Feeding Disorders: Infants and Young Children

1. Feeding Disorders:Infants and Young Children Tessa Chesher, D.O. Assistant Professor Oxley Chair of Child and Adolescent Psychiatry OU School of Community Medicine

2. Objectives • Identify types of feeding disorders in young children • Recognize treatment strategies for these feeding disorders

3. Epidemiology • 25% of normally developing infants • 80% of infants with developmental handicaps • 1-2% of infants have poor weight gain due to feeding disorders • Disrupt infant’s early development

4. Sequelae • Cognitive developmental delays • Behavioral problems • Anxiety disorders • Eating Disorders

5. Feeding and Relationships https://youtu.be/du0LDG9LUAI

6. Diagnostic ClassificationandHistory

7. In the beginning… • Failure to Thrive • FTT was used as a “catch all” for Feeding Disorders (FD) • 2 types: organic and non organic • Later a 3rd type: mixed • What about the infants with FD and no FTT? • Should FTT be a symptom and not a category?

8. Failure to Thrive • What about the infants with a feeding disorder and no FTT? • Should FTT be a symptom and not a category?

9. DC:0-3R • 2005 • 6 feeding disorders • Feeding Disorder of State Regulation • Feeding Disorder of Caregiver-Infant Reciprocity • Infantile Anorexia • Sensory Food Aversions • Posttraumatic Feeding Disorder • Feeding Disorder Associated with a Concurrent Medical Condition

10. Infantile Anorexia • Small appetite • Poor weight gain • Malnourishment during the toddler years • Difficulty turning off excitement, interfering with sleep and eat • In excited state, do not recognize hunger • Prefer playing and talking over food

11. Infantile Anorexia Treatment • Teach how to recognize hunger and fullness • Establish a regular feeding schedule • Feed toddler at 3-4 hour intervals • No in-between snacks • If thirsty – only water

12. Infantile Anorexia Treatment • Offer very small portions of food and allow child to ask for 2nd, 3rd, and 4th helpings • Keeps child engaged in eating process • Prevents boredom • Prevents them from being overwhelmed by large amount of food • Eat meals together as a family • Keep toddler in high chair until “mommy’s or daddy’s tummy is full.”

13. Infantile Anorexia Treatment • Meals should last no longer than 20-30 min • Do not praise or criticize the toddler for how much or how little the toddler is eating • During feeding • No toys or T.V. • Food is not to be used as a reward or expression of affection

14. Infantile Anorexia Treatment • No throwing of food or utensils • No playing with food instead of eating it • Allow toddler to self-feed with own spoon

15. Infantile Anorexia Treatment • Introduce finger foods • Re-focus child if distracted • “We need to eat now, and talk later.” • Enact time-out method if the child wants to leave the table before everyone is finished with their meal • Caveat to using time out

16. Time-Out Method • It’s important to use the time-out method for any distracted behavior at meal times • running away to play • throwing food and utensils • Teaches self-soothing • makes it easier to settle down in all excited situations • Child will learn to calm his or herself to eat and sleep.

17. Time-Out Method • The parents are to give only one warning. • The child should be put in time- out in a safe place • Child is alone and doesn’t see parents • This is for calming and not punishment • Crib or playpen

18. Time-Out Method • Time out begins after child is calm • Parents set the timer for a few minutes • Child is taken back to correct behavior • Parents need to follow through once time out starts

19. Sensory Food Aversions • Children who either change their food preferences often or consistently refuse the same foods. • Two types • Children who change food preferences frequently • Children who develop sensory food aversions, which can be a taste, texture, or even a whole food group.

20. Sensory Food Aversions • Selective eating disorders are caused by several genetic and environmental influences: • Genetic influences • Taste bud sensitivity • Fear of trying new foods is hereditary

21. Sensory Food Aversions • Selective eating disorders are caused by several genetic and environmental influences: • Environmental influences • Exposure to new food • Role of rewards on food preferences • Effect of modeling eating by parents and peers on food preferences • Effect of negative experiences associated with eating certain foods

22. Sensory Food Aversions • These types of eating disorders tend to surface when new foods are introduced. • Can begin the first few weeks of life • Different sucking patterns • 100 fewer sucks per feeding session than non-picky children • 17% refused to suck at all

23. Sensory Food Aversions • Usually begins around 6-10 months • Introduction of baby foods • Often have other sensitivities as well • i.e. don’t want to get hands messy

24. Sensory Food Aversion Treatment • Determine underlying reason for selectivity • Is it food aversion or is the child changing food preference constantly? • Set limits with children who change food preferences frequently by only offering three different types of food at mealtimes and not giving into demands

25. Sensory Food Aversion Treatment • Upon protest of new limits, enable time-out method • Encourage eating meals together, as a family, to increase modeling • If your child gags or vomits upon first try at a new food, keep mood neutral, but make a mental note not to serve that food again

26. Posttraumatic Feeding Disorders • Behaviors exhibited when an infant relates a painful or frightening experience with eating. • Also known as: • choking phobia • swallowing phobia • functional dysphagia

27. Posttraumatic Feeding Disorders • Most of the time, this fear is associated with bottle feedings, but can also be associated with solid food. • The fear can be triggered by more than one incident of vomiting, or gagging or choking as a result of forceful feeding by a caregiver. • Often, toddlers will remember their fear of drinking milk from a bottle and this will transition to a fear of drinking milk from a cup later.

28. Treatment of PFD in Infants • Parents need to recognize signs of infant distress • Crying at sight of a bottle or bib • Crying when positioned for feeding • Crying when approached with bottle • Figure out the baby’s fear

29. Treatment of PFD in Infants • Help infant overcome the fear slowly • Provide positive associations with feeding position • Example: While in feeding position, rock and sing to the infant • Let the infant play with the bottle • Try new feeding devices, like a cup and straw • Avoid force-feeding

30. Posttraumatic Feeding Disorder • Children can also experience a fear of eating solid foods. • They can become fearful of choking after they have had an experience choking, watched someone else choke, or even heard a scary story about someone else choking.

31. Treatment of PFD in Children • If your child refuses to drink any water, take them to the emergency department • If your child does drink water, encourage them to try milk or a liquid supplement to increase nutrients in their diet • Gradually try to add soft foods and purees

32. Treatment of PFD in Children • Eat at the table to help child overcome fear of choking as they watch their parents successfully finish a meal • If your child is unable to overcome their feeding fears, professional help may be necessary.

33. FD with Medical Condition • GERD • Cardiac conditions • Pulmonary Conditions

34. Chatoor, 2009

35. Chatoor, 2009

36. Chatoor, 2009

37. Video Treatment Example • CHOP • https://www.youtube.com/watch?v=0mGbOeuuuB8 • Infant • https://youtu.be/X2nGk2DoOt8

38. DC: 0-3 • Good inter-rater reliability in • Infantile Anorexia • Sensory Food Aversions • Posttraumatic Feeding Disorder • Feeding Disorder Associated with a Concurrent Medical Condition • Hospital Study

39. Updated Information • Major studies reviewed • More reviews published • Clinician reports • Problems • Symptoms overlap • Etiology • Terminology – Infantile Anorexia • One dx is more relational • One dx is more of a symptom • Based on lack of weight gain

40. Changes • Terminology • Focus on child’s observed eating symptoms • Relationship specific or child specific • Thoughts • Culture

41. DC: 0-5 • Overeating Disorder • Undereating Disorder • Atypical Eating Disorder • Other Sleep, Eating, and Excessive Crying Disorder of Infancy/Early Childhood

42. DC: 0-5 • Overeating Disorder • Young children overeat by persistently seeking excessive amounts of food during meals or between meals • Excessively preoccupied with food and eating • Significantly affects child or family functioning • Not in children under 24 months • Lasts more than one month

43. DC:0-5 • Undereating Disorder • Eats less than expected for age • Exhibits maladaptive eating behaviors • Causes distress to child and/or family • No age specifications • Symptoms >1month

44. DC:0-5 • Atypical Eating Disorder • Hoarding – hides food in unusual places • Not been described in children under 2

45. DC:0-5 • Atypical Eating Disorder • Pica – habitual eating of nonnutritive substances • Be cautious in giving this diagnosis under 2

46. DC:0-5 • Atypical Eating Disorder • Rumination – pattern of regurgitating and re-swallowing food • Usually starts between 3-12 months

47. DC:0-5 • Atypical Eating Disorder • No age specification • >1month

48. DSM 5 • Avoidant/Restrictive Food Intake Disorder • Was Feeding Disorders of Infancy and Early Childhood • Feeding disturbance as manifested by persistent failure to meet appropriate nutritional needs • significant weight loss • significant nutritional deficiency • dependence on enteral feeding or oral nutritional supplements • marked interference with psychosocial functioning.

49. DSM 5 • Not d/t GI or other medical condition • Not d/t another mental d/o • i.e. rumination d/o • Not d/t lack of food

50. Evaluating Feeding • Validated Scales • Feeding observation during session