and the parent during feeding. However, biologic, personal, and social factors can interfere with the principle of self-regulation.
Nearly 25% of infants and children are affected by feeding disorders at some point in their development. The rate is much higher, nearly 80%, among children with developmental disabilities. Further breakdown of the prevalence indicates 52% of toddlers are not consistently hungry at mealtimes, 42% end meals after a brief session, 35% are picky eaters, and 33% show food selectivity (3
). However, severe feeding problems are noted in children (3% to 10%), (4
) with greater prevalence in children with physical disabilities (26% to 90%) and among those with medical illness and prematurity (10% to 49%) (5
The consequences of undernutrition on growth and development are well documented (8
) and cause substantial morbidity and mortality. Feeding disorders affect the whole family resulting in significant stress and strain in the caregiver-child relationship (11
). Two thirds of a caregiver’s waking time may be spent in attending to a child with disordered feeding (12
), and this intense involvement of a primary caregiver takes time away from other family and household duties.
Feeding disorders have multiple etiologies, including medical, nutritional, behavioral, psychologic, and environmental factors (8
). Table 67.1
presents examples of common childhood feeding problems. Children with developmental disabilities, medical conditions, and severe behavior problems are unlikely to outgrow their feeding problems without intervention. Therefore, it is important that caregivers and care providers recognize a child’s feeding problem early and have an evaluation to offer early intervention to arrest the downward spiral of the child’s feeding problem.
Children with feeding disorders are a heterogeneous group. They range from those without medical problems to those who have gastrointestinal (GI) tract disorders, systemic illness, developmental delay, and physical disabilities. Forty-five percent of children with normal development have mealtime problems (13
). Most of these children’s feeding concerns were reported as one of poor appetite, and in 23% of cases the children were of normal weight and height.
A child’s feeding progresses from a strictly biologic need to a process combining maturation and learning in a nurturing social environment. Thus, feeding disorders should be conceptualized as biopsychosocial problems. Interactions among the three mechanisms pose a challenge to the differential diagnosis and evaluation and treatment. Many, but not all, persistent feeding difficulties in children
may have an associated underlying structural, neurologic, or physiologic disorder. Yet, in most children with significant feeding disorders, no clear etiology becomes apparent with even the most thorough evaluation.
TABLE 67.1 COMMON FEEDING PROBLEMS
Total food refusal
Food refusal by volume
Food refusal by texture
Food refusal by type
Feeding is a complex task requiring a sequential progression of a repertoire of skills to be successful. Guidance to families based on developmental progressions observed in normal children are inappropriate for children with cerebral palsy, failure to thrive, syndromic disorders, and muscular and neuromuscular problems. Poor coordination of oral structures may interfere with the ability to move food in the mouth, chew, or swallow in a safe and effective manner. Delayed motor skills may interfere with self-feeding.
Successful feeding often is perceived by parents as a measure of parenting competence. Effective feeding is contingent on the ability of both the adult and child to give, read, and interpret the others’ cues. Neurologic impairment may interfere with the ability to give clear hunger or satiety cues.
Children usually refuse food after negative experiences. These negative or aversive experiences may include pain in the act of eating or being fed, painful experiences around the facial-oral area, or adverse oral-sensory reactions. Subsequently, when food is presented, anticipatory anxiety arises and the child may refuse to eat at all, refuse to eat an adequate amount, or refuse to eat certain foods. Parents need to know that this is a learned response. Caregivers should be helped to understand that food refusal behaviors are an expression of anxiety or fear, rather than indicative that the child is “bad” or “difficult,” or that their fear “is all in their head.” Often, problems are worsened unintentionally by caregiver mismanagement. It is important to educate parents and caregivers regarding how the child’s feeding problem developed and what they can learn to do to change their child’s feeding behavior (14
). In many instances, caregivers experience guilt about their contribution, real or imagined, to the child’s feeding problems. They need assurance that a few behavioral changes (e.g., making mealtime pleasant) may improve their child’s eating behavior (Table 67.2
Feeding disorders include various feeding behaviors and characteristics. These behaviors can be categorized into ability (unable to perform) and motivational deficits (unwilling) (15
). A child with low energy or fine motor deficits may not self-feed. A child reported as having poor appetite and reduced consumption may have swallow dys-function, taste aversion, texture sensitivity, dental problems, recurring ear infections, or many other disorders. A child with severe gastroesophageal reflux may actively gag or vomit to relieve the discomfort. Total food refusal is uncommon in normal healthy children, except during illness or transiently when they are emotionally upset. However, a comprehensive assessment is still necessary to rule out physical causes of food refusal.
TABLE 67.2 OPTIMIZING THE FEEDING ENVIRONMENT
Quiet room with limited distractions
Developmentally appropriate positioning
Stable and supportive chair
Developmentally appropriate utensils
Child demonstration of readiness cues for feeding
Stable routine and schedules
Caregiver positioned at eye level
As proposed by the American Psychiatric Association Task Force for Revision of the Diagnostic and Statistical Manual for Mental Disorders,
Fifth edition (DSM
), children with feeding disorders can be broadly divided into three categories: children who do not eat enough or show little interest in eating; children who exhibit severe food selectivity and accept only a limited diet in relation to sensory features; and children whose food refusal is related to aversive experiences. In addition, children with feeding disorders include those who are healthy, have digestive disorders, and have special needs. Feeding difficulties in healthy children often are transitional and resolve spontaneously. However, in some children the problem persists and may require professional care. Suboptimal calorie intake, food selectivity by type, disruptive mealtime behaviors, and excessive meal duration are commonly seen feeding problems in healthy children. Table 67.3
presents ideas on how to improve mealtime behaviors in a child who is a picky eater.
TABLE 67.3 STRATEGIES TO IMPROVE MEALTIME BEHAVIORS OF “PICKY EATERS”
Cut down grazing.
Keep junk foods out of view.
Caregivers should model eating novel foods.
Offer small amounts at each serving.
Present the same novel food for 10 to 20 meals.
Make the foods attractive.
Food consistency should suit the child.
Add condiments and sauces that the child likes.
Add other foods to boost calories, such as grated cheese, cream, gravy, and butter.
Aim for high-density, low-volume foods.
Reinforce appropriate feeding behaviors.
Diagnosing medical disorders in children with feeding difficulties is a challenge, especially in infants and toddlers who are unable to report on their condition. Table 67.4
lists examples of medical conditions commonly seen in children with complex feeding difficulties.
In most cases, a team of experienced professionals from several disciplines including gastroenterology, nutrition, occupational therapy or speech therapy, and psychology are necessary to establish a differential diagnosis of the presenting symptoms to specify the cause or function. In an interdisciplinary team, the physician treats underlying medical causes; the dietician determines calories needed, appropriate foods and required nutrients; the occupational or speech therapist evaluates oral motor and pharyngeal skills, positioning for feeding, the need for adaptive equipment, and self-feeding skills; and the psychologist works to develop strategies in the treatment plan to decrease the child’s mealtime anxiety and related food refusal behaviors, increase the motivation to eat and drink, and eliminate disruptive feeding behaviors. Ultimately, for treatment to be effective over the long term, parents and other caregivers must be trained to implement all feeding recommendations in the home, daycare, and school environments. All referral concerns, no matter how simple or unimpressive, should be addressed, which allays caregiver concerns and averts more serious problems. Prognosis with early intervention is very favorable for most cases. Early intervention increases the effectiveness of therapy.
TABLE 67.4 MEDICAL CONDITIONS SEEN IN FEEDING PROBLEMS
Cleft lip or palate
Pierre Robin sequence
Complex congenital heart disease
Chronic lung disease
Cranial nerve anomalies
Intracranial mass lesion
Disorders of esophageal phase of swallowing
Tracheoesophageal fistula/esophageal atresia repair
Esophageal mass, stricture, web
Gastroesophageal reflux disease
Inflammatory bowel disease
Velocardiofacial syndrome (22q11.2 deletion syndrome)
CHARGE, coloboma, heart disease, atresia choanae, retarded growth and retarded development and/or CNS anomalies, genital hypoplasia, and ear anomalies and/or deafness.
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