Pediatric Feeding Disorder: Financial Support for this presentation was provided by Nestlé Health Science. The views expressed herein are those of the presenter and A Practical Approach do not necessarily represent Nestlé’s views. The material herein is accurate as of the date it was presented, and is for educational Presented on June 27, 2019 purposes only and is not intended as a substitute for medical advice. Reproduction or distribution of these materials is prohibited. James A. Phalen, MD, FAAP © 2019 Nestlé. All rights reserved. Developmental Pediatrics University Health System, San Antonio Adjunct Professor of Peds, UT Health Clinical Professor of Peds, USUHS Medical Director, Feeding Matters, Inc.

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LEARNING OBJECTIVES WHAT WAS KNOWN INTRODUCTION At the end of this presentation the participant will be able to: ● Describe normal feeding patterns in children ●Pediatric feeding disorder previously lacked a universally ● Identify common feeding problems in pediatrics accepted definition ● Explain several strategies to avoid or ameliorate feeding ●Previous diagnostic paradigms defined feeding disorder problems from the perspective of a single discipline ● Describe the differences between feeding problems and pediatric feeding disorder ● Describe how to manage pediatric feeding disorder

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WHAT IS NEW PEDIATRIC FEEDING DISORDER INTRODUCTION A LABOR OF LOVE ● 15 Authors began working together in March 2015 ● A unifying diagnostic term, “Pediatric Feeding Disorder”, using the framework of the World Health ● 7 Disciplines: Organization’s International Classification of Functioning, ○ Applied behavior analysis Disability, and Health ○ Child & pediatric psychology ● PFD unifies the medical, nutritional, feeding skill, and/or ○ Developmental-behavioral pediatrics psychosocial concerns associated with feeding disorders ○ Dietetics / nutritional medicine ● The proposed diagnostic criteria should promote the use ○ Occupational therapy of common, precise, terminology necessary to ○ Pediatric gastroenterology advance clinical practice, research, and health-care policy ○ Speech-language pathology 5 6

1 CONSENSUS ARTICLE PUBLISHED – JANUARY 2019

NORMAL FEEDING

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NORMAL FEEDING COMMON FEEDING PROBLEMS NORMAL FEEDING ●Coordination of multiple body systems

●Developmental progression of food selectivity ●Food selectivity (i.e., “picky eater”) ●Children self-regulate and may vary their oral intake up to ●Reduced appetite for or interest in food 30% daily with no effect on growth ●Slow feeding (i.e., > 30 minutes) ●Feeding plays a central role in the caregiver-child relationship ●Food pocketing

Phalen 2013 Phalen 2013 9 10

Between 25% and 50% of neurotypical children and up to 80% of those with developmental PEDIATRIC FEEDING disabilities have feeding problems DISORDER

Phalen 2013 11 12

2 AMERICAN SPEECH-LANGUAGE HEARING ASSOCIATION

Pediatric feeding disorder previously lacked PEDIATRIC FEEDING DISORDER a universally accepted definition ●Pediatric : impaired oral, pharyngeal, and/or esophageal phases of swallowing (ASHA* 2014)

* American Speech-Language-Hearing Association

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WORLD HEALTH ORGANIZATION AVOIDANT/RESTRICTIVE FOOD INTAKE

DISORDER American Psychological ICD-10 (2016) (DSM-5TM F50.8) – APA 2013 Association

● Eating or feeding disturbance with persistent failure to meet F98.2. Feeding disorder of infancy and childhood: appropriate nutritional &/or energy needs (with ≥ 1 of the “varying manifestations usually specific to infancy and early following): childhood. It generally involves food refusal and extreme ○ Significant weight loss (or poor weight gain or faltering growth faddiness in the presence of an adequate food supply, a in children) reasonably competent caregiver, and the absence of organic ○ Significant nutritional deficiency (or related health impact) disease” ○ Dependence on enteral feeding or oral nutritional supplements ○ Marked interference with psychosocial functioning

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AVOIDANT/RESTRICTIVE FOOD INTAKE AVOIDANT/RESTRICTIVE FOOD INTAKE

DISORDER American DISORDER American Psychological Psychological (DSM-5TM F50.8) – APA 2013 Association (DSM-5TM F50.8) – APA 2013 Association

● Not better explained by lack of available food or culturally ● May be based on sensory characteristics of food qualities (e.g., sanctioned practice (e.g., religious fasting, normal dieting) or appearance, color, smell, texture, temperature, taste) developmentally normal behaviors (e.g., picky eating in toddlers, ○ May manifest as refusal to eat particular brands of foods or to reduced intake in older adults) tolerate the smell of food being eaten by others ● Not exclusively during the course of anorexia nervosa or bulimia ○ Individuals who have autism spectrum disorder may show nervosa similar behaviors ● Not attributable to concurrent medical condition & not better ● May represent a conditioned negative response associated with explained by another mental disorder; severity must exceed that an aversive experience (e.g., choking, esophagoscopy, repeated routinely associated with the condition or disorder and warrants )

additional clinical attention 17 18

3 AVOIDANT/RESTRICTIVE FOOD INTAKE PROBLEMS WITH ARFID

DISORDER American Psychological TM Association (DSM-5 F50.8) – APA 2013 ●Specifically excludes children whose primary challenge is a skill deficit ● Associated Features Supporting Diagnosis: ○ Lack of interest in eating or food ●Severity of eating disturbance must exceed that associated ○ Young infants too sleepy, distressed, or agitated to feed with comorbidity ○ Infants & young children may not: ■ engage with primary caregiver during feeding ●No limitations re: age of onset ■ communicate hunger in favor of other activities ●Non-specific: 29% teens at eating disorder clinic ● In older children & adolescents, may be associated with: ○ Generalized emotional difficulties

de Vries 2014, Fisher 2014, Kurz 2015, Mussatto 2014 19 20

PEDIATRIC FEEDING DISORDER

PEDIATRIC FEEDING DISORDER ●PFD results in disability as defined by the World Health Organization (WHO) International Classification of Functioning, Impaired oral intake that is not age-appropriate, and is Disability, and Health (ICF) associated with medical, nutritional, feeding skill, and/or ○Impairment: a problem in body function or structure, or psychosocial dysfunction. ○Activity limitation: difficulty executing a task or action, or ○Participation restriction: problem with life situations

Goday et al., 2019 Goday et al., 2019 21 22

PROPOSED DIAGNOSTIC CRITERIA PROPOSED DIAGNOSTIC CRITERIA

Pediatric feeding disorder: Pediatric feeding disorder: A. A disturbance in oral intake of nutrients, inappropriate for age, 3. Feeding skill dysfunction, as evidenced by any of the following: lasting at least 2 weeks and associated with 1 or more of the a. Need for texture modification of liquid or food following: b. Use of modified feeding position or equipment 1. Medical dysfunction, as evidenced by any of the following: c. Use of modified feeding strategies a. Cardiorespiratory compromise during oral feeding 4. Psychosocial dysfunction, as evidenced by any of the following: b. Aspiration or recurrent aspiration pneumonitis a. Active or passive avoidance behaviors by child when feeding or 2. Nutritional dysfunction, as evidenced by any of the following: being fed a. Malnutrition b. Inappropriate caregiver management of child’s feeding and/or b. Specific nutrient deficiency or significantly restricted intake nutrition needs of one or more nutrients resulting from decreased dietary c. Disruption of social functioning within a feeding context diversity d. Disruption of caregiver-child relationship associated with c. Reliance on enteral feeds or oral supplements to sustain feeding nutrition and/or hydration 23 24

4 PROPOSED DIAGNOSTIC CRITERIA

Pediatric feeding disorder: B. Absence of the cognitive processes consistent with eating disorders and pattern of oral intake is not due to a lack of food or congruent with cultural norms.

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MEDICAL FACTORS PEDIATRIC FEEDING DISORDER

●Prematurity ●Cardiopulmonary disease ●Genetic/chromosomal anomalies MEDICAL FACTORS ●Craniofacial anomalies ●Neurodevelopmental disorders ●Gastrointestinal disorders

de Vries 2014, Mussatto 2014 27 28

MEDICAL FACTORS MEDICAL FACTORS • Autism spectrum disorder: sensory • Gastroesophageal reflux • Global developmental delay disease (GERD) NEURODEVELOPMENTAL (< 5 years old: cognitive DQ or GI DISORDERS DISORDERS standard score < 70) • Chronic constipation +/- Medical Factors overflow incontinence (i.e., Medical Factors • Intellectual disability: encopresis) (≥ 5 years old: intellectual + adaptive standard score < 70) • Eosinophilic esophagitis • Cerebral palsy: motor

Benfer 2013, Sharp 2013, Shmaya 2015 Benfer 2013, Sharp 2013, Shmaya 2015 29 30

5 NUTRITIONAL FACTORS PEDIATRIC FEEDING DISORDER

●Restricted quality, quantity, variety ●Inadequate energy intake = risk for weight faltering NUTRITIONAL FACTORS ●Excluding entire food groups = risk for micronutrient deficiency ●Excessive energy intake and/or reduced energy requirement = risk for obesity

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NUTRITIONAL FACTORS NUTRITIONAL FACTORS small FOR GESTATIONAL AGE WEIGHT FALTERING: DEFINITION

●Definition: birth weight < 3rd vs. < 10th percentile for ●aka failure to thrive or poor weight gain gestational age ●Sustained decrease in growth velocity, best defined as a ●Etiology: W/L or BMI < 5th percentile ○Fetal (intrauterine) growth restriction ●Inadequate energy intake, reduced absorption, increased energy ○Constitutional (i.e., maternal height, weight, ethnicity, requirement and parity) ●Age-appropriate growth chart ●Up to 15% of infants born SGA fail to catch up by age 2 years ○WHO: 0 to 24 months

33 ○CDC: 2 to 20 years 34

NUTRITIONAL FACTORS WEIGHT FALTERING: COMPLICATIONS

●May result in malnutrition ●If severe, affects linear growth and head circumference FEEDING SKILL FACTORS

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6 FEEDING SKILL FACTORS FEEDING SKILL FACTORS PEDIATRIC FEEDING DISORDER ORAL MOTOR DELAY

●Illness, injury, or developmental delay ●Oral motor hypotonia ●Impaired oropharyngeal or sensory-motor function ●Underdeveloped suck-swallow-breathe pattern ●Altered oral experiences ●Poor lip closure: drooling after age 12 months ●Lack of tongue lateralization ●Loss of liquid or solid from the mouth

Benfer 2013, Dodrill 2014, de Vries 2014 Benfer 2013, Phalen 2013, Dodrill 2014 37 38

FEEDING SKILL FACTORS

●Pathological difficulty swallowing ●Due to underlying neurologic or structural abnormalities ●Symptoms: gagging, choking, coughing, vomiting, apnea, PSYCHOSOCIAL FACTORS cyanosis during feeds ●Complications: aspiration, pneumonitis

Phalen 2013, Dodrill 2015 39 40

PSYCHOSOCIAL DYSFUNCTION • Learned aversion • Stress/distress ●Developmental delay +/- unrealistic caregiver expectations • Disruptive behavior ●Mental and behavioral health disorders in the child PSYCHOSOCIAL • Food over-selectivity or caregiver DYSFUNCTION • Failure to advance to age- ●Social: Disruptive caregiver-child interactions; appropriate feeding inappropriate community or cultural influences • Grazing behavior ●Environmental: Distracting feeding environment, • Caregiver use of inconsistent mealtime scheduling, inadvertent compensatory strategies reinforcement of refusal

Poppert 2015 41 42

7 FEEDING HISTORY

● Formula preparation (i.e., concentration) ● Addition of infant cereal, puréed solids, or EVALUATION proprietary thickeners to formula ● Feeding preferences and nutritional deficits ● Grazing ● Dietary supplements/oral nutrition supplements

43 Phalen 2013 44

FEEDING HISTORY FEEDING OBSERVATION

● Difficulty chewing, excessive drooling, or ● Appropriate child positioning and posture food/liquid leaving the mouth or nose ● Child’s hunger and satiety cues ● Patient’s age at and difficulty with transitions ● Caretaker’s response to and interactions with from liquids ➔ purées ➔ solids the child ● Symptoms of oropharyngeal dysphagia ● Delayed oral motor or self-feeding skills ● Refusal, tantrums, rumination, pica, sensory ● Oropharyngeal dysphagia aversion, sleep-feeding

Phalen 2013 45 Phalen 2013 46

EXAMINATION LABORATORY STUDIES

● Oral motor examination ● Weight faltering: ○ Facial symmetry ○ CBC ○ Hard and soft palate for (submucous) cleft ○ Urinalysis ○ Dentition ○ BMP: BUN, serum electrolytes ○ IgA antibodies to tissue transglutaminase ○ Symmetry and movement of lips and tongue ● Pica: ○ Vocal intensity, pitch, and quality ○ Serum iron and lead levels ○ Cranial nerves

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8 TEAM PLAYERS Pediatric Registered Dietitian ● Caloric intake, nutritional quality, dietary practices Feeding Skills Expert: SLP or OT ● Oral sensory-motor & feeding Optimal care of children with PFD evaluation Developmental Pediatrician ● Video fluoroscopic swallow study ● Global developmental delay, autism spectrum requires a team approach disorder, and parent-child conflict

Pediatric Gastroenterologist ● Severe recalcitrant , Clinical child psychologist or clinical GERD, and eosinophilic esophagitis social worker ● Co-manage enteral feeds ● Parent-child conflict

49 ● Maladaptive mealtime behaviors 50

small FOR GESTATIONAL AGE

● Rapid catch-up growth before age 2 years increases risk of metabolic disease MANAGEMENT ● Excessive weight impacts care and ADLs ● Aim for W/L or BMI between 10th and 50th percentile if child born SGA or has CP

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WEIGHT FALTERING WEIGHT FALTERING

● Multivitamin with iron and zinc ● Insufficient data to support medication ● Increase energy intake to treat PFD or weight faltering ○ Breast milk/formula: 22 to 24 kcal/oz • cyproheptadine ○ Solids: add eggs, cheese, cream, butter, • dronabinol cooking oil, beans, nut butter, avocado megestrol acetate ○ Whole milk + instant breakfast preparation • or non-fat dry milk • oxandrolone • atypical antipsychotics 53 54

9 FOOD RULES FOOD RULES: SCHEDULING

Four simple yet powerful words: ● Three scheduled meals “Kitchen open” ● One or two light snacks ● Same room, same table, same utensils for “Kitchen closed” every meal ● Mealtimes no longer than 30 minutes ● Only water between meals ● No grazing, juice, or coaxing

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FOOD RULES: ENVIRONMENT FOOD RULES: ENVIRONMENT

● Make mealtime pleasant and enjoyable ● If unable to remain seated: buckled in ● Entire family sits at table together highchair or booster seat ● Offer food only at the table ● Expose to same-aged peers for one meal ● Not walking around, at sofa or in bedroom ● Never reward with food ● Neutral atmosphere ● Be patient: kids must see food 20-30x ● Eliminate distractions ● Praise good and ignore bad 57 58

FOOD RULES: PROCEDURES FOOD RULES: PARENTING

● One menu & same food for everyone ● Avoid excessive coaxing, threats, or ● One non-preferred/new food + one or force feeding; never punish two preferred foods ● Division of power*: ● Solids first, fluids last ○ Caretaker chooses what, when, where ● Juice: 100% undiluted 4 oz/day max ○ Child choses: how much or whether ● No toddler formula or sugary drinks ● Milk: 16 oz/day max *Ellyn Satter's Division of Responsibility, 2019, published at EllynSatterInstitute.org

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10 ORAL MOTOR FEEDING THERAPY BEHAVIORAL FEEDING THERAPY

● Feeding expert: SLP or OT ● Ideally: interdisciplinary team ● Proper positioning and posture ● Goal: eliminate factors that reinforce ● Thickened liquids, modification of bolus size ● Oral motor and desensitization exercises maladaptive mealtime behavior ● Specialized nipples and bottles ● Setting: outpatient, partial day, inpatient ● Altering sensory aspects of food ● Caregiver involvement & compliance is ● Transcutaneous neuromuscular electrical key stimulation (i.e., NMES, e-stim)

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ENTERAL NUTRITION ENTERAL NUTRITION

● Indication: oral feeds are unsafe or ● Benefits: provide insufficient energy and nutrients ○ Safe, efficient ○ Allows catch-up growth ● Options: NG, OG, G, or G-J tube ○ Eliminates caretaker pressure for oral feeds ● If tolerated, bolus preferred over ● Risks: continuous ○ Retching or aggravated GERD ● If safe, offer oral tastes/feeds before ○ Overweight/obesity enteral ○ Delayed oral motor and sensory skills 63 64

ENTERAL NUTRITION ENTERAL NUTRITION

● Earlier in life g-tube placed, more difficult ● Goals: ○ Expose to mealtime environment for child to wean from it later ○ Touch & interact with food ● Inappropriate tube dependency: child able ○ Bolus enteral feeds to safely feed by mouth ○ Advance oral feeds, when possible ○ Feeding therapy involving parents ○ No enteral feeds, fluids, or flushes for 12 months

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11 SUMMARY

●Feeding problems and PFD are common ●Multiple factors contribute to PFD SUMMARY ●Many feeding problems are preventable or easily treated ●Untreated PFD may result in complications ●Treatment of PFD improves nutritional status, growth, feeding safety, and quality of life

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REFERENCES REFERENCES

● “Feeding and Eating Disorders” in American ● Dodrill P. Feeding problems and oropharyngeal ● Kurz S, van Dyck Z, Dremmel D, Munsch S, ● Poppert KM, Patton SR, Borner KB, et al. Systematic Psychiatric Association. Diagnostic and Statistical dysphagia in children. J Gastroenterol Hepatol Res Hilbert A. Early-onset restrictive eating review: mealtime behavior measures used in pediatric Manual of Mental Disorders, Fifth Edition. 2014;3(5):1055-60 disturbances in primary school boys and girls. Eur chronic illness populations. J Pediatr Psychol Washington, DC: American Psychiatric Child Adolesc . 2015 Jul. 24 (7):779-85. 2015;40(5):475-86. Association; 2013, pp329-354. ● Dodrill P, Gosa MM Pediatric Dysphagia: Physiology, Assessment, and Management. Ann ● Mussatto KA, Hoffmann RG, Hoffman GM, et al. ● Sharp WG, Berry RC, McCracken C, et al. Feeding ● American Speech-Language-Hearing Association Nutr Metab 2015;66 Suppl 5(24-31. (ASHA). Pediatric Dysphagia. Available at Risk and prevalence of developmental delay in problems and nutrient intake in children with autism https://www.asha.org/Practice-Portal/Clinical- ● Fisher MM, Rosen DS, Ornstein RM, Mammel KA, young children with congenital heart disease. spectrum disorders: a meta-analysis and comprehensive Topics/Pediatric-Dysphagia/ Accessed Katzman DK, Rome ES, et al. Characteristics of Pediatrics 2014;133(3):e570-7. review of the literature. J Autism Dev Disord 12/16/2018. avoidant/restrictive food intake disorder in 2013;43(9):2159-73. children and adolescents: a "new disorder" in ● Phalen JA Managing feeding problems and feeding ● Benfer KA, Weir KA, Bell KL, et al. Oropharyngeal DSM-5. J Adolesc Health. 2014 Jul. 55 (1):49-52 disorders. Pediatr Rev 2013;34(12):549-57. ● Shmaya Y, Eilat-Adar S, Leitner Y, et al. Nutritional dysphagia and gross motor skills in children with deficiencies and overweight prevalence among children cerebral palsy. Pediatrics 2013;131(5):e1553-62. ● Goday PS, Huh SY, Silverman A, Lukens CT, with autism spectrum disorder. Res Dev Disabil Dodrill P, Cohen SS, Delaney AL, Feuling MB, Noel 2015;38(1-6). ● de Vries IA, Breugem CC, van der Heul AM, et al. RJ, Gisel E, Kenzer A, Kessler DB, de Camargo Prevalence of feeding disorders in children with OK, Browne J, Phalen JA. Pediatric feeding cleft palate only: a retrospective study. Clin Oral disorder: consensus definition and conceptual Investig 2014;18(5):1507-15. framework. J Ped Gastr Nutr 2019;68(1):124- 129.

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QUESTIONS

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