Feeding tube use and complications in Prader-Willi syndrome: Data from the Global Prader-Willi Syndrome Registry

Guidance on indications for, and types of, feeding tubes recommended in Prader-Willi syndrome (PWS) is needed. A Global PWS Registry survey was developed to investigate nasogastric (NG) and gastrostomy (G) tube use and associated complications. Of 346 participants, 242 (69.9%) had NG-tubes, 17 (4.9%) had G-tubes, and 87 (25.1%) had both NG- and G-tubes. Primary indication for placement was "feeding difficulties and/or poor weight gain" for both NG- (90.2%) and G-tubes (71.2%), while "aspiration/breathing difficulties" was the procedural indication for 6.4% of NG-tubes and 23.1% of G-tubes. NG-tubes were generally removed by age 6 months (NG Only: 82.9%; NG/G: 98.8%), while G-tubes were often removed by age 2 years (G Only: 85.7%; NG/G: 70.5%). The severe complication rate from G-tubes was 31.7% and from NG-tubes was 1.2%. Overall, caregivers indicated the presence of an NG- or G-tube had a positive effect on quality of life. Feeding difficulties in PWS are largely managed by NG-tube alone. The severe complication rate from G-tubes was about 25 times higher than from NG-tubes; yet, G-tube placement rates have generally increased. G-tube placement puts individuals with PWS at risk for anesthesia and surgery-related complications and should be considered judiciously by a multidisciplinary team.

Premature Babies Can Be Cared for in the Maternity Ward without an Increased Risk and Discharged with a Feeding Tube If Necessary

In general, premature babies are discharged home when they reach full self-feeding. We established a discharge management protocol which allows for discharging late preterm babies with a feeding tube if necessary. This retrospective study included 108 preterm infants (34+ weeks) born in 2019 and 2020. The preterm infants discharged with a feeding tube (n = 32) were born at 35.23 weeks' gestation (±0.884), with a birth weight of 2423 g (±375.1), and were discharged at 7.22 days (±3.63) and had a weight of 3466 g (±591.3) at the first outpatient visit around the expected birth date. The preterm infants discharged without a feeding tube were born at 35.97 weeks' gestation (±0.702) with a birth weight of 2589 g (±424.84), discharged home at 6.82 days (±7.11) and a weight of 3784 g (±621.8) at the first outpatient visit. The gestational week and birth weight were statistically significantly different between the groups, with a p-value of <0.001 for each, and the length of hospital stay (p = 0.762) and weight at follow-up (p = 0.064) did not significantly differ. No infant required tube-feeding at the time of the first outpatient visit, i.e., the time of expected birth. Therefore, with well-thought-out management, it is possible and safe to discharge preterm infants home with a feeding tube.

Feeding difficulties in children with food allergies: An EAACI Task Force Report

The term "feeding difficulties" refers to a spectrum of phenotypes characterized by suboptimal intake of food and/or lack of age-appropriate eating habits. While it is evident that feeding difficulties are prevalent within healthy children, no consensus has been reached for those with food allergies. The aim of this study was to systematically review all the available literature reporting the prevalence of feeding difficulties within food allergic children. We searched eight international electronic databases for all published studies until June 2022. International experts in the field were also contacted for unpublished and ongoing studies. All publications were screened against pre-defined eligibility criteria and critically appraised by established instruments. The substantial heterogeneity of included studies precluded meta-analyses, so narrative synthesis of quantitative data was performed. A total of 2059 abstracts were assessed, out of which 21 underwent full-text screening and 10 studies met the study criteria. In these, 12 different terms to define feeding difficulties and 11 diagnostic tools were used. Five papers included data of feeding difficulty prevalence in children with food allergies, ranging from 13.6% to 40%. Higher prevalence was associated with multiple food allergies. The current literature suggests that feeding difficulties are prevalent within food allergic children, particularly those with multiple food allergies. However, the heterogeneity of terminologies and diagnostic tools makes drawing conclusions challenging. Consensus guidelines for the diagnosis and management of feeding difficulties within food allergic children and further research on the development and perpetuation of feeding difficulties are needed to appropriately manage such patients.

Comparing the effects of 5-minute premature infant oral motor intervention with 15-minute Fucile treatment in term infants with feeding difficulties: A multi-arm randomised clinical trial

PURPOSE

The aim of the present study was to investigate whether term infants with feeding difficulties who received either a 5-minute premature infant oral motor intervention (PIOMI) or a 15-minute Fucile treatment had different outcomes, compared to term infants in a nontreatment group.

METHOD

Stable term infants (N = 51) born between 37-41 weeks of gestational age with feeding difficulties were randomly assigned into one of two intervention groups and a control group. One intervention group received PIOMI and the other group received Fucile treatment once a day for seven consecutive days; the control group received usual care only. The volume of milk intake, the amount of weight gain, and the length of hospital stay were compared across all groups.

RESULT

Findings indicated that the volume of milk intake and weight gain showed significant improvement in all three groups. However, pairwise comparison revealed that infants in the Fucile group had significantly higher volume of milk intake and weight gain compared to infants in both the control and PIOMI groups. Length of hospital stay was not significantly different amongst all groups.

CONCLUSION

The effects of Fucile treatment were more considerable than for usual care or PIOMI. This finding raises the possibility that prolonged exercise may facilitate improvement in feeding skills for term infants with feeding difficulties.

Investigating the impact of autistic children's feeding difficulties on caregivers

AIM

The aim of this study was to investigate the influence of children's autism characteristics, sensory profiles and feeding difficulties on caregiver-reported impact at mealtimes.

BACKGROUND

Caregivers of children (5-12 years) with a diagnosis of Autism Spectrum Disorder completed an online survey examining (a) demographic characteristics, (b) children's autism characteristics (Social Communication Questionnaire), (c) sensory profiles (Sensory Profile 2-short form), (d) feeding difficulties (Behavioural Paediatrics Feeding Assessment Scale, BPFAS) and (c) caregiver-reported impact of feeding difficulties (Feeding-Swallowing Impact Survey, FS-IS).

RESULTS

Seventy-eight caregivers completed surveys for 80 children. Children with clinically significant feeding difficulties on the BPFAS (n = 55, 68.8%) had higher levels of caregiver-reported impact on daily activities, worry and feeding difficulties compared to children without clinically significant feeding difficulties (FS-IS; U = 257.000, z = -4.471, p < 0.01). Spearman's rank correlation showed a statistically significant, moderate correlation between BPFAS total frequency score and FS-IS Daily activities score, rs (98) = 0.56, p < 0.01, indicating that as the frequency of feeding difficulties increased, the impact of these feeding difficulties on caregivers also increased. Using multiple regression, a model comprising of the three factors was statistically significant (F[1, 78] = 87.75, p < 0.001, adj. R2  = 0.52), with children's frequency of feeding difficulties the strongest predictor of caregiver-reported impact with a moderate effect size (r = 0.49).

CONCLUSION

Autistic children's feeding difficulties had a greater impact on caregivers than autism or sensory profiles, with the frequency of feeding difficulties and the caregiver impact of these feeding difficulties positively correlated. The findings demonstrate that efforts to understand and address feeding difficulties in autistic children must extend beyond the children to include their families.

The Irritable Infant in the Neonatal Intensive Care Unit: Risk Factors and Biomarkers of Gastroesophageal Reflux Disease

OBJECTIVES

To determine risk factors for arching/irritability in high-risk infants and examine the significance of comorbidity and gastroesophageal reflux (GER) characteristics.

STUDY DESIGN

Retrospective analysis of 24-hour pH-impedance studies of symptomatic infants in a neonatal intensive care unit (ICU) (n = 516, 30.1 ± 4.5 weeks of gestation, evaluated at 41.7 ± 3.2 weeks postmenstrual age) was conducted. Comparisons were made between infants with >72 vs ≤72 arching/irritability events per day. We characterized risk factors for arching/irritability along with clinical, pH-impedance, and outcome correlates.

RESULTS

Of 39 973 arching/irritability events and 42 155 GER events, the averages per day were 77.6 ± 41.0 and 81.7 ± 48.2, respectively. Acid reflux and impedance bolus characteristics were not significantly different between infants with >72 and ≤72 arching/irritability events (P ≥ .05). The odds ratios (ORs) and 95% confidence intervals (CIs) adjusted for postmenstrual age and weight at evaluation were significant for risk factors of preterm birth (2.3 [1.2-4.4]), moderate or severe neuropathology (2.0 [1.1-3.6]), and presence of oral feeding at testing (1.57 [1.07-2.30]).

CONCLUSIONS

Acid GER disease is unlikely the primary cause of arching/irritability and empiric treatment should not be used when arching/irritability is present. Prematurity and neurologic impairment may be more likely the cause of the arching/irritability. Arching/irritability may not be a concern in orally fed infants.

A Comparative Evaluation of the Caloric Intake and Economic Efficiency of Two Types of Homogenized Diets in a Hospital Setting

The prevalence of malnutrition is increasing globally due to factors such as age-related pathological conditions and diseases that impact food and beverage intake. In hospital settings, older adult patients often require homogenised diets, which can lead to malnutrition due to poor palatability and limited variety. This study compared the Standard Homogenised Diet (HSD) and a Modified Homogenized Diet (HMD) proposed in a tertiary hospital in Northern Italy. A retrospective and observational design was used to analyse data from 86 adult patients with various conditions requiring a homogenised diet. The primary goal was to compare food intake, rheological characteristics, and palatability of the two diets. The secondary objective was to evaluate the economic impact by comparing costs and quantifying food waste from unused meals. Patients on HMD had a median daily caloric intake of 852 kcal (IQR 787-926 kcal) compared to 631 kcal (IQR 506-797 kcal) in the HSD group. Taste, texture, palatability, and ease of intake for HMD outperformed HSD with scores such as 3.7 ± 0.6 vs. 2.5 ± 0.4 for taste. Economically, HMD was EUR 0.53 less expensive per day than HSD, and food wastage costs were significantly lower for HMD (EUR 2.66 ± 0.81) than HSD (EUR 4.66 ± 1.27). Overall, HMD presented substantial benefits in patient satisfaction and cost-efficiency. This insight may aid diverse care settings to enhance meal acceptance and nutritional intake for patients needing homogenised diets.

Nutritional status as predictors for quality of life among caregivers of children with severe cerebral palsy

Background

Individuals with severe cerebral palsy (CP) often experience various health issues, including feeding difficulties, which can adversely affect their nutritional status and caregivers' quality of life, e.g., more time spent for feeding rather than own selfcare. This study aimed to determine the prevalence of poor nutritional status among individuals with severe CP and explore its role as predictors for caregivers' quality of life.

Methods

This cross-sectional study was conducted in a government hospital (Cheras Rehabilitation Hospital), Community-Based Rehabilitation (CBR) Program, and Spastic Centre [non-profit organization (NGO)] in Klang Valley, Malaysia. Seventy-one participants with Gross Motor Function Classification System (GMFCS) level IV and V were recruited. Sociodemographic data, health-associated data, and anthropometric data were collected. Caregivers' quality of life was assessed using the Pediatric Quality of Life Inventory (PedsQL) CP module version 3.0 which included domains such as Movement and Balance, Eating Activities, and School Activities.

Results

Most participants were males (60.6%), with 61 classified as level IV in the GMFCS classification. According to the Eating and Drinking Ability Classification System (EDACS), 59 children were at level IV. In total, 40.8% were underweight according to CP growth chart and 49.3% had mid-upper arm circumference (MUAC) readings below the 5th percentile. The lowest scores in the PedsQL CP module version 3.0 were observed in the Daily Activities (5.34±10.87), and School Activities domains (8.15±18.65). Sociodemographic and anthropometric data, including body mass index (BMI)-for-age, MUAC, body fat, triceps, and subscapular skinfold measurement, were predictors for the School Activities domain [F (11, 44)=3.981, P<0.005, R2=0.499].

Conclusions

Poor nutritional status in individuals with severe CP has been shown to negatively impact caregivers' quality of life. Therefore, a multidisciplinary approach involving nutritional intervention is essential to improve dietary provision and the nutritional status of children with CP.

Evaluation of feeding difficulties using videofluoroscopic swallow study and swallowing therapy in infants and children

BACKGROUND

Infants and children with feeding difficulties have swallowing dysfunction and high risk of aspiration, which could be silent without choking, resulting in recurrent pneumonia and long-term respiratory morbidity. Videofluoroscopic swallow study (VFSS) is a useful tool for real-time visualization of the swallowing process and airway aspiration. This study reported a single-institutional 10-year experience of VFSS in pediatric patients with feeding difficulties and the efficacy of swallowing therapy.

METHODS

From 2011 to 2020, 30 infants and children with feeding difficulties received VFSS examinations in a medical center at a median age of 19 months (range 7 days-8 years). The images of the swallowing process (oral phase, triggering of pharyngeal swallowing, and pharyngeal phase) under videofluoroscopy were analyzed by a radiologist and a speech-language pathologist. Aspiration severity was assessed from VFSS observations and rated by an eight-point Penetration-Aspiration-Scale (PAS), with higher scores indicating increased severity. Swallowing therapy was performed by experienced speech-language therapists, and follow-up of oral feeding tolerance and risk of aspiration pneumonia was done.

RESULTS

Of the 30 patients, 24 (80%) had neurological deficits. High PAS scores (6-8) were observed in 25 (83.4%) patients, and 22 had a PAS score of 8, indicating silent aspiration. Of the 25 patients with high PAS scores, 19 (76%) had neurological deficits, and 18 (72%) depended on tube feeding at a median age of 20 months. Swallowing problems occurred most frequently during the pharyngeal phase in the patients with high PAS scores. VFSS-based swallowing therapy improved oral feeding ability and reduced aspiration episodes.

CONCLUSION

Infants and children with swallowing dysfunction and neurological deficits had high risk of severe aspiration. Swallowing problems in the pharyngeal phase were the most common VFSS findings in patients with severe aspiration. VFSS may help guide problem-oriented swallowing therapy to reduce the risk of recurrent aspiration.

Prevalence of Feeding Problems in Children and Associated Factors-A Cross-Sectional Study among Polish Children Aged 2-7 Years

Food neophobia is an aversion to eating or a reluctance to try unfamiliar or new foods. From an evolutionary perspective, this behaviour may minimise the risk of consuming foods that are harmful to health. However, such aversion causes food monotony, which may result in nutritional deficiencies. This study aimed to assess the prevalence of feeding problems among Polish children aged 2-7 years using the Montreal Children's Hospital Feeding Scale and to investigate the correlation between age, gender, mode of feeding in infancy, including complementary feeding, and the prevalence of feeding difficulties in the study group of children.

MATERIAL AND METHOD

The study group consisted of 585 children: 299 boys (51.11%) and 286 girls (48.89%). The study was conducted using a questionnaire-based method, with an indirect survey technique using a web-based form (CAWI). The research tool used was the Montreal Children's Hospital-Pediatric Feeding Program.

RESULTS

Groups with the lowest risk feeding problems, risk 0, comprised 445 children (76.06%); group 1, middle difficulties, 59 children (10.08%); group 2, moderate difficulties, 40 children (6.84%); and group 3, most difficulties, 40 children (7.01%). The mean MCH-FS score for the entire study group was calculated and was 37.29 points ± 12.02; for 2 year olds, 35.69 points; for 3 year olds, 37.41 points; for 4 year olds, 38.31 points; for 5 year olds, 38.46 points; for 6 year olds, 37.95 points; and for 7 year olds, 36.06 points. The mean value of the MCH-FS scale for girls was 37.44 points, and for boys, 37.32 points. None of the above parameters correlated with the risk of feeding problems, including age, except with a non-significative tendency to be higher in the youngest age.

CONCLUSION

Breast milk feeding and the time of complementary feeding (CF) in the study group did not influence the risk of feeding problems. Using the full BLW method during CF can protect the child against the occurrence of feeding problems such a food selectivity or picky eating in the future. In our study, children with difficulties during CF, mainly the vomiting reflex, were more likely to develop feeding problems such as food neophobia. Based on our study, we did not observe a correlation between age, gender, and the occurrence of feeding problems, and there was only a non-significant tendency to be higher in the youngest age. However, further research needs to be undertaken to assess how such behaviour affects subsequent feeding difficulties.

The prevalence and predictors of feeding difficulties in children at self-feeding transition stage

Aim

To understand the prevalence of feeding difficulties (FD) in young children at self-feeding transition stage (6-24 months age), and the protective and risk predictors associated with FD are to be determined through this study.

Methods

A cross-sectional study was conducted within 5 representative Women's and Children's hospitals in Chengdu, Southwest China. Children age 6-24 months who underwent routine child health care examination at outpatient and their parents were enrolled, while the Montreal Children's Hospital Feeding Scale which is validated was used to determine whether these children have FD.

Results

A total of 1,211 subjects were enrolled in this survey, where 380 children were reported as FD with an prevalence of 31.4%. Adjusted binary logistic regression in the multivariate analysis showed 10 independent predictors of FD. Specifically there were 6 risk predictors: (1) frequent constipation (OR = 1.603, CI = 1.006-2.555) in CHILD sub-theme; (2) anxiety (OR = 4.322, CI = 3.074-6.079) and (3) indulgent parenting style (OR = 2.108, CI = 1.306-3.405) in PARENT sub-theme; (4) luring to eat (OR = 2.806, CI = 2.000-3.937), (5) forcing to eat (OR = 2.040, CI = 1.407-2.958), and (6) allowing playing during mealtime (OR = 2.023, CI = 1.435-2.853) in FEEDING PRACTICE sub-theme. The remaining 4 factors were protective predictors including (1) food preparing (OR = 0.586, CI = 0.385-0.891) in FOOD sub-theme; (2) observing hunger and satiety signals (OR = 0.667, CI = 0.457-0.974), (3) interacting with child during mealtime (OR = 0.505, CI = 0.308-0.828), as well as (4) providing exclusive tableware (OR = 0.370, CI = 0.191-0.719) in FEEDING PRACTICE sub-theme.

Conclusions

There appeared to be an increasing trend of FD prevalence. Child health care clinicians and pediatricians are expected to attach more importance to FD in their daily work, and are obliged to provide parents with practical and effective preventive strategies highlighted in this study.

Feeding Difficulties in Late Preterm Infants and Their Impact on Maternal Mental Health and the Mother-Infant Relationship: A Literature Review

Late preterm infants constitute the largest subset of premature infants and are more likely to experience feeding issues leading to delayed oral feeding independence and low breastfeeding rates. Considering the increased parental concern about their infants' nutrition and growth, we performed a literature review to provide an update on the feeding challenges faced by late preterm infants and the impact of these issues on maternal mental health and the mother-infant relationship. Based on our findings, late preterm infants have a high prevalence of feeding difficulties which need to be addressed by targeted support interventions to promote breastfeeding success and the establishment of a harmonious dyadic interaction between the mother and her infant, all of which contribute to the prevention of altered feeding behavior later in life. There is still a need for additional research to develop a standardized and shared strategy that can be proven to be effective. Should this be accomplished, it will be possible to offer appropriate support for mothers, encourage the oral skills and maturation of late preterm infants, and improve the relationship quality within the dyad.

Breastfeeding rates fell in an Italian baby friendly hospital during the 2020 COVID-19 pandemic year and difficulties increased

AIM

Our aim was to evaluate the impact of the COVID-19 pandemic on breastfeeding at discharge in a Baby Friendly hospital in 2020.

METHODS

This study retrospectively compared healthy neonates born in 2019 with those born in 2020 at the Baby Friendly San Bonifacio Hospital in Verona, Italy. We also compared those born to mothers who tested negative and positive for the virus that causes COVID-19. Breastfeeding support practices, nationality and type of birth were evaluated. The outcomes were type of breastfeeding at discharge and the presence of breastfeeding difficulties.

RESULTS

We analysed 2171 healthy neonates, which was 83.5% of those born in the hospital in 2019 and 2020, and 20 were born to mothers with the virus. Exclusive breastfeeding rates were 4.6% lower in 2020 than 2019 and breastfeeding difficulties rose by 10.1%. Mixed feeding, at the mother's request, and formula feeding due to medical indications, increased by 5.9% and 18.1% respectively. Most of the Baby Friendly hospital practices were implemented, but prenatal and intrapartum support decreased.

CONCLUSION

Exclusive breastfeeding fell during the COVID-19 pandemic in 2020 and breastfeeding difficulties rose. These may have been due to the effect of maternal and healthcare factors during the pandemic.

Prevalence and Risk Factors for Post-Discharge Feeding Problems in Children Born Extremely Preterm

OBJECTIVES

Preterm infants have a high risk of post-discharge feeding problems, but there is a lack of population-based studies in infants born extremely preterm and little is known about underlying mechanisms. The objectives were to assess the incidence of post-discharge feeding problems and underweight in a population-based cohort of infants born extremely preterm in Sweden (EXPRESS) and identify perinatal risk factors.

METHODS

Perinatal health data and prenatal/postnatal growth data was prospectively collected in the cohort. Data on clinical diagnoses related to feeding problems were obtained from the Swedish Patient Register and population prevalence data was also obtained. The main outcome was a composite of post-discharge feeding problem diagnosis and/or underweight at 2.5 years of age.

RESULTS

In total, 66 children (19%) had post-discharge feeding problems diagnosed before 2 years and/or underweight at 2.5 years of age. The risk of feeding problems when compared to the general population was significantly higher, with an odds ratio (OR) of 193 (95% confidence interval (CI) 137.6-270.9). The strongest risk factors for feeding problems were the number of days on mechanical ventilation during the first 8 postnatal weeks, OR of 1.59 (CI 95% 1.29-1.98), and the Clinical Risk Index for Babies-score, OR of 1.14 (CI 95% 1.03-1.26).

CONCLUSIONS

Post-discharge feeding problems and underweight are common in children born extremely preterm. The strongest perinatal risk factor for later feeding problems was early treatment with mechanical ventilation. Identifying infants at risk of post-discharge feeding problems might be useful for targeting of nutritional support.

Predictors of enteral tube dependence in pediatric esophageal atresia

Children with esophageal atresia (EA) may require enteral tube feedings in infancy and a subset experience ongoing feeding difficulties and enteral tube dependence. Predictors of enteral tube dependence have never been systematically explored in this population. We hypothesized that enteral tube dependence is multifactorial in nature, with likely important contributions from anastomotic stricture. Cross-sectional clinical, feeding, and endoscopic data were extracted from a prospectively collected database of endoscopies performed in EA patients between August 2019 and August 2021 at an international referral center for EA management. Clinical factors known or hypothesized to contribute to esophageal dysphagia, oropharyngeal dysphagia, or other difficulties in meeting caloric needs were incorporated into regression models for statistical analysis. Significant predictors of enteral tube dependence were statistically identified. Three-hundred thirty children with EA were eligible for analysis. Ninety-seven were dependent on enteral tube feeds. Younger age, lower weight Z scores, long gap atresia, neurodevelopmental risk factor(s), significant cardiac disease, vocal fold movement impairment, and smaller esophageal anastomotic diameter were significantly associated with enteral tube dependence in univariate analyses; only weight Z scores, vocal fold movement impairment, and anastomotic diameter retained significance in a multivariable logistic regression model. In the current study, anastomotic stricture is the only potentially modifiable significant predictor of enteral tube dependence that is identified.

Pharyngeal biorhythms during oral milk challenge in high-risk infants: Do they predict chronic tube feeding?

BACKGROUND

Eating difficulties are common in high-risk neonatal intensive care unit (NICU) infants; mechanisms remain unclear. Crib-side pharyngo-esophageal motility testing is utilized to assess contiguous swallowing physiology, and cross-system interplay with cardio-respiratory rhythms. Aims were to: (1) identify whether distinct pharyngeal rhythms exist during oral milk challenge (OMC), and (2) develop a chronic tube feeding risk prediction model in high-risk infants.

METHODS

Symptomatic NICU infants (N = 56, 29.7 ± 3.7 weeks birth gestation) underwent pharyngo-esophageal manometry with OMC at 40.9 ± 2.5 weeks postmenstrual age (PMA). Exploratory cluster data analysis (partitioning around k-medoids) was performed to identify patient groups using pharyngeal contractile rhythm data (solitary swallows and swallows within bursts). Subsequently, (a) pharyngeal-esophageal, cardio-respiratory, and eating method characteristics were compared among patient groups using linear mixed models, and (b) chronic tube feeding prediction model was created using linear regression.

RESULTS

Three distinct patient groups were identified with validity score of 0.6, and termed sparse (high frequency of solitary swallows), intermediate, or robust (high swallow rate within bursts). Robust group infants had: lesser pharyngeal and esophageal variability, greater deglutition apnea, pharyngeal activity, and esophageal activity (all p < 0.05), but less frequent heart rate decreases (p < 0.05) with improved clinical outcomes (milk transfer rate, p < 0.001, and independent oral feeding at discharge, p < 0.03). Chronic tube feeding risk = -11.37 + (0.22 × PMA) + (-0.73 × bronchopulmonary dysplasia) + (1.46 × intermediate group) + (2.57 × sparse group).

CONCLUSIONS

Robust pharyngeal rhythm may be an ideal neurosensorimotor biomarker of independent oral feeding. Differential maturation of cranial nerve-mediated excitatory and inhibitory components involving foregut, airway, and cardiac rhythms distinguishes the physiologic and pathophysiologic basis of swallowing and cardio-respiratory adaptation.

Factors associated with the early emergence of atypical feeding behaviours in infants and young children: A scoping review

BACKGROUND

Atypical feeding behaviours such as significantly limited food preferences, hypersensitivity to food textures or temperatures and pocketing food without swallowing are common concerns in child health. Current reports indicate an inter-relationship between early growth, feeding problems and developmental disorders, yet little is known about how these behaviours develop in early childhood. There is also a lack of consensus about clinical definitions for atypical feeding behaviours, diagnostic thresholds and the associated precursors. To date, there has been no synthesis of the extant literature about factors associated with the early onset of atypical feeding behaviours in young children.

OBJECTIVE

This scoping review aimed to characterize the factors associated with the early emergence of atypical feeding behaviours in typically developing young children.

METHODS

CINAHL, MEDLINE, PsycINFO and Scopus databases were searched. Studies published in the last 5 years were included if they examined factors associated with the development of atypical eating behaviours in infants and young children. Of the 2137 records obtained after the search strategy was applied, 202 full-text articles were retrieved for a more detailed examination and to ensure they met the inclusion criteria. This resulted in 54 studies being included in this scoping review.

RESULTS

Of the 54 studies, three studies analysed precursors responsible for atypical feeding behaviours, and 51 studies discussed the factors associated with the early emergence of feeding difficulties. Multiple factors, including genetic factors, breastfeeding, late introduction of solids and lumpy foods, complementary feeding techniques, parental mental health, prematurity and child factors including temperament, were identified. There is inconsistent evidence for the associations between breastfeeding exposure and feeding difficulties.

CONCLUSIONS

This study identified multiple factors potentially associated with the early onset of atypical feeding behaviours in young children; however, there is insufficient evidence at this time to support specific recommendations for early feeding practices in young children. More methodologically rigorous studies are needed to extend these findings.

Assessment and management of feeding difficulties for infants with complex CHD

Early surgical intervention in infants with complex CHD results in significant disruptions to their respiratory, gastrointestinal, and nervous systems, which are all instrumental to the development of safe and efficient oral feeding skills. Standardised assessments or treatment protocols are not currently available for this unique population, requiring the clinician to rely on knowledge based on neonatal literature. Clinicians need to be skilled at evaluating and analysing these systems to develop an appropriate treatment plan to improve oral feeding skill and safety, while considering post-operative recovery in the infant with complex CHD. Supporting the family to re-establish their parental role during the hospitalisation and upon discharge is critical to reducing parental stress and oral feeding success.

'it was that … specialist … that finally listened to us … that's probably a weird answer to what you were expecting': Clinician and carer perspectives on brilliant feeding care

INTRODUCTION

To extend research on positive aspects of health care, this article focusses on health care for children who tube-feed-this is because knowledge about tube-feeding for children is limited and fragmented. This is achieved by consulting with clinicians and carers who supported children who tube-feed to clarify their understandings of and experiences with brilliant feeding care.

METHODS

Nine clinicians and nine carers who supported children who tube-fed were interviewed. The interview transcripts were analysed thematically.

RESULTS

Findings highlighted several features of brilliant feeding care-namely: practices that go above and beyond; attentiveness; empowerment; being 'on the same page'; hopefulness and normalcy.

CONCLUSIONS

These findings show that seemingly trivial or small acts of care can make a significant meaningful difference to carers of children who tube-feed. Such accounts elucidate brilliant care as grounded in feasible, everyday actions, within clinicians' reach. The implications associated with these findings are threefold. First, the findings highlight the need for clinicians to listen, be attuned and committed to the well-being of children who tube-feed and their carers, share decision-making, source resources, and instil hope. Second, the findings suggest that carers should seek out and acknowledge clinicians who listen, involve them in decision-making processes, and continue to source the resources required to optimize child and carer well-being. Third, the findings point to the need for research to clarify the models of care that foster brilliant feeding care, and the conditions required to introduce and sustain these models.

PATIENT OR PUBLIC CONTRIBUTION

All of the carers and clinicians who contributed to this study were invited to participate in a workshop to discuss, critique, and sense-check the findings. Three carers and one clinician accepted this invitation. Collectively, they indicated that the findings resonated with them, and they agreed with the themes, which they indicated were well-substantiated by the data.

Labial Frenotomy for Symptomatic Isolated Upper Lip Tie

BACKGROUND

The benefits and challenges of successful breastfeeding for both mother and child have been well-established in the literature. While ankyloglossia, or tongue tie, alone or in combination with upper lip tie has been the focus of several previous studies, very few have directly addressed isolated symptomatic upper lip tie and the role of surgical correction for breastfeeding difficulties.

MATERIALS AND METHODS

Seven infants with isolated upper lip tie and breastfeeding difficulty were taken to the operating room for labial frenotomy. These infants were assessed at their follow-up visits for their degree of weight gain since their procedure. Their mothers were surveyed regarding their experiences with breastfeeding since the frenotomy was performed.

RESULTS

In this article, we present seven infants with isolated upper lip tie and breastfeeding difficulty who were treated with labial frenotomy. Subsequently, these infants demonstrated improved weight gain, and all mothers reported increased ease of breastfeeding.

CONCLUSION

These findings implicate lip tie as an underrecognized cause of breastfeeding difficulty and suggest that labial frenotomy is an effective treatment in these patients. Larger-scale randomized controlled studies are necessary to further evaluate this topic.

Factors contributing to neonatal readmissions to a level 4 hospital within 28 days after birth

AIM

To identify maternal and neonatal factors associated with neonatal readmissions.

METHODS

A case controlled, cross-sectional, retrospective review of neonatal readmissions within 28 days from birth to a level 4 hospital in Western Sydney was conducted from January to December 2018. Maternal and neonatal factors for readmission were assessed. A control group of 122 neonates were randomly selected. Comparative statistics and logistic regression analysis were used to analyse the data.

RESULTS

Of the 3914 neonatal discharges following birth, there were 129 neonatal readmissions (3.3%). Following regression analysis, gestational age (odds ratio 0.82, 95% confidence interval 0.7-0.97, P = 0.02) and intrapartum intravenous (IV) fluids (odds ratio 2.78, 95% confidence interval 1.66-4.67, P < 0.001) were associated with readmission. The majority of readmissions were feeding-related (72.9%). Of these readmissions, 29.8% had feeding concerns noted by nursing or midwifery staff during the initial hospital stay. During the initial hospital stay following birth, neonatal feeding issues were significantly associated with primiparous mothers (P = 0.005). Mothers who did not receive IV fluids during labour were also more likely to experience feeding issues (P = 0.015).

CONCLUSION

Our findings indicate that hospital discharge prior to established feeding patterns may be associated with an increased incidence of neonatal readmission. The factors associated with neonatal readmission are earlier gestational age and intrapartum IV fluid administration. These findings suggest that more comprehensive feeding assessment prior to discharge, flexibility of discharge timing and increased community support may reduce neonatal readmission.

Characterization of Severity in Zellweger Spectrum Disorder by Clinical Findings: A Scoping Review, Meta-Analysis and Medical Chart Review

Zellweger spectrum disorder (ZSD) is a rare, debilitating genetic disorder of peroxisome biogenesis that affects multiple organ systems and presents with broad clinical heterogeneity. Although severe, intermediate, and mild forms of ZSD have been described, these designations are often arbitrary, presenting difficulty in understanding individual prognosis and treatment effectiveness. The purpose of this study is to conduct a scoping review and meta-analysis of existing literature and a medical chart review to determine if characterization of clinical findings can predict severity in ZSD. Our PubMed search for articles describing severity, clinical findings, and survival in ZSD resulted in 107 studies (representing 307 patients) that were included in the review and meta-analysis. We also collected and analyzed these same parameters from medical records of 136 ZSD individuals from our natural history study. Common clinical findings that were significantly different across severity categories included seizures, hypotonia, reduced mobility, feeding difficulties, renal cysts, adrenal insufficiency, hearing and vision loss, and a shortened lifespan. Our primary data analysis also revealed significant differences across severity categories in failure to thrive, gastroesophageal reflux, bone fractures, global developmental delay, verbal communication difficulties, and cardiac abnormalities. Univariable multinomial logistic modeling analysis of clinical findings and very long chain fatty acid (VLCFA) hexacosanoic acid (C26:0) levels showed that the number of clinical findings present among seizures, abnormal EEG, renal cysts, and cardiac abnormalities, as well as plasma C26:0 fatty acid levels could differentiate severity categories. We report the largest characterization of clinical findings in relation to overall disease severity in ZSD. This information will be useful in determining appropriate outcomes for specific subjects in clinical trials for ZSD.

Impact of COVID-19 public health restrictions on hospital admissions for young infants in Victoria, Australia

AIM

Strict public health measures during the COVID-19 pandemic led to less support for infants and their parents. We aimed to characterise the frequency and nature of infant admissions to the Royal Children's Hospital (RCH), Melbourne in 2020, compared to the previous year.

METHODS

A retrospective review of medical records identified infants ≤3 months admitted to the general medicine unit, RCH from March to September in 2019 and 2020. Diagnoses potentially related to the impact of public health measures and reduced family and community supports were identified and compared to all infant diagnoses across both years. Clinical characteristics and need for referral for additional supports or mental health services were also ascertained.

RESULTS

There were fewer admissions for infants ≤3 months in 2020 (n = 411) compared to 2019 (n = 678), with a threefold increase in admissions with a primary or secondary diagnosis of feeding difficulties, growth disturbance, infant irritability or maternal mental health concerns (191/411; 46% vs. 97/678; 14%). There were more infants of first-time parents (112/191; 59% vs. 44/97; 45%) and a reduction in the number of admissions due to infection (145/411; 35%; vs. 467/678; 69%).

CONCLUSION

During the COVID-19 pandemic, there was a threefold increase in admissions for infants ≤3 months due to poor growth, feeding difficulties, irritability and maternal mental health concerns in 2020 compared to 2019. These findings may inform future pandemic planning and policy development to ensure maintenance of community supports such as maternal child health nurse (MCHN) service delivery for young infants.

Feeding outcomes in post-discharge feeding clinic for infants following cardiac surgery

INTRODUCTION

The aim of this study was to describe the development and assess the usefulness of a feeding clinic to help infants with CHD tolerate the highest level of oral feeding while achieving growth velocity and supporting neurodevelopment.

MATERIALS AND METHODS

This retrospective, cohort study assessed feeding outcomes for infants who underwent cardiac surgery at <30 days of age with cardiopulmonary bypass between February 2016 and April 2020. Diagnoses, age at surgery, hospitalisation variables, and feeding outcomes were compared between two cohorts, pre- and post-implementation of a specialised feeding clinic using Exact Wilcoxon signed-rank test, chi-squared, or Fisher's exact test. The association between time to full oral feed and risk factors was assessed using univariable and multivariable Cox regression model.

RESULTS

Post-clinic infants (n = 116) surgery was performed at a median of 6 days of life (interquartile range: 4, 8) with median hospital length of stay of 19 days (interquartile range: 16, 26). Infants' median age at first clinic visit was at 30 days old (interquartile range: 24, 40) and took median 10 days (interquartile range: 7, 12) after hospital discharge to first clinic visit. In the post-clinic cohort, the median time to 100% oral feeding was 47 days (interquartile range: 27, 96) compared to the 60 days (interquartile range: 20, 84) in the pre-clinic cohort (n = 22), but the difference was not statistically significant.

DISCUSSION

The cardiac feeding clinic was utilised by our neonatal surgery population and feasible in coordination with cardiology follow-up visits. Future assessment of cardiac feeding clinic impact should include additional measures of feeding and neurodevelopmental success.

Understanding Cystic Fibrosis Comorbidities and Their Impact on Nutritional Management

Cystic fibrosis (CF) is a chronic, multisystem disease with multiple comorbidities that can significantly affect nutrition and quality of life. Maintaining nutritional adequacy can be challenging in people with cystic fibrosis and has been directly associated with suboptimal clinical outcomes. Comorbidities of CF can result in significantly decreased nutritional intake and intestinal absorption, as well as increased metabolic demands. It is crucial to utilize a multidisciplinary team with expertise in CF to optimize growth and nutrition, where patients with CF and their loved ones are placed in the center of the care model. Additionally, with the advent of highly effective modulators (HEMs), CF providers have begun to identify previously unrecognized nutritional issues, such as obesity. Here, we will review and summarize commonly encountered comorbidities and their nutritional impact on this unique population.

Feeding difficulties in Asian children with autism spectrum disorder

BACKGROUND

To characterize the nature and severity of feeding difficulties in Asian young children with Autism Spectrum Disorders (ASD) and identify potential predictors of poorer feeding outcomes.

METHODS

Cross sectional study of children aged 1-7 years with ASD. Parents completed the following: demographic information, brief autism mealtime behavior inventory, aberrant behavior checklist (ABC), behavioral pediatrics feeding assessment scale (BPFAS) and caregiver feeding style questionnaire. Additional information (medical data, cognitive and developmental assessment results, e.g., Autism Diagnostic Observation Schedule Second Edition, Autism Diagnostic Interview, Revised, Vineland Adaptive Behaviour Scales, etc.) were subsequently obtained from electronic medical records retrospectively by one of the study team members.

RESULTS

Of the 67 children, 28.4% had feeding difficulties (high BPFAS total frequency score). Caregiver feeding styles were authoritarian (34.8%) or indulgent (39.4%). Child characteristics did not significantly predict for the severity of feeding difficulties. Univariate analysis revealed that authoritarian feeding style (p = 0.001) and ABC hyperactivity score (p = 0.006) were significantly associated with BPFAS severity score. Multivariate analysis revealed that ABC hyperactivity score remained significantly associated with BPFAS severity score after controlling for all other ABC subscale scores. A final regression model including all child characteristics and ABC scores did not reveal any significant predictors of BPFAS total frequency score (R2 = 0.557).

CONCLUSION

Our findings suggest an association between hyperactivity, authoritarian feeding style and feeding difficulties. Children with ASD who have significant hyperactivity behaviors in the context of parents with an authoritarian feeding style should be actively screened for problematic feeding behaviors.

Assessment of Swallowing Disorders, Nutritional and Hydration Status, and Oral Hygiene in Students with Severe Neurological Disabilities Including Cerebral Palsy

BACKGROUND

Special needs schools (SNS) educate children and young people with major neurological disabilities who are at high risk of oropharyngeal dysphagia (OD) and malnutrition (MN). We aimed to assess the prevalence of OD, MN, dehydration (DH), and oral health (OH) in students at an SNS.

METHODS

A cross-sectional observational study was conducted at SNS L'Arboç, Catalonia, Spain. We assessed (a) demographics, health status, comorbidities, and gross motor function classification system (GMFCS), (b) swallowing function, oral-motor evaluation, masticatory capacity, and EDACS classification for eating and drinking abilities, (c) nutritional and DH status (anthropometry, bioimpedance and dietary records), and (d) OH (Oral Hygiene Index Simplified).

RESULTS

A total of 33 students (mean age 13.3 years; 39.4% level V of GMFCS) were included. Main diagnosis was cerebral palsy at 57.6%. All students presented OD, 90.6% had impaired safety, 68.7% were at levels II-III of EDACS, and 31.3% required PEG; furthermore, 89.3% had chronic MN, 21.4% had acute MN, 70% presented intracellular DH, and 83.9% presented impaired OH.

CONCLUSION

MN, DH, OD, and poor OH are highly prevalent conditions in students with cerebral palsy and other neurological disabilities and must be specifically managed through nutritional and educational strategies. The multidisciplinary team at SNS should include healthcare professionals specifically trained in these conditions.

Disruptions in the development of feeding for infants with congenital heart disease

Congenital heart disease (CHD) is the most common birth defect for infants born in the United States, with approximately 36,000 affected infants born annually. While mortality rates for children with CHD have significantly declined, there is a growing population of individuals with CHD living into adulthood prompting the need to optimise long-term development and quality of life. For infants with CHD, pre- and post-surgery, there is an increased risk of developmental challenges and feeding difficulties. Feeding challenges carry profound implications for the quality of life for individuals with CHD and their families as they impact short- and long-term neurodevelopment related to growth and nutrition, sensory regulation, and social-emotional bonding with parents and other caregivers. Oral feeding challenges in children with CHD are often the result of medical complications, delayed transition to oral feeding, reduced stamina, oral feeding refusal, developmental delay, and consequences of the overwhelming intensive care unit (ICU) environment. This article aims to characterise the disruptions in feeding development for infants with CHD and describe neurodevelopmental factors that may contribute to short- and long-term oral feeding difficulties.

Patient-reported experiences of mealtime care and food access in acute and rehabilitation hospital settings: a cross-sectional survey

BACKGROUND

Nutrition and mealtime interventions can improve nutritional intake amongst hospital inpatients; however, patient-reported experience is rarely considered in their development and evaluation. The present study aimed to measure patient-reported food and mealtime experience to evaluate and inform continuous quality improvement of hospital nutrition care.

METHODS

A cross-sectional survey with inpatients in seven acute care and rehabilitation wards was conducted. A 27-item validated questionnaire measured five domains of patient experience: food choices, organisational barriers, feeling hungry, physical barriers to eating and food quality. Responses were summarised descriptively and compared between settings (acute versus rehabilitation), patient demographics (age, gender) and time in hospital.

RESULTS

Responses from 143 participants (mean age 67 years, 57% male, 28% rehabilitation, median 6 days into hospitalisation) showed that 10% or fewer respondents reported difficulties with food choices, feeling hungry or food quality. The most common difficulties were opening packets (36%), insufficient menu information provided (29%), being interrupted by staff when eating (28%), being disturbed when eating (27%), being in an uncomfortable position when eating (24%) and difficulty reaching food (21%). There were no significant differences in domain patterns by sex, age group or time in hospital. Organisational barriers were reported less frequently amongst rehabilitation participants compared to acute care (P = 0.01).

CONCLUSIONS

This survey highlights areas of positive patient-reported experience with nutrition care and suggests that local improvement efforts should focus on physical assistance needs and organisational barriers, especially in acute care wards. The questionnaire may be useful for informing and evaluating systematic nutrition care improvements.

A New Case of de novo Variant c.892C>T (p.Arg298Trp) in NACC1: A First Case Report From China

Background: The nucleus accumbens associated 1 (NACC1) gene is a transcription factor member of the BTB/POZ family. A de novo heterozygous c.892C>T (p.Arg298Trp) variant in the NACC1 may define a syndrome characterized by intellectual disability, infantile epilepsy, congenital cataract, and feeding difficulties. Case Presentation: We report a new case with a neurodevelopmental disorder characterized by severe intellectual disability, infantile epilepsy, congenital cataract, and feeding difficulties. Brain MRI reveals brain dysplasia. We observe a de novo heterozygous c.892C>T (p.Arg298Trp) variant in the NACC1 gene in this case. Now, the child regularly goes to the hospital for rehabilitation training (once a month). Sodium Valproate (10 mg/kg/day) and Clobazam (10 mg/kg/day) are used in the treatment of epilepsy. A total of three articles were screened, and two papers were excluded. The search revealed one article related to a syndrome caused by a de novo heterozygous c.892C>T (p.Arg298Trp) variant in the NACC1; they screened the main clinical features of eight cases of a syndrome, which were summarized and analyzed. Conclusions: The NACC1 gene is a member of the BTB/POZ family of transcription factors. A de novo heterozygous c.892C>T (p.Arg298Trp) variant in the NACC1 may define a syndrome characterized by intellectual disability, infantile epilepsy, congenital cataract, and feeding difficulties. At present, there is no effective cure. In the future, we need more cases to determine the phenotype-genotype correlation of NACC1 variants. Many questions remain to be answered, and many challenges remain to be faced. Future transcriptional studies may further clarify this rare, recurrent variant, and could potentially lead to targeted therapies.

DYRK1A pathogenic variants in two patients with syndromic intellectual disability and a review of the literature

BACKGROUND

DYRK1A-Related Intellectual Disability Syndrome is a rare autosomal dominant condition characterized by intellectual disability, speech and language delays, microcephaly, facial dysmorphism, and feeding difficulties. Affected individuals represent simplex cases that result from de novo heterozygous pathogenic variants in DYRK1A (OMIM 614104), or chromosomal structural rearrangements involving the DYRK1A locus. Due to the rarity of DYRK1A-Related Intellectual Disability Syndrome, the spectrum of symptoms associated with this disease has not been completely defined.

METHODS AND RESULTS

We present two unrelated cases of DYRK1A-Related Intellectual Disability Syndrome resulting from variants in DYRK1A. Both probands presented to the National Institutes of Health (NIH) with multiple dysmorphic facial features, primary microcephaly, absent or minimal speech, feeding difficulties, and cognitive impairment; features that have been previously reported in individuals with DYRK1A. During NIH evaluation, additional features of enlarged cerebral subarachnoid spaces, retinal vascular tortuosity, and bilateral anomalous large optic discs with increased cup-to-disc ratio were identified in the first proband and multiple ophthalmologic abnormalities and sensorineural hearing loss were identified in the second proband.

CONCLUSION

We recommend that the workup of future of patients include a comprehensive eye exam. Early establishment of physical, occupational, and speech therapy may help in the management of ataxia, hypertonia, and speech impairments common in these patients.

Feeding characteristics of infants in a lower-middle-income country

AIM

To describe feeding characteristics (such as breast feeding and complementary feeding) and determine the nature of feeding difficulties of infants in a primary health-care clinic (PHC) in South Africa.

METHODS

A total of 200 infants aged 6-12 months (mean = 8.54, standard deviation = 2.18) received a feeding screening by a speech-language therapist at a PHC in a semi-urban area using the Montreal Children's Hospital-Feeding Scale (MCH-FS). Children who failed screening underwent further clinical feeding evaluation using the Schedule of Oral Motor Assessment.

RESULTS

The sample consisted of 200 participants, and most participants (n = 174; 87%) received breastfeeding, irrespective of their mothers' human immunodeficiency virus status. The longer the breastfeeding period, the less likely parents were to show concern about infants' feeding (P = 0.035). Complementary feeding was introduced between 6 and 8 months (n = 122; 82%). The MCH-FS identified 13 participants with feeding difficulties (6.5%), of which 11 were diagnosed with oral motor dysfunction (OMD) using the Schedule of Oral Motor Assessment. The 6.5% (n = 13) that failed had mild (n = 8; 61.5%), moderate (n = 2; 15.4%) and severe (n = 3; 23.1%) feeding difficulties, as reported by care givers using the MCH-FS. The MCH-FS showed that distraction during meals/following infants (n = 42; 21%); food refusal (n = 31; 15.5%); care giver unease about feeding (n = 29; 14.5%); and problems with vomiting, gagging or spitting (n = 28; 14%) were characteristics of feeding in this sample. Participants in the age groups 6 (n = 3; 27.3%) and 10 months (n = 3; 27.3%) were prone to OMD.

CONCLUSIONS

This study is the first of its kind to describe the feeding characteristics of a group of infants during the transitional feeding stage in late infancy in South Africa. Important findings were the existence of OMD in 11 infants and feeding difficulties during transitional feeding in 13 infants. The study's findings may be used as a starting point for larger-scale studies in a similar setting, investigating the development of future care giver education and health-care professional training programmes regarding transitional feeding. Research endeavours by speech-language therapists need to prioritise late infancy and transitional feeding in order to prevent possible difficulties arising from sub-optimal care giver feeding practices. The study may be valuable to all health-care providers in PHC.

Parents experiences of feeding their extremely preterm children during the first 2-3 years - A qualitative study

AIM

To describe parents of extremely preterm children experiences regarding feeding of their children during the first 3 years of the child's life.

METHODS

This is a qualitative study involving interviews conducted with 12 parents of nine children who had been cared for at one neonatal intensive care unit in Sweden. The interviews were conducted between May and September 2018; the data were analysed using qualitative content analysis.

RESULTS

All parents experienced some difficulties with their child's eating development and described feeding their child as sometimes both difficult and frustrating. Variation in when these difficulties arose made it hard for the parents to obtain the individual support they wanted and needed. Parents experienced a need for more support - from both staff members and parents with similar experiences - during and after their child's stay at the NICU.

CONCLUSION

All parents participating in the study experienced difficulties during some phase of their child's feeding development. They expressed the need for more specialised support both during and after their child's time at the hospital.

Onset, Trajectory, and Pattern of Feeding Difficulties in Toddlers Later Diagnosed with Autism

OBJECTIVE

To examine the emergence and trajectory of feeding difficulties in young children who are later diagnosed with autism spectrum disorder (ASD).

METHODS

The Behavioral Pediatrics Feeding Assessment Scale (BPFAS) was administered to a sample of 93 toddlers with an older sibling with ASD-the high-risk group-and 62 toddlers with no known familial ASD-the low-risk group-as part of a larger infant sibling study. The BPFAS was completed by parents at 15, 18, 24, and 36 months of age. At 36 months, participants underwent a diagnostic assessment and were classified into 1 of the following 4 outcome groups: ASD, nontypical development, high-risk typically developing, and low-risk typically developing. The BPFAS was scored for total frequency of feeding difficulties and autism-specific factor scores previously described in the literature.

RESULTS

The frequency of feeding difficulties increased significantly more rapidly in the ASD group between 15 and 36 months of age, and by 36 months, they exhibited a significantly higher total frequency score than all other groups. Analysis of the factor scores revealed a similar pattern for the food acceptance and mealtime behavior domains but no significant differences in the medical/oral motor domain.

CONCLUSION

Feeding difficulties develop significantly more rapidly in children with ASD, with longitudinal monitoring revealing the steeper trajectory earlier than can be detected with cross-sectional analysis. Children with ASD are at risk of health and social consequences of poor feeding behavior that may potentially be minimized if addressed early and appropriately.

upd(20)mat is a rare cause of the Silver-Russell-syndrome-like phenotype: Two unrelated cases and screening of large cohorts

Silver-Russell syndrome (SRS) is an imprinting disorder characterized by prenatal and postnatal growth retardation, relative macrocephaly, feeding difficulties and body asymmetry. Recently, upd(20)mat has been identified in few patients with SRS-like features, suggestive of a new imprinting disorder characterized by prenatal and postnatal growth failure. Here, we describe two male patients with upd(20) and feeding difficulties, prenatal and postnatal growth retardation and normal cognitive development. During pregnancy, confined placental mosaicism for trisomy 20 was detected in one of the patients but was not investigated further until identification of upd(20)mat in the neonatal period. To evaluate whether upd(20)mat should be part of the first trier genetic diagnostic in patients with growth retardation, we screened a large cohort of patients (n = 673) referred to our laboratories for SRS-testing without detecting any upd(20). Our results, along with the existing evidence, indicate that upd(20)mat is a very rare cause of growth retardation, but should be followed up when confined placental mosaicism for trisomy 20 mosaicism is observed during pregnancy.

Fixed the gap, solved the problem? Eating skills in esophageal atresia patients at 3 years

Although eating problems have been described as long-term morbidities of esophageal atresia (EA), there have been few studies exploring eating outcomes in children born with EA as primary aim. Parents of children operated on for EA in our Institution from January 2012 to January 2016, answered a telephone structured interview developed specifically to conduct the present study, assessing eating skills at 3 years of age. Clinical data were collected from children's medical records. Parents (45 mothers and 6 fathers) of 51 children (male = 34; female = 17) with a median age of 3.5 years form the object of the study. Considering eating problems, parents reported that 23 children (45%) still have episodes of choking during meals at 3 years of age, 9 (45%) of these have more than one episode a week, and 19 parents (39%) reported higher levels of anxiety during mealtimes. Forty-four children (86%) were described by their parents as able to eat alone, 32 (65%) accepted all food textures and 45 (90%) was described as curious about food (3 years). Forty-three (86%) parents let their children eat with other people. Correlations showed that weaning age was significantly associated with number of dilatations (rs = 0.35, P = 0.012), days of mechanical ventilation (rs = 0.40, P < 0.001), and presence of gastrostomy tube at discharge (rs = 0.45, P < 0.001). Chewing age resulted associated with number of dilatations (rs = 0.34, P < 0.01) and days of mechanical ventilation (rs = 0.38, P < 0.01). Presence of choking episodes was associated with curiosity about food (rs = 0.29, P < 0.05), while frequent choking episodes were associated with higher parental anxiety during mealtimes (rs = 0.45, P < 0.05). In order to prevent delay in the achievement of eating developmental milestones in children operated on of EA, we advocate a dedicated preventive intervention from birth to follow-up.

Parental concern of feeding difficulty predicts poor growth status in their child

BACKGROUND

Parents often express concerns about feeding difficulties in their child. We hypothesized that these parental concerns were associated with adverse growth status in early childhood. We aimed to determine the prevalence of such concerns and whether these concerns were associated with adverse growth status in early childhood.

METHODS

We performed a cross-sectional study among healthy children aged 12-36 months attending three well-baby clinics in three urban areas in Malaysia and Singapore between December 2016 and February 2017. Parents were interviewed for concerns about their child's feeding and presence of behavioral and organic red flags for feeding difficulties. We defined growth faltering as weight-for-age < 3rd centile and short stature as height-for-age < 3rd centile according to World Health Organization Growth Standards.

RESULTS

Of the 303 children studied (boys = 160, 52.8%; mean [± SD] chronological age at interview 21.3 [± 4.0] months), 13% (n = 38/292) had growth faltering and 19.5% (n = 50/256) had short stature. Overall, 36.3% (n = 110) of parents expressed concerns about their child's feeding behavior. Sixty-eight percent (n = 206) of parents reported presence of at least one behavioral and 18.5% (n = 56) had at least one organic red flag for feeding difficulties, respectively. 9.9% (n = 30) had both behavioral and organic red flags for feeding difficulties. Growth faltering was significantly associated with parental concern about feeding (odds ratio [OR] 3.049, p < 0.001), food refusal (OR 4.047, p < 0.001) and presence of at least one organic red flag (OR 2.625, p = 0.012).

CONCLUSION

We found that parental concerns about their child's feeding to be common. Presence of parental concern, food refusal in the child and presence of organic red flags for feeding difficulties are associated growth faltering in early childhood.

Feeding difficulties in children with autism spectrum disorder: Aetiology, health impacts and psychotherapeutic interventions

Feeding difficulties are common and significant issues for children with autism spectrum disorder and their families. Key features of autism are intrinsically linked with factors contributing to these children's feeding difficulties. Following a multidisciplinary assessment to exclude non-behavioural reasons for the feeding difficulty, there are two mainstay modalities of treatment: operant conditioning and systematic desensitisation. Currently, evidence points towards operant conditioning as the most efficacious psychotherapy. However, recent research into cognitive behavioural therapy for older children with feeding difficulties has shown promising results and will be an area to monitor in the coming years. This review outlines the causes and health impacts and evaluates current evidence supporting the available psychotherapeutic interventions for children with autism spectrum disorder experiencing feeding difficulties.

The prevalence and role of coping strategies in the nutritional intake of children born with esophageal atresia: a condition-specific approach

This study describes results of a condition-specific approach to the assessment of coping strategies in nutritional intake situations used by children with esophageal atresia. One hundred three families of children 2-17 years old with esophageal atresia participated (94% response rate). Following standardized focus groups with 30 families, nine coping items were developed, reflecting nine different coping strategies in nutritional intake situations. The coping items were pilot tested by 73 new families and evaluated for feasibility, validity, and reliability. The families also completed a validated condition-specific quality-of-life questionnaire for children with esophageal atresia, which included the scale Eating-Quality-of-life. Data were analyzed using descriptives, between-group analysis, and Spearman's rho (P < 0.05). Altogether, the coping items were feasible, valid, and reliable. Items reflecting problem-focused strategies revealed that 89% of 2-17 years old 'recognized their responsibility' and managed nutritional intake problems on their own, 79% 'tried to solve their feeding problems' testing different solutions, 79% took a 'confronting approach' to do what peers did in eating situations, and 54% 'sought other people's support'. Items reflecting emotion-focused strategies showed that 86% of the children 'accepted' their feeding difficulties, 68% 'reappraised feeding difficulties into positive outcomes' such as to eat only when food tasted good. Moreover, 63% of the children 'avoided' nutritional intake situations, 29% 'expressed worry or fear' when faced with these situations, while 25% 'distanced' themselves from eating problems by hiding or throwing away food. The children's use of coping strategies were mostly related to the existence of digestive symptoms (P < 0.05). Positive and negative coping strategies were identified. Of particular note was a correlation cluster of the so-called disengagement strategies 'avoidance', 'expression of emotional concerns' and 'distancing'. These strategies were negatively correlated with Eating-Quality-of-Life. Conversely, taking a 'confronting approach' correlated positively with Eating-Quality-of-life (P < 0.05). Hence, most children with esophageal atresia employ various coping strategies in nutritional intake situations. A good Eating-Quality-of-life may be positively affected by treating digestive morbidity and encouraging children to take an active approach to their eating problems rather than using disengagement coping.

Gastrointestinal Conditions in Children With Severe Feeding Difficulties

Feeding aversion in children may progress to severe feeding difficulties. While oral-motor and sensory issues are usually the leading causes, organic etiologies should be considered. This study aimed to assess the prevalence of gastrointestinal conditions in children with severe feeding difficulties. We conducted a retrospective study of 93 children requiring an intensive feeding program. The medical records, radiologic and diagnostic tests, use of gastric tube feedings, preexisting medical conditions, and medications were reviewed. Fifty-two percent (52%) had esophagitis, 26.2% gastritis, and 40.7% lactase deficiency in upper endoscopy. In those who underwent an upper endoscopy, 26% of patients that were also tested for small intestinal bacterial overgrowth were found to be positive. Allergy testing was abnormal in 56.6% of those tested, while 27.5% and 75% had abnormal gastric emptying times and pH impedance results, respectively. Constipation was present in 76.3%. Thirteen of 32 were weaned off tube feedings. We conclude that gastrointestinal conditions are common in children with feeding disorders and should be investigated prior to feeding therapy.

Feeding difficulties in infants with unrepaired cleft lip and palate and HIV-exposure

BACKGROUND

There is limited description of the feeding characteristics of infants with unrepaired cleft lip and palate, exposed to HIV, but not necessarily infected.

OBJECTIVE

To compare the feeding characteristics of infants with unrepaired cleft lip and palate and HIV-exposure, to infants with unrepaired cleft lip and palate only.

METHOD

A two-group comparative design with a validated measure, the Neonatal Feeding Assessment Scale was used. The effectiveness of oral feeding skills were included as objective measure. Twelve participants with unrepaired cleft lip and palate and HIV-exposure and 13 with unrepaired cleft lip and palate were matched according to cleft type and use of feeding obturator. There were no differences between the groups for mean age, birth weight and gestation. Participants were between two and 89 days old, bottle fed, and had no syndrome/co-occurring disorder.

RESULTS

Nine (75%) participants in the research group and only two (15.38%) in the control grouppresented with the likelihood of oropharyngeal dysphagia. Apart from feeding difficulties as a result of structural impairment, the research group showed symptoms of neurological involvement.

CONCLUSION

The research group presented with distinctive symptoms of oropharyngeal dysphagia. More studies using different measuring tools are required to strengthen the evidence.

Nutritional disorders resulting from food allergy in children

The elimination of food allergens that contribute essential nutrients in paediatrics may lead to the development of nutritional disorders. The most common nutritional disorders include poor growth, micronutrient deficiencies and feeding difficulties. Of the aforementioned, growth faltering has been well studied and is seen as a common presenting factor in paediatric food allergy. However, the use of different criteria and cut-off values makes it difficult to establish the overall effect. The impact of number and type of foods eliminated and comorbidities has yielded varying results, although there seems to be a trend towards worsening growth with atopic dermatitis and the avoidance of cow's milk. Low micronutrient intake is common in paediatric food allergy; however, a low intake does not necessarily translate into a deficiency as measured by biomarkers. Vitamin D and calcium have been well studied, and a long-lasting impact on bone mineral density has been found. However, other micronutrient deficiencies have also been found and should also be considered. Feeding difficulties is a common complaint in clinical practice, but limited data have been published in food allergy. Poor growth and reflux/vomiting have been shown to be associated with feeding difficulties, in particular in non-IgE-mediated food allergies. There seems to be a long-lasting effect on feeding, in particular in cow's milk allergy, which needs to be taken into account with dietary input. The interplay between growth, feeding difficulties and micronutrient deficiencies has been implied in some studies, but cause and effect is not well established and requires further research.

Effectiveness of the IMFeD tool for the Identification and Management of Feeding Difficulties in Taiwanese children

BACKGROUND

The Identification and Management of Feeding Difficulties (IMFeD™) tool was introduced in 2011 for management of children with feeding difficulties and has been used in various countries around the world. This study aimed to assess its acceptance and effectiveness in clinical practice in Taiwan.

METHODS

This was a prospective, observational, multicenter study where subjects were followed over 3 months. Outpatients identified as picky eaters, having poor appetite, poor weight gain, or weight loss were enrolled. The acceptance and effectiveness of IMFeD tool were evaluated by caregivers and pediatricians.

RESULTS

Among 423 children who completed the study (235 boys, 188 girls; 78.8% aged <5 years, 21.3% aged 6-10 years), the most common feeding difficulties were poor appetite in a fundamentally vigorous child (85.3%) and highly selective intake (70.2%). Mean percentiles for height and weight were 34.6 ± 25.3 and 20.3 ± 21.3 at enrolment, and increased by 5.4 and 5.9 (p < 0.0001) at the last visit, respectively. Most caregivers (86.5%) thought that the IMFeD tool helped them to understand and better identify picky eating behaviors. Pediatricians reported that the IMFeD tool was effective in 99.3% of patients for managing picky eaters in clinical practice.

CONCLUSIONS

The IMFeD tool was effective in addressing differences in needs according to type of feeding difficulty by providing a systematic approach to manage feeding difficulty in Taiwanese children. It is applicable to the clinical practice and well-accepted by pediatricians and caregivers.

Elucidating the diagnostic odyssey of 22q11.2 deletion syndrome

Clinical molecular testing has been available for 22q11.2 deletion syndrome (22q11.2DS) for over two decades yet under-recognition and diagnostic delays are common. To characterize the "diagnostic odyssey" in 22q11.2DS we studied 202 well-characterized unrelated adults, none ascertained through an affected relative. We used a regression model to identify clinical and demographic factors associated with length of time to molecular diagnosis. Kaplan-Meier analysis compared time to diagnosis for the molecular testing era (since 1994) and earlier birth cohorts. The results showed that the median time to molecular diagnosis of the 22q11.2 deletion was 4.7 (range 0-20.7) years. Palatal and cardiac anomalies, but not developmental delay/intellectual disability, were associated with a shorter time to molecular diagnosis. Non-European ethnicity was associated with longer time to diagnosis. Inclusion of a cohort from another 22q11.2DS center increased power to observe a significantly earlier diagnosis for patients born in the molecular testing era. Nonetheless, only a minority were diagnosed in the first year of life. On average, patients were seen in seven (range 2-15) different clinical specialty areas prior to molecular diagnosis. The findings indicate that even for those born in the molecular testing era, individuals with 22q11.2DS and their families face a diagnostic odyssey that is often prolonged, particularly in the absence of typical physical congenital features or for those of non-European ancestry. The results support educational efforts to improve clinical recognition and testing, and ultimately newborn screening as a means of maximizing early detection that would provide the best opportunity to optimize outcomes.

A Program for Weaning Children from Enteral Feeding in a General Pediatric Unit: How, for Whom, and with What Results?

OBJECTIVE

To describe a series of children who were hospitalized for a tube-weaning program in the general pediatric ward of a pediatric tertiary university hospital: describe our method, to determine the success rate of our inpatient pediatric tube weaning program, and search for relevant factors linked to its success or failure.

METHOD

We analyzed the medical files of consecutive children who were hospitalized for gastric-tube weaning over an 8-year period. We analyzed outcomes in terms of feeding and growth with at least 2 years of data. Success (weaning within 3 months) and failure were compared by characteristics of children.

RESULTS

We included 37 children (29 females) with mean (SD) age 31.4 (21) months. Most had a severe medical history (30% prematurity; 50% intrauterine growth restriction, 50% neurological and genetic anomalies). The weaning program was successful for half of the children. Factors linked to success of the program were female sex (p = 0.0188), normal neurodevelopment (p = 0.0016), nasogastric tube (p = 0.0098), and with <24 months on EF before the stay (p = 0.0309).

DISCUSSION

Comparing the efficiency of various methods and results among teams was difficult, which indicates the need to establish consensus about the outcome criteria. We confirm the need for these types of stays and programs.

Gastrointestinal and feeding difficulties in CHARGE syndrome: A review from head-to-toe

CHARGE syndrome is an autosomal dominant genetic condition that is primarily diagnosed based on clinical features, with genetic testing available for confirmation. The CHARGE mnemonic stands for some of the common characteristics: coloboma, heart defects, atresia/stenosis of the choanae, retardation of growth/development, genitourinary anomalies, and ear abnormalities (CHARGE). However, many of the common clinical features are not captured by this mnemonic, including cranial nerve dysfunction, considered by some to be one of the major diagnostic criteria. Over 90% of individuals experience feeding and gastrointestinal dysfunction, which carries great morbidity and mortality. The aim of this review is to examine the nature of gastrointestinal (GI) symptoms and feeding difficulties in CHARGE syndrome, focusing on their underlying pathology, associated investigations, and available treatment options. We also provide information on available tools (for parents, clinicians, and researchers) that are important additions to the lifelong healthcare management of every individual with CHARGE syndrome. We review how cranial nerve dysfunction is one of the most important characteristics underlying the pervasive GI and feeding dysfunction, and discuss the need for future research on gut innervation and motility in this genetic disorder.

Mutations in CRLF1 cause familial achalasia

We here report a family from Libya with three siblings suffering from early onset achalasia born to healthy parents. We analyzed roughly 5000 disease-associated genes by a next-generation sequencing (NGS) approach. In the analyzed sibling we identified two heterozygous variants in CRLF1 (cytokine receptor-like factor 1). Mutations in CRLF1 have been associated with autosomal recessive Crisponi or cold-induced sweating syndrome type 1 (CS/CISS1), which among other symptoms also manifests with early onset feeding difficulties. Segregation analysis revealed compound heterozygosity for all affected siblings, while the unaffected mother carried the c.713dupC (p.Pro239Alafs*91) and the unaffected father carried the c.178T>A (p.Cys60Ser) variant. The c.713dupC variant has already been reported in affected CS/CISS1 patients, the pathogenicity of the c.178T>A variant was unclear. As reported previously for pathogenic CRLF1 variants, cytokine receptor-like factor 1 protein secretion from cells transfected with the c.178T>A variant was severely impaired. From these results we conclude that one should consider a CRLF1-related disorder in early onset achalasia even if other CS/CISS1 related symptoms are missing.

Feeding Methods at Discharge Predict Long-Term Feeding and Neurodevelopmental Outcomes in Preterm Infants Referred for Gastrostomy Evaluation

OBJECTIVE

To test the hypothesis that oral feeding at first neonatal intensive care unit discharge is associated with less neurodevelopmental impairment and better feeding milestones compared with discharge with a gastrostomy tube (G-tube).

STUDY DESIGN

We studied outcomes for a retrospective cohort of 194 neonates <37 weeks' gestation referred for evaluation and management of feeding difficulties between July 2006 and July 2012. Discharge milestones, length of hospitalization, and Bayley Scales of Infant Development-Third Edition scores at 18-24 months were examined. χ², Mann-Whitney U, or t tests and multivariable logistic regression models were used.

RESULTS

A total of 60% (n = 117) of infants were discharged on oral feedings; of these, 96% remained oral-fed at 1 year. The remaining 40% (n = 77) were discharged on G-tube feedings; of these, 31 (40%) remained G-tube dependent, 17 (22%) became oral-fed, and 29 (38%) were on oral and G-tube feedings at 1 year. Infants discharged on a G-tube had lower cognitive (P <.01), communication (P = .03), and motor (P <.01) composite scores. The presence of a G-tube, younger gestation, bronchopulmonary dysplasia, or intraventricular hemorrhage was associated significantly with neurodevelopmental delay.

CONCLUSIONS

For infants referred for feeding concerns, G-tube evaluations, and feeding management, the majority did not require a G-tube. Full oral feeding at first neonatal intensive care unit discharge was associated with superior feeding milestones and less long-term neurodevelopmental impairment, relative to full or partial G-tube feeding. Evaluation and feeding management before and after G-tube placement may improve long-term feeding and neurodevelopmental outcomes.

Maternal Feeding Practices among Children with Feeding Difficulties-Cross-sectional Study in a Brazilian Reference Center

BACKGROUND

Given the positive influence of responsive caregiving on dietary habits in childhood, to raise awareness of caregivers regarding their behavior is crucial in multidisciplinary care on infant feeding.

OBJECTIVES

To identify the most common responsive and non-responsive feeding practices in mothers of children with feeding complaints, as well as to seek associations between practices and caregivers' profile.

METHODS

Cross-sectional study with 77 children under 18 years old, with complaints of feeding difficulties. Data were collected during interviews with mothers: child age, gender, duration of exclusive breastfeeding, presence of organic disease, dynamics of bottle use, self-feeding practices and posture at meals, use of appropriate feeding equipment; basic information about the mothers (parity and level of education), caregiver feeding style, presence of coercive feeding, frequency and characteristics of family meals. Statistical analysis considered significance level at 5%.

RESULTS

The non-responsive profile predominated among mothers (76.2%, with the Authoritarian style being the most prevalent-39.7%). The responsive profile was characterized by absence of coercive feeding, stimulation of self-feeding practices, use of appropriate feeding equipment and meal environment, with interaction at meals. Non-responsive profile consisted of both inadequate environment and posture at meals, use of distraction and coercive feeding, lack of shared meals, and disregard for children's hunger signals. Only the habit of sharing meals with children was associated with mothers' profile, and considered a protection factor against non-responsive care (OR 0.23; 95% CI 0.06-0.88). Both Authoritarian (p = 0.000) and indulgent mothers (p = 0.007) breastfed exclusively for longer time than negligent ones. There was a higher level of interaction with children in "responsive" parental style (OR 0.056; p = 0.01) compared to other feeding styles.

CONCLUSION

Results highlight the need for educational interventions focused on caregivers' behaviors.

Delayed Development of Feeding Skills in Children with Feeding Difficulties-Cross-sectional Study in a Brazilian Reference Center

BACKGROUND

Delays in gross motor development, sensory processing issues, and organic and behavioral problems are known to interfere in the development of feeding skills (FS); and-therefore-in the success of the process of feeding a child. Children with feeding difficulties (FD) commonly present inadequacy of FS.

OBJECTIVES

Assessment of five FS in Brazilian children with FD, and search of associations with types of FD.

METHODS

Cross-sectional study with 70 children below 10 years old. Data were obtained from medical records: age, gender, age at texture transitions, feeding phase (breastfeeding, weaning to solids or full solids) at first complaint; characteristics of the meal (duration, environment, and shared meals with adults), self-feeding practices, use of feeding equipment and bottle, mouthing, feeding position and FD diagnosis. Skills were categorized according to standards for age. Chi-Square, Anova Test (or non-parametric equivalent) and Multinomial logistic regression tests were used, with a significance level of 5%.

RESULTS

There was no difference in FS (p > 0.05) or in the number of FS inadequateness (p = 0.84) according to FD diagnosis. The majority (94%) of children presented at least one delayed development of FS; 1/3 presented delays in more than half of the FS. The most prevalent inadequacies in FS were inadequate feeding position (73.5%), prolonged bottle feeding (56.9%), and inadequate self-feeding practices (37.9%). Feeding complaints first appeared at 10.9 ± 11.4 months, and picky eating was the most prevalent type of FD (37.1%). Most children were fed in inadequate environments (55.2%), without the company of adults (78%). Transition to solid foods occurred at 16 ± 5.6 months. Multinomial logistic regression showed no difference in likelihood of presenting any type of FD compared to picky eating, according to FS. Age at texture transition both from breastfeeding to complementary feeding (p = 0.95), and from complementary feeding to solid foods (p = 0.43) did not vary according to FD diagnosis.

CONCLUSION

FS development or number of FS inadequateness did not vary according to FD diagnosis. Identification of these inadequacies could help the discussion for multi-professional treatment of patients with FD.