Feeding Disorders

1. Feeding Disorders

2. Feeding • Complex, dynamic process • Continuous sequence of hierarchical steps • Results in adequate growth in weight, height, and head circumference • Feeding problems are common • 25-35% overall • Found more commonly in children with medical conditions and developmental delays • Over 60% of parents of toddlers reported more than one eating concern

3. Stages of Feeding • Nursing period (newborn – 4 months) • Breast milk or formula • Transitional period (4-6 months) • Semisolid foods are added • Modified adult period (1-2 years on) • Solid foods • Food preferences

4. Development of Feeding Behaviors • 8 months: begin eating from spoon • 18 months: self-feeding exclusively • 24 months: learn social skills associated with eating

5. Development of Feeding Behaviors • Toddlers • Assert self and quest for autonomy • Noncompliant behaviors can emerge • Onset of self-feeding • Establishment of food preferences • Shift from parental control to shared control

6. Variables affecting parent’s response • Importance attached to feeding • CF child needing to consume 150% RDA • Feelings of success as a parent through the child’s eating • Tolerance and patience

7. Classification of Causes of Feeding Problems • Medical basis • Oral-motor delay or dysfunction • Behavioral mismanagement • Or…a combination of some or all • See page 190 of Piazza (2003) article

8. Feeding problems • Inappropriate mealtime behaviors • Lack of self feeding • Food selectivity • Failure to advance texture

9. Feeding Problems • Food refusal • Oral-motor immaturity • Frequent vomiting • Aspiration or swallowing problems • Gastro-intestinal reflux • See page 190 of Piazza (2003) article

10. Assessment • Review of medical records • Clinical interview with caregivers • Sample records of food intake • Other measures • Developmental assessment • Child, parental, family behavior rating scales

11. Assessment • Direct observation of feeder-child interactions during a simulated or actual meal • Piazza (2003) article discussion • Study 1: Observed… • Escape: removal of food • Attention: reprimands, coaxing, redirection • Tangible item: gave preferred food, toy • Page 192

12. Assessment • Study 2: Functional Analysis • Baseline control – free access to attention and preferred items • Escape • Attention • Tangible • Purpose: to simulate situations • High levels of inappropriate behavior in each condition would suggest that child’s behavior was sensitive to the experimental condition • Results: Environmental variables play a role in the occurrence of feeding disorders

13. Behavioral Framework for Feeding • Two Factor Model (both classical and operant conditioning) • Negative feeding experience occurs • Child associates other feeding stimuli with this negative experience (classical conditioning) • Anxiety regarding negative experience leads to avoidance behaviors • Avoidance behaviors result in removal of food (negative reinforcement)

14. Behavioral Interventions • Contingent differential social attention • Positive attention to appropriate behavior • Opening mouth • Closing lips • Chewing • Planned ignoring of inappropriate behavior • Throwing • Hitting • Clenched teeth • Brief time out for inappropriate behavior • E.g., turn child’s high chair to face wall

15. Behavioral Interventions • Positive tangible consequences • Offering bites of preferred food • Providing access to television, toy play, sensory reinforcement, or tokens • Negative tangible consequences • Removal of favored items • *Escape extinction • E.g., hold spoon at child’s lips until food is accepted • Physical guidance (rarely used)

16. Behavioral Interventions • Appetite manipulation • Changing feeding schedule • Controlling artificial feedings • Restricting between meal snacks

17. Behavioral Interventions • Providing consistent verbal or physical prompts to eat • E.g., every 30 sec • Modeling • Shaping

18. Treatment of Mild Feeding Problems • Parent training • Short term and long term goals • Nutrition education • Interaction coaching • Suggestions for preparing and presenting food

19. Severe Feeding Problems • Experienced by 3-10% of children • Tend to persist and worsen with time • More prevalent in children with • Physical disabilities • Mental retardation • Medical illness • Prematurity • Low birth weight

20. Inpatient vs Outpatient Treatment • Prerequisites for outpatient treatment • Child’s medical status is stable • One or more caregivers is available to participate in treatment • Recommended treatment is acceptable to all caregivers

21. Inpatient vs Outpatient Treatment • Advantages of inpatient treatment • Can control and measure child’s intake • Medical coverage is immediately available • Medical monitoring • Permits consistency of trainers • Easier to restrict access to food to induce hunger • Disadvantages • High cost • Substantial professional time requirements (3-4 feeding sessions per day) • Possible problems of generalization of treatment effects to home after discharge

22. Failure to Thrive • Weight less than 5th percentile for age and sex OR downward trend in weight • Distinguished from “feeding problems” • Often accompanied by physical and psychological problems • Not a diagnosis, but an outcome resulting from various etiologies

23. Failure to Thrive • Parental influences • Limited food availability • Feeding patterns and relations • Maternal psychological status • Child influences • Physical and medical problems • Behavioral difficulties • Parent-child risk factors • Quality of home environment • Security of attachment