njota - current trends in pediatric feeding

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

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: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: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: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

To Gag or Not to Gag

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


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


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


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

What do you think? Oral Motor or Sensory?

Now what do you think?Oral Motor or Sensory?

Is This Behavior or Not?

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

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


TasteFoods

Touch Foods

Tolerate Sights/Smells of Foods

No Physical Interaction with Actual Foods

Eat Foods


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


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


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


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 Swallowing food (small large 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

Reinforcement Positive Negative

Punishment Escape prevention

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

Examples of Positive Reinforcement

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: Behavior occurs consequence follows

(something is either added or taken away) behavior decreases

Reinforcement Procedure: Behavior occurs consequence follows

(something is either added or taken away) 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”

What types of reinforcement are being used?

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

What to avoid….

Outcomes

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

njota - current trends in pediatric feeding

Health & Medicine