8/19/2018 Understanding Feeding Challenges in Young Children - - PDF document

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8/19/2018 Understanding Feeding Challenges in Young Children - - PDF document

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8/19/2018 Understanding Feeding Challenges in Young Children Noreen Clarke, DNP , RN, CNS Olivia Hsin, PhD Karen Park, OTD, OTR/L, BCP , SWC, CLE Anet Piridzhanyan, MS, RD GROW Symposium 2018 | Childrens Hospital Los Angeles Objectives

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Understanding Feeding Challenges in Young Children

Noreen Clarke, DNP , RN, CNS Olivia Hsin, PhD Karen Park, OTD, OTR/L, BCP , SWC, CLE Anet Piridzhanyan, MS, RD

GROW Symposium 2018 | Children’s Hospital Los Angeles

Objectives

2

  • Understand the early developmental signs of

potential feeding challenges in young children.

  • Identify the multiple interrelated factors that

impact feeding and eating in young children.

  • Describe some developmental, medical,

environmental, sensory, and nutritional considerations when feeding difficulties are identified. Case Study Jan…

  • 3 year 5 month old girl female
  • Hx of underweight; <5th percentile
  • Diet: vanilla yogurt only; does not chew food
  • Hx of force feeding by caregiver

What else do you need to know? Who would you want to consider collaborating with?

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  • I. Feeding Challenges
  • II. Early Identification: Factors that Impact

Feeding

  • III. Interventions

Overview

  • I. FEEDING CHALLENGES

Normative Picking Eating

  • Can tolerate touching or tasting food.
  • May have preferences but are able to tolerate

different brands of same food.

  • Eat a variety of textures.
  • Can accept new foods after a few exposures (~15).
  • After burning out on a food, food is regained quickly

after a break.

  • 40% of children continue to have picky eating after 2

years.

6

Normative Picky Eating versus Feeding Difficulties

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More than Picky Eating When does it become a problem?

  • Nutritional deficit
  • Impairment on functioning

– Individual

  • Anxiety, crying, or other distress around new food
  • Behavior problems – tantrumming, throwing food

– Parent

  • Stress, time spent

– Parent-Child Relationship

  • Battles at most meals

– Spousal Relationship

7

Prevalence

8

  • 8-50% of children have feeding concerns:

– picky eating – selective eating – challenging feeding problems

  • Feeding difficulties are found more often in

children with special health care needs (CSHCN). Feeding Difficulties in..

  • Children with chronic medical concerns:

– 40-70% have feeding difficulties

  • Children with developmental disabilities:

– Up to 80% have element of a feeding disorder – 3-10 % have severe feeding disorders

  • Children with Autism Spectrum Disorder:

– Up to 87% have feeding difficulties

9

Feeding in Children with Special Health Care Needs

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Feeding Difficulties -Difficulties related to feeding that

impact physical or emotional health may consist of..

  • Food and/or liquid refusals
  • Food selectivity
  • by type (pasta versus tortillas)
  • by texture (mushy foods, wet foods, pasta with sauce, pizza)
  • by brand (only McDonald’s fries or only Tyson brand nuggets)
  • by shape (rotini but not spaghetti)
  • Oral motor problems/not advancing textures
  • Dysphagia (swallowing disorder)

10

Normative Picky Eating versus Feeding Difficulties

Feeding Difficulties continued..

  • Frequent vomiting
  • Reduced or absent self-feeding for

developmental level

  • Inappropriate meal time behaviors
  • Stressful mealtimes
  • Long mealtimes
  • Feeding dependent on child being distracted

(screen time) or sleepy

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Normative Picky Eating versus Feeding Difficulties

EARLY IDENTIFICATION: FACTORS THAT IMPACT FEEDING

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  • Medical
  • Structural, Physiological, and Sensory
  • Nutritional
  • Developmental
  • Experiential / Cultural / Psychological

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Factors Impacting Feeding Development

MEDICAL CONSIDERATIONS

Early Identification: Factors that Impact Feeding

History

  • Prenatal
  • Birth
  • Feeding
  • Developmental milestones
  • Parent’s understanding of feeding

challenges

Medical Considerations

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Medical Considerations

  • NICU (birth trauma,

prematurity, congenital malformations)

  • Dentition (caries,

pain, trauma) Medical Considerations

  • GERD
  • Food allergies and

Eosinophilic Esophagitis (EoE)

  • Delayed gastric

emptying

  • Constipation

STRUCTURAL, PHYSIOLOGICAL, AND SENSORY CONSIDERATIONS

Early Identification: Factors that Impact Feeding

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  • Developmental
  • Oral structures
  • Development of head/neck and postural control
  • Oral motor and swallowing coordination
  • Self feeding skills
  • Developmental expectations and readiness

Structural, Physiological, and Sensory Considerations

  • Sensory Consideration
  • Sensory systems (olfactory, visual, auditory, tactile,

gustatory, proprioceptive, vestibular)

  • Sensory experiences
  • Response to taste, texture, temperature
  • Hyperresponsiveness vs. hyporesponsiveness
  • Exploration
  • Sensory regulation and modulation
  • Praxis/motor planning

Structural, Physiological, and Sensory Considerations

  • Sensory Consideration
  • Sensory systems (olfactory, visual, auditory, tactile,

gustatory, proprioceptive, vestibular)

  • Sensory experiences
  • Response to taste, texture, temperature
  • Hyperresponsiveness vs. hyporesponsiveness
  • Exploration
  • Sensory regulation and modulation
  • Praxis/motor planning

Structural, Physiological, and Sensory Considerations

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  • Structure of mealtime routines
  • Distracted eating
  • iPad/TV as distractor
  • Physical space
  • Social environment
  • Isolated eating
  • Temporal environment

Structural, Physiological, and Sensory Considerations

NUTRITIONAL CONSIDERATIONS

Early Identification: Factors that Impact Feeding

  • Growth: more than any other assessment tool, reliably

indicates the nutritional status of a pediatric patient. Growth

  • most rapid during infancy
  • decelerates during childhood
  • increase in velocity during puberty

Protein and Energy Needs

  • Increased during infancy
  • decelerates during childhood
  • Increases during puberty

Nutritional Considerations

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  • Growth: indicates the nutritional status of a

pediatric patient.

  • Medical conditions/diagnosis: can impact growth

and assessment of energy and nutrient needs.

  • Medications: can impact appetite as well as

vitamin/mineral absorption/reactions.

  • Overweight | underweight | healthy weight
  • Can still be malnourished in all three.
  • Ex. only eats chicken nuggets and tortillas with butter all day.

Nutritional Considerations

  • Nutritional Support: can this child thrive on

current diet alone?

  • Nutritional supplements/enteral feeding: separates

delivery of nutrients/calories from the act of eating.

  • Opportunities for child to feel hungry:
  • Frequency of meals/snacks
  • Quality of foods in diet
  • Ex. high intake of sugary sweet beverages –reduce appetite
  • Ex. lack of fiber in diet –increase constipation / reduce appetite
  • Mealtime routine –what does it look like

Nutritional Considerations Nutritional Considerations

  • Overall goal of medical nutrition therapy is to improve

the child’s health and nutritional status while promoting a family’s enjoyment of their child at mealtime.  Meeting nutritional needs to support growth / development.  Correcting energy imbalances.  Encouraging success with self feeding.

  • Family centered approach.
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Nutrition Assessment answers 3 important questions: 1) Is the child being fed a diet that meets his/her nutritional requirements? 2) Is the child growing as expected for his or her age, gender, condition? 3) Is there a feeding or eating problem interfering with growth/ meeting nutritional requirements? Nutritional Considerations

EXPERIENTIAL, CULTURAL, PSYCHOLOGICAL CONSIDERATIONS

Early Identification: Factors that Impact Feeding

Child Parent / Caregiver Community / Culture

Parent-child Fam & Com. Child-comm.

Experiential, Cultural, Psychological Considerations

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Experience

  • Eating is not instinctive
  • Children can learn to

eat

  • Children can also learn

NOT to eat

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Child Parent / Caregiver Community / Culture

Parent-child Fam & Com. Child-comm.

Experiential, Cultural, Psychological Considerations Children Learning to Eat Children Learning to Eat

  • Parent smiles
  • Parent praises or pays attention to eating
  • Child enjoys the taste
  • Child plays with the food
  • Child watches others eat and enjoy food
  • Child is successful with manageable foods

32

EATING CAN BE FUN & I CAN DO IT!

Experiential, Cultural, Psychological Considerations Children Learning Not to Eat

  • Negative experiences in hospital with things

being done near the face

  • GERD
  • Motor problems
  • Breathing problems
  • Ear infections or dental problems
  • Developmental delays
  • Parent-child arguments

33

EATING IS HARD, PAINFUL, FRUSTRATING, OR ANXIETY-PROVOKING EATING IS HARD, PAINFUL, FRUSTRATING, OR ANXIETY-PROVOKING

Experiential, Cultural, Psychological Considerations

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Parents Learning

  • Child accepts food
  • Child smiles
  • Child grows well
  • Child is underweight
  • Grandparents or other providers’ messages
  • Child rejects food
  • Child turns head away
  • Child has poor growth
  • Child gags or chokes

34

My child is a good eater I can feed my child Mealtimes are battles Am I a bad parent? Will my child choke?

Experiential, Cultural, Psychological Considerations Other Learning Experiences

  • Food security
  • Cultural expectations
  • Modeling “I don’t eat that”
  • Negative associations with

power battles

  • Home environment (e.g.,

calm, chaotic)

  • Multiple caregivers with

different approaches

35

Child Parent / Caregiver Community / Culture

Parent-child Fam & Com. Child-comm.

Experiential, Cultural, Psychological Considerations

  • Early Symptoms
  • Parent anxiety, difficult experiences
  • Red Flags
  • Tantrums
  • Tearfulness
  • Avoidance or “Escape”
  • Fearfulness
  • Forced feeding
  • Pleading
  • Disruptions to parent-child relationship

Experiential, Cultural, Psychological Considerations

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  • Not a helpful dichotomy
  • Problems that start out medically can start

involving behavior

  • Behavioral and environmental difficulties will
  • ften also cause medical issues

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Feeding Problems can be multifactorial, not just medical vs behavioral

Medical versus Behavioral

III INTERVENTIONS –FAMILY CENTERED APPROACH

Multidisciplinary Approach

  • Medical complications
  • Medical specialists and primary care provider
  • Physical limitations
  • Physical therapist or occupational therapist
  • Oral motor/oral sensory or swallowing challenges
  • Speech-language pathologist or swallow certified occupational

therapist

  • Nutritional challenges
  • Registered dietitian experienced with feeding challenges
  • Challenges with anxiety, negative associations, child-parent

behavioral or emotion regulation challenges, behaviors at mealtime

  • Psychologist

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Accessing Resources

Treatment for feeding challenges

  • Developmental challenges:
  • Regional Center
  • Rehabilitative program i.e.: CHLA
  • Behavioral Challenges:
  • USC UCEDD
  • Insurance may refer to other providers
  • Discussion with PCP

40

Case Study

Jan…

  • 3 year 5 month old girl
  • Hx of underweight; <5th percentile
  • Diet: yogurt only; does not chew food
  • Hx of force feeding by caregiver
  • Family Concerns: Mom wants her to eat

more foods so she is healthy.

Nutritional Concerns:

  • Is the child being fed a diet that meets his/her nutritional

requirements?

  • Is the child growing as expected for his or her age,

gender, condition?

  • Is there a feeding or eating problem interfering with

growth or meeting nutritional requirements?

Case Study

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Medical Considerations

  • Bowel movements usually every 2-3 days.
  • Current week: bowel movements 1 x day.
  • Episode of vomiting and dehydration.

Next steps:

  • Address constipation
  • Address dehydration

Case Study Structural, Physiological, and Sensory Considerations

  • Sensory vs. oral motor
  • Limited food repertoire
  • Does not put other foods in mouth
  • Occasionally licks food

Next Steps:

  • Address oral motor skill development
  • Explore and assess sensory processing
  • Food play for exploration
  • Food Chaining

Case Study Experiential, Cultural, Psychological Considerations

  • Turns face away when she sees food
  • Stopped accepting solid foods at 1 ½ years
  • Parent tried to force feed client
  • Client resists and cries when it is time to eat

Next Steps

  • Parent education on impact of experiences on

anxiety: not oppositional behavior

  • Parent education on anxiety and role of exposures

Case Study

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Experiential, Cultural, Psychological Considerations Next Steps continued..

  • Establish mealtime routine at the table
  • Discuss the language of feeding parents use around

mealtimes

  • Parent-child sessions teaching both to have

pleasurable experiences with food through exposures

  • Collaborate with dietitian to strategize which foods

to start exposures with and meal times

Case Study Interventions

  • Many barriers to address before you can recommend

child to eat all 5 food groups and enough of it.

So where do you start?

Case Study

Interventions

  • What can the child do/eat?
  • Likes creamy, soft textures, vanilla flavor, white colors.
  • What can you recommend to help child meet

nutritional/energy needs?

  • Calorie/nutrient rich foods that resemble vanilla yogurt.
  • Vanilla Pediasure/Boost Kid Essentials/Smoothies?
  • How can you help encourage child to eat?
  • Create opportunities for the child to be hungry.
  • Meal time routine vs yogurt every 1-2 hours.
  • Reduce constipation..fiber rich foods.

Case Study

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  • Collaborate with providers.
  • Consider medical, structural, physiological,

sensory, environmental, experiential, cultural, psychological, and nutritional factors.

  • Be patient.

Conclusion

THANK YOU! Questions?

  • Manikam, R., & Perman, J. A. (2000). Pediatric feeding disorders. Journal of Clinical Gastroenterology, 30(1),

34-46.

  • Mascola, A. J., Bryson, S.W., & Agras, W.S. (2010). Picky eating during childhood: A longitudinal study to age 11
  • years. Eating Behaviors. 11, 253-257. D.o.i. 1 0.1016/j.eatbeh.2010.05.006
  • Ledford, J., & Gast, D. (2006). Feeding problems in children with autism spectrum disorders: A review. Focus on

Autism and Other Developmental Disabilities, 21, 153-166.

  • Lukens, C., & Silverman, A. (2014). Systematic review of psychological interventions for pediatric feeding
  • problems. Journal of Pediatric Psychology, 39, 903–917.
  • Manikam & Perman, 2000; Silverman, 2010)
  • (see Ledford and Gast, 2006 for review)
  • Mayes & Volkmer, 1993; Kerwin, 1999; Williams, Field, & Seiverling, 2010; Wolf, Glass, & Carr, 1992; Piazza,

2008).

  • Silverman, A. H. (2010). Interdisciplinary care for feeding problems in children. Nutrition in Clinical Practice,

25(2), 160-165. doi: 10.1177/088453361036160925/2/160 [pii]

References