Empirically supported treatments for feeding difficulties in young children

Online occupational therapy group training for mothers of children with feeding problems: A randomized controlled trial

AIM

The aim of this study was to scrutinize how online occupational therapy group training for mothers influenced their attitudes and stress levels relating to feeding their children and the eating behaviours of the children. The secondary purpose of the study is to evaluate the satisfaction of the participants of this program. Twenty-nine mothers of children aged 3-6 years, experiencing feeding issues, were randomly allocated to either an intervention or control group.

BACKGROUND

Feeding problems including selective eating, loss of appetite, and mealtime behaviour problems are prevalent during childhood. Parents play a fundamental role in acquiring knowledge about feeding. Problems in the feeding process may lead to parental stress, feelings of despair, and incorrect attitudes.

RESULTS

The mothers in the research group participated in the 4-week training. Results indicated positive effects on both maternal attitudes and their children's eating behaviours (p < 0.05). No significant change was found in mothers' state and trait anxiety levels (p > 0.05). Participants were asked to score their satisfaction level with the program between 1 and 10, and the average of the scores was 9.78 ± 0.42.

CONCLUSION

This study shows that online group education for mothers can support existing treatments and guide clinicians working with children with feeding problems.

Mothers' experiences and perceptions of their child's weaning process from tube feeding within a multidisciplinary Paediatric Feeding Program

OBJECTIVES

Previous studies have described the negative impact that tube feeding of children with complex chronic diseases has on the caregivers' emotions, relationships and daily life. It is unclear whether these negative experiences persist or change during and after the weaning process. We sought to explore mothers' experiences and perceptions of their child being weaned off tube feeding within a Paediatric Feeding Program (PFP).

METHODS

We conducted a qualitative study using semi-structured interviews with mothers whose children <4 years old had experienced feeding tube weaning within an outpatient, family-centred, telemedicine-supported PFP. The transcripts were analyzed using thematic analysis.

RESULTS

We conducted 9 interviews with mothers of children (n = 10) in the PFP at which point data saturation was achieved. Three main themes emerged: a) the initial emotional toll on mothers stemming from fear of perceived adverse consequences of decreasing tube feeds and uncertainty surrounding efficacy of weaning; b) achievement of weaning via a family-centered approach through gaining trust, close contact, and collaboration with the team; and c) attainment of mothers' expectations of family life through transformed relationships and social activities. A positive evolution of emotions was observed, attributable to the support of the PFP.

CONCLUSIONS

These experiences suggest that our outpatient weaning program had a positive impact on the stress, fear, and relational challenges that mothers reported before and during initial tube weaning. These findings highlight potential areas of discussion with families at multiple stages of the child's tube feeding experience, to help normalize emotions for families and support coping strategies.

Family mealtime behaviors in children who are tube fed and preparing to transition to oral eating: A comparison to other pediatric populations

This study examined differences in observed mealtime behaviors between children preparing to transition to oral feeding and children with various other chronic illnesses using a standardized measure of mealtime beaviors. The parent-child mealtime relationship can become strained due to problematic mealtime behaviors that limit food intake, as well as inadvertent reinforcement of disruptive behavior by caregivers. Frequency/rate of behaviors were compared between children with tube feeding (CwTF) and from previous studies of children with chronic illnesses using the Dyadic Interactive Nomenclature for Eating (DINE). Parents of CwTF used more coaxing, physical prompts, and reinforcement during meals, while parents of children with chronic illnesses used more direct commands and engaged in more parent talk. Findings support differences in parent-child mealtime interactions and eating behaviors across pediatric illness subgroups.

Outcomes for Feeding Tube-Dependent Children With Oral Aversion in an Intensive Interdisciplinary Treatment Program

Purpose Feeding challenges in children are common, at times reaching a severity that requires the placement and long-term use of enteral feedings. A significant barrier to advancing the oral eating of some tube-dependent children is the presence of oral aversion. Although some research exists regarding the treatment of tube-dependent children who are averse to food or the process of eating, specifically, there has yet to be an examination of children who are truly "orally" averse-resisting not just the presentation of food or liquid but also nonnutritive stimuli presented extra- or intra-orally. Method Using a retrospective chart review, the current study aimed to examine the treatment outcomes of 18 feeding tube-dependent children with significant oral aversion (nine boys, nine girls; M _age = 46.7 months, SD = 20.0 months, range: 11.4-89.3 months) as compared to 29 tube-dependent, but nonorally averse, clinical controls. Children completed approximately 6-8 weeks of intensive interdisciplinary feeding treatment. Results Analyses revealed significant improvements in all measured treatment outcomes for both patient groups, including children's rates of acceptance and maladaptive mealtime behavior. Significant reductions in tube use were also observed across both groups, with tube utilization decreasing, on average, by 76.2% for orally averse and by 64.3% for nonorally averse children by program discharge. Conclusion Results demonstrate the therapeutic benefits of intensive interdisciplinary intervention for both groups of tube-dependent children, highlighting that orally averse children, believed to be an especially challenging subset of pediatric feeding patients, demonstrate similarly positive treatment responses. Interestingly, in this preliminary examination, orally averse children demonstrated significantly greater reductions in tube utilization following discharge when compared with their nonorally averse clinical peers.

Swallowing Screening: Purposefully Different From an Assessment Sensitivity and Specificity Related to Clinical Yield, Interprofessional Roles, and Patient Selection

Purpose The purpose of this clinical focus article is to summarize the goal and process by which identification of individuals at risk for having feeding problems or dysphagia is clinically screened across the life span by speech-language pathologists (SLPs). The topic of this clinical focus article was presented at the Charleston Swallowing Conference in Chicago, Illinois, in July 2018. The contents of this clinical focus article offer an expanded summary of information discussed at this meeting with focus on critical considerations to guide clinical decisions by SLPs regarding the optimal feeding and dysphagia screening approach and process. Conclusion Screening is a critical first step in the identification of individuals at risk for feeding problems and dysphagia across the life span. Understanding the difference between screening and assessment objectives as well as having the knowledge, skills, and clinical competency to implement psychometrically sound screening approaches is a recommended clinical practice standard for SLPs working with these clinical populations. This clinical focus article summarizes critical considerations for identifying individuals at risk for feeding problems and dysphagia across the life span to guide clinicians working with dysphagia populations.

An Economic Analysis of Intensive Multidisciplinary Interventions for Treating Medicaid-Insured Children with Pediatric Feeding Disorders

Background. Intensive multidisciplinary intervention (IMI) represents a well-established treatment for pediatric feeding disorders (PFDs), but program availability represents an access care barrier. We develop an economic analysis of IMI for weaning from gastronomy tube (G-tube) treatment for children diagnosed with PFDs from the Medicaid programs' perspective, where Medicaid programs refer to both fee-for-service and managed care programs. Methods. The 2010-2012 Medicaid Analytic eXtract claims provided health care data for children aged 13 to 72 months. An IMI program provided data on average admission costs. We employed a finite-horizon Markov model to simulate PFD treatment progression assuming 2 treatment arms: G-tube only v. IMI targeting G-tube weaning. We compared the expenditure differential between the 2 arms under varying time horizons and treatment effectiveness. Results. Overall Medicaid expenditure per member per month was $6814, $2846, and $1550 for the study population of children with PFDs and G-tube treatment, the control population with PFDs without G-tube treatment, and the no-PFD control population, respectively. The PFD-diagnosed children with G-tube treatment only had the highest overall expenditures across all health care settings except psychological services. The expenditure at the end of the 8-year time horizon was $405,525 and $208,218 per child for the G-tube treatment only and IMI arms, respectively. Median Medicaid expenditure was between 1.7 and 2.2 times higher for the G-tube treatment arm than for the IMI treatment arm. Limitations. Data quality issues could cause overestimates or underestimates of Medicaid expenditure. Conclusions. This study demonstrated the economic benefits of IMI to treat complex PFDs from the perspective of Medicaid programs, indicating this model of care not only holds benefit in terms of improving overall quality of life but also brings significant expenditure savings in the short and long term.

A Functional Approach to Feeding Difficulties in Children

PURPOSE OF REVIEW

This review provides an approach for resolving a variety of feeding difficulties in children, ranging from normal eating behavior that is misperceived as a problem to substantial feeding disorders.

RECENT FINDINGS

Criteria to identify pediatric feeding disorders have been thoroughly addressed in the newly established designations of avoidant restrictive food intake disorder (ARFID) and pediatric feeding disorder (PFD). These diagnostic criteria improve the accuracy of identifying, classifying, and managing significant feeding disorders in young children. While recent definitions of feeding difficulties are particularly appropriate in multidisciplinary settings, in this paper, we advocate for a progressive approach of managing feeding problems in all clinical settings. It begins by identifying red flags indicative of serious threats to the child, screening for oral motor dysfunction, stabilizing nutrient intake, and eliminating aversive feeding practices. The next step, if eating behavior does not improve, involves strategies that target specific eating behaviors and parental feeding styles. In severe or resistant cases, referral to specialists or interdisciplinary feeding teams is advised.

Feeding difficulties in young paediatric intensive care survivors: A scoping review

BACKGROUND

Although feeding difficulties are commonly described amongst children with chronic diseases, those admitted to a paediatric intensive care unit (PICU) represent a mix of previously healthy children as well as those with pre-existing diseases. There is, however, a lack of evidence describing the prevalence and type of feeding difficulties amongst healthy children who survive a period of critical illness and the subsequent impact on growth and family life. The aim of this work was to complete a scoping review of evidence describing feeding difficulties amongst PICU-survivors.

METHOD

Six electronic databases were searched from January 2000-October 2018. NICE Healthcare Databases Advanced Search website (https://hdas.nice.org.uk/) was used as a tool to complete multiple searches within multiple databases, including the Cumulative Index to Nursing and Allied Health Literature (CINAHL), PsycInfo and Medline. Any studies considering feeding difficulties amongst previously healthy children following discharge from PICU or those which explored the parental/caregiver experiences were included.

RESULTS

As the initial search yielded only one study which fulfilled the inclusion criteria, the criteria was extended to include studies relating to feeding difficulties (post-discharge) amongst otherwise healthy ex-preterm infants (born < 37 weeks gestational age) and infants/children with chronic diseases where feeding difficulties were described following a PICU admission. A review team screened and extracted the data of published qualitative and quantitative studies, using content analysis techniques. Of the 9622 articles identified from the searches, 22 full-text studies were reviewed with seven studies included. Four overarching categories represented the results: prevalence of feeding difficulties; risk factors and predictors for developing feeding difficulties; parental/carer experience and emotional response to feeding difficulties; and challenges in accessing feeding support.

CONCLUSIONS

The results of this scoping review suggest there are gaps in the research, particularly those exploring the prevalence of feeding difficulties amongst previously healthy children and the negative impact this may have on family life. Future research should focus on addressing the extent of the problem and identifying risk factors, in addition to the potential development of toolkits for health care professionals to better support parents.

Intervention for Feeding Difficulties in Children With a Complex Medical History: A Randomized Clinical Trial

OBJECTIVE

This study aimed to compare outcomes of different multidisciplinary feeding therapy approaches in children with feeding difficulties.

METHODS

Children aged 2 to 6 years with feeding difficulties and a medically complex history (MC) were recruited. Children with feeding difficulties and a nonmedically complex history (NMC) were included as a comparison group. Participants attended a clinical assessment, and eligible participants were randomized to receive targeted feeding intervention incorporating either operant conditioning or systematic desensitization. Parents could elect to receive intervention in an intensive (10 sessions in a week) or weekly (10 sessions during 10 weeks) format. Both groups received immersive parent training. A review was completed 3 months post-intervention.

RESULTS

In total, 98 participants were eligible to participate (MC, n = 43; NMC, n = 55). Data from 20 children from the MC group (47%) and 41 children from the NMC group (75%) were included in the final analysis. Clinically significant improvements were observed following both arms of therapy, consistent with previous research. Parents of children in the MC arm were significantly more likely to elect for intensive intervention than weekly (MC = 12/20, 60%; 12/41, 29%; P = 0.02).

CONCLUSIONS

Both therapy protocols were considered clinically effective. The difference in attrition rates between the etiological groups suggests primary differences in how service delivery should be managed. Progress for the medically complex child may be slower while medical issues are stabilized, or while the focus for parents shifts to other developmental areas. In planning services for a medically complex group, therefore, it is essential that consideration be given to medical and family needs.

Preliminary Study of a Caregiver-based Infant and Child Feeding and Swallowing Screening Tool

OBJECTIVES

The Infant and Child Feeding Questionnaire (ICFQ) was created to facilitate early detection of feeding and swallowing problems. This is achieved by promoting effective communication between caregivers and health care providers resulting in referral for evaluation and treatment of feeding and swallowing problems by specialists. The purpose of this pilot study was to determine whether items from the ICFQ could be used to screen for differences between children with known feeding problems (FP) and without known feeding problems (NFP).

METHODS

Caregivers of children ages 36 months or younger with FP and NFP were recruited to complete the ICFQ and demographic questions. T tests were completed to compare demographic characteristics of the research groups. Responses to ICFQ items were analyzed using receiver operating characteristic analysis and odds ratios to determine whether questionnaire items distinguished between study groups.

RESULTS

Sixty-four caregivers of children with FP and 57 caregivers of NFP children were recruited. Three participants in the NFP group did not meet inclusion criteria and were excluded from analysis. A combination of 4 ICFQ questions distinguished between groups (receiver operating characteristic = 0.974). Significant odds ratios were also found for 9 feeding behaviors that distinguished between groups.

CONCLUSIONS

A subset of items from the ICFQ showed promise for distinguishing FP from NFP groups. Future work will expand the regional representation of the participant samples and obtain equal representation of participants across all age-adjusted questionnaires to determine whether the same combination of ICFQ items continues to distinguish between FP and NFP groups.

Evidence to support treatment options for children with swallowing and feeding disorders: A systematic review

PURPOSE

A rise in pediatric patients with swallowing and feeding problems has resulted in increased interest in multidisciplinary treatments to address these issues. This evidence based systematic review (EBSR) examined the published evidence for the use of common strategies used by clinicians across disciplines to treat pediatric swallowing and feeding problems.

METHODS

A systematic search of 10 electronic databases was completed to identify relevant, peer reviewed literature published in English prior to December 2015 reporting original data that addressed at least one of the five identified clinical questions.

RESULTS

Sixty-one studies of varying methodological quality were included. The majority of the included studies (60/61) focused on the use of behavioral therapies to remediate swallowing and feeding disorders in children and reported mixed findings across all of the targeted outcomes.

CONCLUSION

There is insufficient quantity of evidence to determine the effects of oral motor, sensory, and pharmaceutical therapies on functional feeding outcomes in pediatric populations. A larger body of phase 1 evidence is available that establishes the efficacy of behavioral strategies to treat some swallowing and feeding difficulties in small cohort and single subject studies. This analysis identified limited high quality (phase 4) research articles that establish the efficacy and benefit of joint nutrition and behavior intervention programs and systematic desensitization and operant conditioning behavioral therapy approaches to improve functional feeding and swallowing outcomes in children.

Feeding problems in infancy and early childhood: evolutionary concept analysis

AIM

The aim of this study was to report an analysis of the concept of pediatric feeding problems.

BACKGROUND

Reviews of the literature on pediatric feeding problems and disorders repeatedly reference the lack of a shared conceptualization of feeding problems. It is difficult to track aetiology, prevalence and incidence of a phenomenon when available definitions and diagnoses lack practical utility.

DESIGN

An evolutionary concept analysis.

DATA SOURCES

A search was conducted in October 2014 of Google Scholar, CINAHL, PubMed and Web of Science databases, with MeSH terms and key words including: failure to thrive, feeding disorder/difficulty/problems, infantile anorexia, oral aversion, mealtime behaviour and dysphagia. Inclusion criteria were: subject of feeding problems, index children 0-10 years of age, English language and full text.

METHODS

The articles (n = 266) were sorted into disciplines of authorship, including Psychology, Medicine, Nursing, Nutrition, Occupational Therapy, Speech Language Pathology or Other. The sample was divided into a historical sample (n = 42) for pre-2000 articles and current for those published post-2000. The current sample was later reduced to 100 and coded for surrogate terms, related concepts, attributes, antecedents and consequences.

RESULTS

The historical view of pediatric feeding problems shows a tradition of mother blame or parental culpability, both direct and indirect. Currently, there exist many different definitions and typologies, but none have sound validity or generalizability. Areas of attribute consensus across disciplines are problematic feeding behaviours and selective or restrictive intake.

CONCLUSION

A spectrum conceptualization of feeding problems is suggested for further development, with attributes that would be critical to have a feeding problem.

Intensive, Manual-based Intervention for Pediatric Feeding Disorders: Results From a Randomized Pilot Trial

OBJECTIVES

The aim of this pilot study was to investigate feasibility and preliminary efficacy of an intensive, manual-based behavioral feeding intervention for children with chronic food refusal and dependence on enteral feeding or oral nutritional formula supplementation.

METHODS

Twenty children ages 13 to 72 months (12 boys and 8 girls) meeting criteria for avoidant/restrictive food intake disorder were randomly assigned to receive treatment for 5 consecutive days in a day treatment program (n = 10) or waitlist (n = 10). A team of trained therapists implemented treatment under the guidance of a multidisciplinary team. Parent training was delivered to support generalization of treatment gains. We tracked parental attrition and attendance, as well as therapist fidelity. Primary outcome measures were bite acceptance, disruptions, and grams consumed during meals.

RESULTS

Caregivers reported high satisfaction and acceptability of the intervention. Three participants (1 intervention; 2 waitlist) dropped out of the study before endpoint. Of the expected 140 treatment meals for the intervention group, 137 (97.8%) were actually attended. The intervention group showed significantly greater improvements (P < 0.05) on all primary outcome measures (d = 1.03-2.11) compared with waitlist (d = -1.13-0.24). A 1-month follow-up suggested stability in treatment gains.

CONCLUSIONS

Results from this pilot study corroborate evidence from single-subject and nonrandomized studies on the positive effects of behavioral intervention. Findings support the feasibility and preliminary efficacy of this manual-based approach to intervention. These results warrant a large-scale randomized trial to test the safety and efficacy of this intervention.

Systematic review of psychological interventions for pediatric feeding problems

OBJECTIVE

To conduct a systematic review of the research evaluating the effect of psychological interventions for pediatric feeding problems.

METHODS

A search was conducted to identify studies using psychological interventions for pediatric feeding problems published between 1998 and 2013. Randomized controlled trials (RCTs) and nonrandomized studies that examined aggregated outcome data were included. Primary outcomes were child mealtime behavior, nutritional status, and caregiver stress. A risk of bias assessment was conducted and the quality of the evidence rated using Grading of Recommendations Assessment, Development, and Evaluation methodology.

RESULTS

13 studies were identified and a narrative synthesis framework was used to report findings.

CONCLUSIONS

The preponderance of evidence suggests positive effects of psychological intervention for the treatment of feeding problems. However, limited data and the paucity of studies using RCT methodologies limit conclusions that can be drawn regarding the efficacy of these interventions. Future studies using more rigorous research methods are needed to enhance understanding of these interventions.

Pediatric feeding and eating disorders: current state of diagnosis and treatment

The Diagnostic and Statistical Manual of Mental Disorders now recognizes six primary feeding and eating disorders including pica, rumination disorder, avoidant/restrictive food intake disorder, anorexia nervosa, bulimia nervosa and binge-eating disorder. Guided by research from the past 3 years, the current review outlines diagnostic criteria for each disorder, their clinical correlates and treatment options. Recent modifications to diagnostic criteria will likely help to improve treatment outcomes and prognosis. Nevertheless, several concerns remain regarding the validity of current diagnostic criteria for youth, including the clinical relevance of the size and frequency of binge eating episodes. Additionally, the lack of randomized controlled trials has led to an overreliance on data from quasi-experimental studies, case series and single case studies that impede development of strong clinical recommendations for treating feeding and eating disorders. Recommendations for future research include identifying empirically supported treatments and prevention programs focused on early markers of pediatric feeding and eating concerns.

Aspiration and Swallowing Dysfunction in Pediatric Patients

Early identification and management of aspiration associated with oral intake will help contribute to the best possible outcome for infants and children who have airway protection issues with swallowing. Though the incidence and prevalence of aspiration specifically related to swallowing dysfunction across medical conditions in the pediatric population is unknown, there is accumulating evidence of swallowing-related aspiration in infants and children with diagnoses that include structural abnormalities of the upper airway, central nervous system abnormalities, and progressive neurological disease. Chronic aspiration is associated with compromised respiratory health, progressive lung disease, bronchiectasis, and respiratory failure; thus, early detection and appropriate management is crucial. Determining the etiology and effect of aspiration is complex, and multiple evaluations are often required. This article will focus on instrumental studies of swallowing physiology used in the diagnosis and management of swallowing dysfunction and aspiration. Therapeutic strategies to improve airway protection during swallowing will also be described.