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Oral Feeding Transition & Disorder Programs: Literature Review

Oral Feeding Transition & Disorder Programs: Literature Review. Kayley George UH Dietetic Intern, Spring 2017. Pathophysiology. Feeding relies on a series of reflexes controlled by the brainstem 3 Phases: Oral, Pharyngeal, Esophageal Requires physical and mental coordination

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Oral Feeding Transition & Disorder Programs: Literature Review

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  1. Oral Feeding Transition & Disorder Programs: Literature Review Kayley George UH Dietetic Intern, Spring 2017

  2. Pathophysiology Feeding relies on a series of reflexes controlled by the brainstem 3 Phases: Oral, Pharyngeal, Esophageal Requires physical and mental coordination Neural control of swallowing involves the nucleus tractussolitarus(NTS) and nucleus ambiguus(NA) The NTS relays information on taste, swallowing, and cardiovascular signals The NA signals the laryngeal, pharyngeal, and stylopharyngeus muscles Dysfunction can arise at any point in the mechanism

  3. Prevalence • Occur in 25-40% of healthy children • Severe feeding problems are 40-70% more common in children with chronic medical conditions • Premature infants represent a large portion of children who develop serious feeding difficulties • Improved preterm infant survival has increased the prevalence of feeding problems in older infants and toddlers • Patients with early hospitalization may miss early learning milestones or develop negative associations

  4. Risk Factors • Infant feeding in NICU • Cardiology • Dental sensitivities • Gastrointestinal diseases • Reflux • Short gut • Liver disease • Long term tube feeding • Neurological insult • Oral aversion • Post-op cleft/reconstruction/repair • Pulmonary • Renal disease • Tracheostomies • Failure to Thrive • Concern for aspiration • Decreased oral motor skills • Need for parent education

  5. Causative Factors The distribution of the most common medical diagnostic categories of children presenting to a feeding team: • neurologic (62%) • Developmental delays, traumatic brain injury, myasthenia gravis, muscular dystrophy, tardive dyskinesia • mechanical/structural (53%) • laryngeal cleft, esophageal stenosis, tracheoesophageal fistula, tumors • behavioral (43%) • Selective eating, food refusal, pica, rumination • cardiorespiratory (34%) • pyriform aperture stenosis, choanal atresia, laryngomalacia • metabolic (12%)

  6. Oral Feeding Disorders • DSM-V describes three types of food intake disorders: • Avoidant/Restrictive Food Intake Disorder (ARFID) • Significant loss of weight/failure to thrive • Significant nutritional deficiency • Dependence on enteral feeding or oral nutritional supplements • Marked interference with psychosocial functioning • Other Specified Feeding or Eating Disorder (OSFED) • Unspecified Feeding or Eating Disorder (UFED)

  7. Treatment Programs Outpatient: allows for more frequent contact and tighter control over the feeding environment Day Treatment: more accessible and less expensive than other models of care Inpatient: provides closest medical oversight, increases opportunities for coordinated care across disciplines Patients typically categorized as tube dependent, liquid dependent, or food selective

  8. Success of Feeding Therapy Programs Wide range of literature from several decades, mostly retrospective observational studies Most trial studies have small sample sizes Limited in generalizability due to disease focus Reviewed studies involve transition from nutrition support and feeding disorders All studies reviewed had some degree of success in programs 1 study had 100% success in weaning to oral feedings (Davis et. al, 2016)

  9. Oral Feeding Transition Programs • Systematic review of 11 studies on oral transition feeding programs (2000-2015) • All programs have multidisciplinary teams • Behavioral intervention was the most common approach • Overall percentage of patients successfully weaned from tube feeding was 71%

  10. Oral Feeding Transition Programs • Small prospective cohort study of congenital heart disease infants • Infants received oral motor invention used Beckman method 4x/day for 15 mins • 57% of patients discharged on full oral feeds compared to 45% in control group

  11. Oral Feeding Transition Programs • Small RCT study of children fully dependent on tube feeding >3 months • Children weaned off of tube feeding gradually over 1 week • 82% of participants weaned to full oral feeds after 4 weeks of treatment

  12. Oral Feeding Transition Programs • Small RCT study of 21 children testing use of nerve pain/antidepressant drug • 24-week outpatient program for patients transition from tube to oral feeding • 100% of participants were weaned to oral feeding after trial in both groups

  13. Oral Feeding Disorder Programs • Small RCT study of ARFID children in multidisciplinary day program • Week-long program that included 40-minute feeding blocks for 14 meals • 89% of participants demonstrated increase in bite-size food acceptance

  14. Oral Feeding Disorder Programs • Review of treatments for children who eat orally or have tube feedings • Discussed advantages of program options and limited study availability • Explained difficulties in funding feeding programs

  15. Summary of Approaches Medical/Mechanical  Behavior/Psychological Orally Sustained Children: Contingent social attention, reinforcement, punishment, appetite manipulation, stimulus control procedures, systematic desensitization, nutrition education,oral therapy, and flooding Tube Feeding Dependent Children: Positive and negative reinforcement,oral-motor therapy, shaping, discrimination, fading, hunger provocation/tube weaning, escape extinction, appetite stimulants Behaviorally based interventions are the most empirically supported interventions for feeding disorders Appetite stimulants and hunger provocation show promise

  16. Final Thoughts A wide variety of techniques have been proven effective Continuing need for studies with larger sample sizes and more rigorous study designs Better research will come with improved funding Goal is to find the most effective and generalizable treatment for the lowest cost and smallest family burden

  17. Reimbursement Most insurers will not allow for simultaneous billing of clinicians Insurance considers professional services for pediatric intensive feeding programs medically necessary when allof the following conditions are met: Behavior problems are interfering with feeding; and Diagnosis-specific treatment plan with child-specific interventions and estimated length of treatment are proposed and documented; and Medical causes of failure to thrive have been treated (e.g., acidosis, renal insufficiency, malabsorption) without resolution of the feeding problem; and Neurological or oral-motor problems exist; and Normal feeding milestones have not been met; and Physician will coordinate and oversee the treatment program; and Suboptimal score on nutritional assessment has been documented

  18. Bibliography Carrau, R. L., Murry, T., & Howell, R. J. (2017). Comprehensive Management of Swallowing Disorders (2nd ed.) Davis, A. M., Bruce, A., Cocjin, J., Mousa, H., & Hyman, P. (2010). Empirically Supported Treatments for Feeding Difficulties in Young Children. Current Gastroenterology Reports,12(3), 189-194. doi:10.1007/s11894-010-0100-9 Davis, A. M., Dean, K., Mousa, H., Edwards, S., Cocjin, J., Almadhoun, O., . . . Hyman, P. E. (2016). A Randomized Controlled Trial of an Outpatient Protocol for Transitioning Children from Tube to Oral Feeding: No Need for Amitriptyline. The Journal of Pediatrics,172. doi:10.1016/j.jpeds.2016.02.013 Indramohan, G., Pedigo, T. P., Rostoker, N., Cambare, M., Grogan, T., & Federman, M. D. (2017). Identification of Risk Factors for Poor Feeding in Infants with Congenital Heart Disease and a Novel Approach to Improve Oral Feeding. Journal of Pediatric Nursing. doi:10.1016/j.pedn.2017.01.009 Lukens, C. T., & Silverman, A. H. (2014). Systematic Review of Psychological Interventions for Pediatric Feeding Problems. Journal of Pediatric Psychology,39(8), 903-917. doi:10.1093/jpepsy/jsu040 Nicely, T. A., Lane-Loney, S., Masciulli, E., Hollenbeak, C. S., & Ornstein, R. M. (2014). Prevalence and characteristics of avoidant/restrictive food intake disorder in a cohort of young patients in day treatment for eating disorders. Journal of Eating Disorders,2(1), 21. doi:10.1186/preaccept-1149759184129961 Sharp, W. G., Stubbs, K. H., Adams, H., Wells, B. M., Lesack, R. S., Criado, K. K., . . . Scahill, L. D. (2016). Intensive, Manual-based Intervention for Pediatric Feeding Disorders. Journal of Pediatric Gastroenterology and Nutrition,62(4), 658-663. doi:10.1097/mpg.0000000000001043 Sharp, W. G., Volkert, V. M., Scahill, L., Mccracken, C. E., & Mcelhanon, B. (2017). A Systematic Review and Meta-Analysis of Intensive Multidisciplinary Intervention for Pediatric Feeding Disorders: How Standard Is the Standard of Care? The Journal of Pediatrics,181. doi:10.1016/j.jpeds.2016.10.002 Udall, J. N. (2007). Infant Feeding: Initiation, Problems, Approaches. Current Problems in Pediatric and Adolescent Health Care,37(10), 374-399. doi:10.1016/j.cppeds.2007.09.001

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