njota current trends in pediatric feeding
TRANSCRIPT
Current Trends in Pediatric Feeding – Evaluation, Treatment and Outcomes
Nichole M. Turmelle, OTRKaren E. Sclafani, MOT, OTR
NJOTA ConferenceOctober 23, 2010
Learning Outcomes/Objectives
Participants will:1. Summarize current literature related to the
diagnosis and treatment of feeding difficulties2. Identify the domain areas and methods used by
occupational therapists working as part of multi-disciplinary team, to assess feeding/eating skills
3. Compare available treatment options that occupational therapists can utilize to treat feeding/eating difficulties in children
4. Identify possible methods to document outcomes related to the treatment of eating and feeding difficulties in pediatrics
Literature Review:Multi-disciplinary Team Evaluations
Multi-disciplinary evaluations are supported in documentation from a variety of disciplines
Key disciplines identified include occupational therapy, speech therapy, psychology, nutrition and physician
Other disciplines also identified include social work, nursing and radiology
Chart review, interview, mealtime observation, clinical observations, and referrals are indicated as key parts of the evaluation Citations: 4, 17, 21, 36, 37
Literature Review:Diagnosis of Feeding Difficulties
DSM-IV-TR Diagnosis – Feeding and Eating Disorders in Childhood
ICD 9 Diagnosis – Feeding Difficulties and Mismanagement
Criteria for both include: Persistent Failure to eat adequately, associated with weight loss Significant failure to gain weight
Need a better system of classification Suggested by a number of authors to better represent
feeding Current classifications do not account for feeding
difficulties associated with: State regulation Feeding disorder of reciprocity Sensory food aversions Post-traumatic feeding disorder
Citations: 3, 13, 15, 22, 27, 39
Literature Review:Treatment Techniques
Discusses the use of behavioral approaches to feeding including reinforcement, non-removal techniques and escape prevention
Looks at cognitive behavioral approaches/education regarding the sensory aspects of food
Discusses sensory-motor preparatory activities for the mouth and body to improve feeding
Highlights the components of parent education Looks at the use of medication, along with more
traditional therapy approaches to increase appetite, improve gastric emptying and decrease anxiety surrounding feeding
Citations: 6, 7, 8, 12, 14, 15, 16, 24, 25, 26, 29, 30, 31, 33, 35, 38
Literature Review:What Was Not Documented
Consistent outcome measures Medical Behavioral
OT treatment options Limited documentation of OT’s role during feeding
therapy Limited discussion of sensory preparation for
feeding Identified that sensory processing issues were present,
but did not measure or speak to how they were addressed Lack of protocols for treatment by OT
Oral motor Sensory
Citations: 6, 12, 15, 16, 18, 24, 26, 29, 30, 31, 33, 35, 38
Evaluation of Feeding Difficulties
Feeding impairments are complex, often impacting the health, development and nutritional status of pediatric clients
Prevalence rates of feeding impairments span a wide range
Impact up to 25% of infants/children at some point during development
Impact 33% or more (up to 80%) of children with developmental disabilities
Citations: 6, 21
Evaluation of Feeding Difficulties: Multi-Disciplinary Team Members
Physician Speech/Language Pathologist Occupational Therapist Psychologist Registered Dietitian May also include:
Social Worker Radiologist Nurse Dentist
Evaluation of Feeding Difficulties:Team Assessment
Assessment process should include the following components: Medical assessment Consideration of the child’s feeding history Assessment of motor, sensory, cognitive and
psychosocial skills impacting feeding Direct observation of feeding, including child
and caregiver interactions Video-swallow fluoroscopy (as
necessary/available)
Evaluation of Feeding Difficulties:Team Assessment
Multi-disciplinary versus Trans-disciplinary Team members must be competent in their
own discipline-specific topics Must also have knowledge of other
discipline domains to elicit responses if necessary
Evaluation of Feeding Difficulties:Aspects of OT’s Domain
Areas of Occupation Activities of Daily Living
Eating – The ability to keep and manipulate food or fluid in the mouth and swallow it
Eating and swallowing are often used interchangeably Feeding – The process of setting up, arranging, and bringing the
food (or fluid) from the plate or cup to the mouth Feeding is sometimes referred to as self-feeding
Social Participation Community – Engaging in activities that result in successful
interaction at the community level Family – Engaging in activities that result in successful
interaction in specific required/desired familial roles Peer/friend – Engaging in activities at different levels of intimacy
Citation: 2
OT’s Role in Team Evaluation:Parent/Client Goals and Concerns
Identify family concerns for the evaluation Values/beliefs/spirituality Context and Environment – Cultural,
Temporal, Physical, and Social Self-feeding Acceptance of a bottle Acceptance of different food types (baby food
versus table food) Performance Patterns
Consider Habits, Routines, Rituals and Roles
OT’s Role in Team Evaluation:Medical and Social History
History of hospitalizations, surgeries, illnesses
History of social and psychosocial events related to feeding
Identify medications and consider their role in appetite
Look for signs/symptoms of GI distress, food allergies
Current and previous therapy services
OT’s Role in Team Evaluation: Assessment Tools
Standardized Assessment Sensory Profile Peabody Developmental Motor Scales – 2nd
Edition Parent Questionnaires
Mealtime Behavior Questionnaire Feeding Strategies Questionnaire 3-day Food Diary
OT’s Role in Team Evaluation:Observation of Movement
Ability to move in the environment Functional skills, transitions, ambulation
Quality of movement during play Use of hands in play Body Functions – Neuromuscular
ROM, strength, endurance, postural alignment Body Structure – Structures related to
movement Performance Skills – Motor and praxis skills
OT’s Role in Team Evaluation:Observation of Social Skills
Interaction with parents Ability to interact with team members Play skills, both spontaneous and when
directed by others Body Functions – Mental Functions
Global mental functions Performance Skills – Emotional
Regulation Skills, Cognitive Skills, Communication and Social Skills Imitation Communication
OT’s Role in Team Evaluation:Observation of Feeding Skills
Food Choices Identification of patterns
Texture Temperature Color Flavor Food groups
Identification of what is lacking Food groups Food textures Sensory input
OT’s Role in Team Evaluation:Observation of Feeding Skills
Motor Postural control, positioning Finger feeding Utensil use Body Systems – respiration
Oral Motor Biting/Chewing – placement of the food Lip closure – on spoon, cup, straw Lateralizing – movement of food in the mouth Timing – duration of chewing, timeliness of
swallow
OT’s Role in Team Evaluation:Observation of Feeding Skills
Sensory Level of arousal during feeding Willingness to explore foods with hands and
mouth Response to presentation of foods Ability or inability to manipulate food in
mouth
OT’s Role in Team Evaluation:Observation of Feeding Skills
Cognitive/Behavioral/Social Ability to understand/follow directions Ability to communicate needs Response to structure Attempts to influence environment with
behaviors Ability to be redirected
OT’s Role in Team Evaluation:Development of Recommendations
Individual occupational therapy Group occupational therapy Referral to other disciplines/specialties Strategies to implement at home
Treatment Considerations
Treatment techniques rarely happen in isolation
Need to consider the occupational profile of the child
Not one solution for each child
Treatment Considerations
Activity Demands (Activity Analysis) Tools – utensils, cups, plates, equipment
What tools are used by the child/family; why Space – environment of feeding, high chair
Distractions used or not used Social – what are the expected social interactions
during mealtime, cultural influences Sequence/Timing – self-feeding skill, oral motor skills
(holding food) Performance skills – cognitive, sensory, motor
demands Required body structures/functions
Treatment Techniques
Desensitization Behavioral Ayres Sensory Integration®
Sensory-Motor Medication Group Treatment Parent Education
Desensitization
Sensory Desensitization Body Functions
Tactile Oral
Hierarchical Desensitization to Food Chaining Pairing
Sensory Desensitization: Body Functions
Tactile System Wilbarger Deep Pressure Protocol Dry textures (rice, beans, pasta) Wet/sticky textures (Play-doh, Funny Foam) Vibratory input to hands
Oral System Massage to outside of mouth (towel rubs, deep
pressure) Vibratory input to inside and outside of mouth (z-
vibe) Nuk brush Blowing/sucking activities (bubbles, whistles;
drinking thick liquids through a straw)
Hierarchical Desensitization to Food
Slowly and systematically introducing new and non-preferred foods to the child
Exposing the child to a graduated hierarchy of anxiety-producing stimuli to help him/her overcome his/her fear of food/eating
Begin with the least-threatening technique and work up to more challenging strategies as comfort level increases
Hierarchical Desensitization to Food
TasteFoods
Touch Foods
Tolerate Sights/Smells of Foods
No Physical Interaction with Actual Foods
Eat Foods
Hierarchical Desensitization to Food
No Physical Interaction with Actual Foods Looking at pictures of the food (books, videos) Singing songs about food, meal preparation,
eating Playing with pretend kitchen, toy food Setting the table
Hierarchical Desensitization to Food
Tolerate Sights/Smells of Foods Shopping for food in the grocery store Talking about food characteristics Tolerating foods in the room (away from the
child, on another person’s plate) Tolerating foods within close proximity (on
table, on plate) Serving self/others with utensils Watching meal preparation or watching
others eat the food
Hierarchical Desensitization to Food
Touch Foods Simple meal preparation Touching food with utensil one finger two
fingers whole hand Picking food up Placing food on hands, arms, shoulders, head,
ears, cheeks, nose Touching food to lips
Hierarchical Desensitization to Food
Taste Foods Licking lips after food has been placed on them Touching food to teeth Licking food with tip of tongue, full tongue Gnawing on food Biting and spitting out Biting, chewing, and spitting out
Eat Foods Swallowing food (small large
portions/amounts)
Food Chaining
Part of a sensory/behavioral approach to feeding
Reduces risk for refusal as it is based on the child’s preferences
Emphasizes the relationship between characteristics of foods/liquids, such as taste, shape, texture, or temperature
Parents need to be provided with specific food chains and instructions on how they introduce and modify foods
Food Chaining
Discusses four levels of treatment: Level 1 – Optimize nutritional status, scheduled
meals/snacks, analyze patterns and preferred foods
Try to expand number of preferred foods in current taste/texture/temperature range
Level 2 – Introduce new flavors within the child’s currently preferred texture
Level 3 – Slightly alter texture of food while remaining in taste preference
Level 4 – Modify taste and texture of foods
Food Chaining
Uses a rating scale Evaluate the success of the modification
attempt Monitor progress in the program Assess changes in taste/texture preferences Ratings also help determine which new
chains may be most successful
Food Chaining: Rating Scale
1 Gagging and/or vomiting upon touching, smelling or seeing the foods
1+ Gagging upon tasting the food 2 Chews the food or manipulates it
briefly in the mouth 3 Chews the food, but strongly aversive
to the taste, grimace, refusal to try more 4 Chews and swallows food, tolerated it,
but not enjoyable at this time 5 Chews and swallows the food, it was
“so-so”
Food Chaining: Rating Scale
6 Chews and swallows several bites of the food item, no major grimace or reaction
7 Chews and swallows the food without problems
8 Chews and swallows food, takes a small serving easily, pleasant look on the face
9 Chews and swallows the food, asks for or reaches for more, appears to like the food very much
10 Chews and swallows the food, takes a serving or more easily, a strong favorite
Food Chaining
Eats Goldfish – Target is Grilled Cheese Goldfish Cheez-its White Cheez-its White crackers White crackers with cheese Plain cheese Cheese on bread Cheese on toast
Food Chaining
Chicken Nuggets/French Fries – Target is Other Meat Cut preferred chicken nugget into strips New brands of chicken nuggets cut into strips Breaded chicken strips from home Breaded pork strips Naked chicken/pork White meat turkey strips Dark meat turkey strips Beef strips
Food Pairing
Some presenters may call it “Flavor Masking”
Using preferred food to help decrease anxiety and increase acceptance of new food
Use a safe flavor/texture to help introduce a new food
Gradually separate the preferred and non-preferred foods at presentation
Change the ratio of preferred to non-preferred food
Food Pairing
Child accepts cheese: Dip cheese in cracker “crumbs” Offer reverse cheese/cracker sandwich Increase size of cracker and reduce amount
of cheese offered Place cracker in mouth first, then offer
cheese to help with chewing Offer cracker for chewing, then offer cheese
to help with swallowing Offer cracker for chewing/swallowing, then
offer cheese as a reward
Food Pairing
Child accepts pasta without sauce: Dip plain pasta in preferred “juice” and
encourage to eat Dip plain pasta in “sauce” and encourage to
eat, or wipe off then eat Place “dot” of sauce on pasta and allow
child to eat Increase the amount of “dots” Have pasta “fall” into the sauce Offer lightly-covered pasta
Behavioral Treatments:Positive Reinforcement
When desired behaviors are rewarded in order to encourage them to persist
The addition of a consequence immediately following a behavior, which increases the likelihood that the behavior will be repeated
Example of Positive Reinforcement: Jane takes a bite of her sandwich and is rewarded with verbal praise or a sticker
It is important to positively reinforce all appropriate behaviors related to feeding and eating
Behavioral Treatments:Positive Reinforcement
Types of Positive Reinforcement Verbal praise, cheering Clapping hands, high fives, hugs Toys Stickers Preferred food (pairing)
Therapist/parents should adjust the frequency that the behavior is reinforced (1:1 ratio, 5:1 ratio)
Must remember that giving attention to the child when he/she refuses to eat is positively reinforcing that behavior
Behavioral Treatments:Negative Reinforcement
The removal of an aversive stimulus immediately following a behavior, which increases the likelihood that the behavior will be repeated
Example of Negative Reinforcement: Sam takes a bite of his chicken and then the chicken is removed from his plate
Do not confuse this concept with punishment
Behavioral Treatments:Negative Reinforcement
Types of Negative Reinforcement Removing the food from the table after the
child complies with request Allowing the child to get up from the table
after consuming a bite
Behavioral Treatments:Punishment
Punishment is removing an object/situation that the child likes or setting up a situation that the child does not like
Results in a decreased frequency of the inappropriate behavior
Example of punishment: “If you continue to spit your peas, you cannot have ice cream”
Behavioral Treatments: Punishment versus Reinforcement
Punishment Procedure: Undesired behavior occurs consequence
follows (something is either added or taken away) undesired behavior decreases
Reinforcement Procedure: Desired behavior occurs consequence
follows (something is either added or taken away) desired behavior increases
Reinforcement results in lasting behavioral modification, whereas punishment changes behavior only temporarily and can have negative side effects
Behavioral Treatments:Escape Prevention
Also called “escape extinction” Based on the premise that the child’s
undesired behaviors do not result in termination of the meal or demand
Non-removal of spoon, non-removal of meal Re-presenting the food after expulsion Example of Escape Prevention: “You have to
lick the cheese three times before you can get up from the table”
Ayres Sensory Integration (ASI®)
ASI "is the process by which people register, modulate and discriminate sensations received through the sensory systems to produce purposeful, adaptive behaviors in response to the environment"
Must follow 10 principles of ASI in order to call it true ASI treatment
If poor feeding is resultant of poor sensory integration, then providing the child with opportunities for sensory processing and integration following the principles of ASI will improve the child’s ability to participate in feeding/mealtime
Do not necessarily need to address feeding during the session
Citations: 1, 28
Sensory-Motor Approach
Uses the basic principles that form the foundation for the sensory integration frame of reference
Providing the child with sensory-motor activities to prepare him/her for feeding which will be addressed later in the session
Vestibular Proprioceptive Tactile Oral sensory
Once arousal level is at optimal, then introduce feeding using a treatment approach pertinent to the child’s needs
Medication
Primary medical conditions that may benefit from treatment with medication: GERD Eosinophilic Esophagitis Poor gastric motility
Secondary conditions that result from medical diagnoses may also benefit from treatment with medication: Post-traumatic eating disorder Anxiety Poor appetite
Medication
Work with physician to determine if medication would be helpful in managing feeding difficulties
Medication, when combined with traditional feeding therapy and counseling/behavioral management, can be an effective treatment for feeding difficulties
Group Treatment
Group treatment is a great opportunity for social role modeling
Approximately 12 weeks in duration, cohort of 6-8 children
Structure: Group sensory preparation activities and parent education Wash hands “March” to the table Pass out plates/cups/napkins Feeding trials Clean-up routine
Group Treatment
Feeding trials Lead therapist presents each food, one at a
time, and determines when to introduce next food
Therapists, parents and other children in group model the sequence of steps to accepting foods
Parents may work with other children to move them through the hierarchy
Children may act as “leaders,” demonstrating their abilities to the group
Parent Education/Participation
Parents’ understanding of their child’s feeding/eating difficulties, as well as his/her strengths and limitations, is crucial to the child’s progress
Providing a supportive, nurturing and safe environment will increase the likelihood of the child exploring new foods and learning new eating skills
Behavioral treatments are important for parents to understand (reinforcement versus punishment)
Parent Education/Participation:Hands-on During Feeding Trials
It is important for parents to become familiar with the process in order to carry over at home
Consider when to involve the parents in treatment
May want to wait until the negative behaviors are better managed by the therapist before introducing parents
May be easier to have parents take an active role from the beginning, with coaching from therapist
Parent Education/Participation:
Providing Structure It will be easier for the
child to learn the process and to know what to expect at meal times if the meal can be consistent in several aspects
Develop an eating schedule (minimize grazing)
Eat in the same room, at same table, in the same chair
Have the child assist with meal preparation
Have a mealtime routine
Parent Education/Participation:Social Role Modeling
Includes all members of the family during mealtime
Enables the child to observe others receiving consequences (praise, rewards) for their actions Model good feeding behaviors Discuss foods and their characteristics Over-exaggerate the motor components Let the child be the leader and family imitates Provide positive reinforcement for all attempts Do not punish
Parent Education/Participation:Portion Size
The child can become overwhelmed or frustrated if there is too much food on his/her plate
Therefore, it is important to present foods in manageable bites and small portions No more than three
foods on the child’s plate One tablespoon of
food per year of age
Parent Education/Participation:Managing “Food Jags”
“Food jag” is a term used when the child will only eat the same food, same brand, prepared the same way over long periods of time
This is a problem because: Eventually the child will not want to eat that
food anymore The child will not accept any similar food if it
is not exactly what his/her preferred food is
Measures of Feeding Treatment
Quantities of food consumed Weight in grams Percentage consumed (oral versus g-tube)
Weight gain during treatment Medical evaluation Hierarchical progression Reinforcement required/utilized
Tools Used to Measure Outcomes of Feeding
Child Feeding Questionnaire Children’s Eating Behavior Inventory Short Sensory Profile Feeding Strategies Questionnaire Mealtime Behavior Questionnaire About Your Child’s Eating
Outcome Measure Tools:Child Feeding Questionnaire
Birch, L. L., et al. (2001) 31-item parent questionnaire assessing perceptions, beliefs,
attitudes and practices regarding: Child feeding Their relationships to the child’s development of food acceptance
patterns Designed for use with parents of typically-developing children
ages 2-11 years of age Focus is on obesity proneness in children Follows a 7-factor model:
4 factors measuring parental beliefs related to their child’s obesity proneness
3 factors measuring parental control practices and attitudes regarding child feeding
Likert-type scale Obesity is not often the primary concern of children/families that
are being treated
Outcome Measure Tools:Children’s Eating Behavior Inventory
Archer, L. A., Rosenbaum, P. L., & Streiner, D. L. (1991) 40-item parent questionnaire that assesses eating and
mealtime problems in pre-school and school-aged children
28 items pertaining to the child - food preferences, motor skills, and behavioral compliance
12 items pertaining to the parent/family systems - parental child behavior controls, cognitions and feelings about one's child and interactions between family members
5-point frequency scale Also asks "is this a problem for you?" - yes/no response
Initially designed for use with children with a wide variety of medical and developmental disorders
Takes family systems into consideration
Outcome Measure Tools:Short Sensory Profile
Dunn, W. (1999) 38-item parent questionnaire used to quickly
identify children with sensory processing difficulties
Children ages 3-17 Measures sensory modulation during daily life
- Tactile Sensitivity - Taste/Smell Sensitivity- Movement Sensitivity - Under-responsive/Seeks Sensation- Auditory Filtering - Low Energy/Weak- Visual/Auditory Sensitivity
5-point frequency scale More reliable outcome measure, as compared to
the Sensory Profile
Outcome Measure Tools:Feeding Strategies Questionnaire
Berlin, K. S., Davies, W. H., Silverman, A. H., & Rudolph, C. D. (2005, 2009)
40-item parent questionnaire that assesses the strategies used to address and prevent feeding problems in children (ages 2-6 years)
Factors include:- Child Control of Intake- Schedule Structure- Setting Structure - Laissez Faire- Parent Control of Intake - Coercive Interactions
Likert-type scale Good option for treatment outcomes, as it
focuses on caregiver and child factors that are frequently the target of family-based assessment and intervention around feeding/meals
Outcome Measure Tools:Mealtime Behavior Questionnaire
Berlin, K. S., et al. (2010) 33-item parent questionnaire that assesses the
frequency of mealtime behavior problems in young children (ages 2-6 years)
Four subscales to reflect a variety of problematic mealtime behaviors:- Food refusal/avoidance - Food manipulation- Mealtime aggression/distress - Choking/gagging/vomiting
5-point frequency scale Provides a measure of feeding problems based only
on the frequency of child behaviors versus how the caregiver feels about or manages these behaviors
Can be used during evaluation process and as a treatment outcome measure
Outcome Measure Tools:About Your Child’s Eating
Davies, W. H., Noll, R. B., Davies, C. M., & Bukowski, W. M. (1993)
Valid and reliable 25-item parent questionnaire that assesses parental beliefs and concerns regarding their child’s eating
Used with school-aged children Consists of three subscales
Child’s Resistance to Eating: Frequency of child’s eating behaviors
Positive Mealtime Environment: Parents’ mealtime interactions with the child
Parent Aversion to Mealtime: Parents’ feelings about mealtimes Likert-type scale Assesses parental feelings/beliefs regarding
mealtime, but does not capture the child’s response to feeding
Reference List
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34. Schwarz, S. M., Corredor, J., Fisher-Medina, J., Cohen, J., & Rabinowitz, S. (2001). Diagnosis and treatment of feeding disorders in children with developmental disabilities. Pediatrics, 108(3), 671-676.
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Reference List
Information also obtained from the following Continuing Education courses:
Mealtime Success for Kids on the Spectrum. Susan Roberts, MDiv, OTR/L
More than “Picky:” Taking the Fight Out of Food with Food Chaining Treatment Programs for Feeding Aversion. Cheri Fraker, CCC/SLP, Laura Walbert, CCC/SLP, and Sibul Cox, MS, RD, LD.
Picky Eaters vs. Problem Feeders: The SOS Approach to Feeding. Kay Toomey, PhD, Erin Sundseth Ross, MA, CCC/SLP, Susan Todd Massey, OTR, LCSW.
Practical Strategies for Treating Complex Pediatric Feeding Disorders: Treating the Whole Child. Mary Cameron Tarbell, MEd, CCC/SLP