Feeding disorders in infants and children

Feeding disorders in infants and childrenDeddy S Putra1DefinitionThe inability or refusal to eat certain foods because of neuromotor dysfunction, organic, and/or psychososial factors2Clinical presentationsFeeding disorder begins in the postnatal period and is characterized by irregular , poor feedings and inadequate food intake.Food refusal / oral aversionFailure to thriveRecurrent pneumoniaRecurrent vomiting3Diagnosis criteriaThe infants feding difficulties start in the first few month of life and should be present for at least 2 weeksThe infants has difficulty reaching and maintaining a calm state of alertness for feeding ; he or she too sleepy or too agitated and/or distress to feedCont The infants fail to gain age-appropiate weigh or may show loss of weight

Teh infants feeding difficulties cannot be explained by a physical illness.Nutritional ManagementNutritional assessmentDietary history, anthropometry, physical signs of possible nutritional deficiencies, laboratory tests Nutritional supportEstablishing nutrient needs, choosing feeding modality, guidelines for nutritional support, goals for nutrition support, treatment planTeam work

6Evaluation of the child with a feeding disordersFeeding historyCurrent dietTexturesRoute & time of administrationHealthy children >30 min behavioural feeding problemChildren with other disorders ineffective feeding mechanicsSpesific food aversion metabolic/alergic disordersFeeding position7Evaluation of the child with a feeding disorders (cont)Medical comorbiditiesRecurrent pneumonia chronic aspiration ?Recurrent vomiting GER ?Snoring tonsillar and adenoid hypertrophyNutritional assessmentsNutrition statusEstimating caloric intake & metabolic needsPsychological assessmentsBehavioural & parental factors

8Evaluation of the child with a feeding disorders (cont)Observation of feedingNeuromuscular tone, posture & positionMotivationOral structure and functionEfficiency of oral intakeAbility to handle oral secretions

9TABLE 2 -- CAUSES OF FEEDING DISORDERS IN CHILDREN Disorders that affect appetite, food-seeking behavior, and ingestion DepressionDeprivationCNS disease (diencephalic syndrome)Poverty (inadequate food available)Metabolic diseases Hereditary fructose intoleranceUrea cycle disordersOrganic acidemiasSensory defects AnosmiaBlindnessNeuromuscular disease (see below)Oral hypersensitivity or aversion resulting from a lack of feeding experience during crucial sensitive periods (long-term parenteral or enteral tube feeding)Conditioned dysphagia AspirationOral inflammation (see below)Gastroesophageal refluxDumping syndrome or gastric bloating after gastric surgeryFatigue (heart disease, lung disease)h10TABLE 2 -- CAUSES OF FEEDING DISORDERS IN CHILDREN(cont)Anatomic abnormalities of the oropharynx Cleft lip and/or palateMacroglossiaAnkyloglossiaPierre Robin sequenceRetropharyngeal mass or abscessVelopharyngeal insufficiencyTonsillar hypertrophyDental cariesAnatomic/congenital abnormalities of the larynx and trachea Laryngeal cleftLaryngomalaciaLaryngeal cystSubglottic stenosisTracheomalaciaTracheoesophageal cleftTracheoesophageal compression from vascular ring/sling11TABLE 2 -- CAUSES OF FEEDING DISORDERS IN CHILDREN(cont)Anatomic abnormalities of the esophagus Tracheoesophageal fistulaCongenital esophageal atresiaCongenital esophageal stenosis because of tracheobronchial remnantsEsophageal stricture, web, or ringEsophageal mass or tumorForeign bodyVascular rings and dysphagia lusorum

Disorders affecting suck-swallow-breathing coordination

Choanal atresiaBronchopulmonary dysplasiaCardiac diseaseTachypnea (respiratory rates > 60 breaths/min)

12TABLE 2 -- CAUSES OF FEEDING DISORDERS IN CHILDREN(cont)Disorders affecting neuromuscular coordination of swallowing Cerebral palsyBulbar atresia or palsyBrain stem gliomaArnold-Chiari malformationMyelomeningoceleFamilial dysautonomiaTardive dyskinesiaNitrazepam-induced dysphagiaPostdiphtheritic and polio paralysisMbius syndrome (cranial nerve abnormalities)Myasthenia gravisInfant botulismCongenital myotonic dystrophyOculopharyngeal dystrophyMuscular dystrophies and myopathiesCricopharyngeal achalasiaPolymyositis/dermatomyositisRheumatoid arthritis13TABLE 2 -- CAUSES OF FEEDING DISORDERS IN CHILDREN(cont)Mucosal infections and inflammatory disorders causing dysphagia AdenotonsillitisDeep neck space infectionsEpiglottisLaryngopharyngeal reflux from gastroesophageal refluxGastroesophageal refluxCaustic ingestionCandida pharyngitis or esophagitisHerpes simplex esophagitisHIVCytomegalovirus esophagitisMedication-induced esophagitisCrohn's diseaseBehcet diseaseChronic graft-versus-host disease14TABLE 2 -- CAUSES OF FEEDING DISORDERS IN CHILDREN(cont)Other miscellaneous disorders associated with feeding and swallowing difficulties XerostomiaHypothyroidismIdiopathic neonatal hypercalcemiaTrisomy 18 and 21Velocardiofacial syndromeRett syndromePrader-Willi syndromeAllergiesLipid and lipoprotein metabolism disordersNeurofibromatosisWilliams syndromeCoffin-Siris syndromeOptiz-G syndromeCornelia de Lange syndromeInterstitial deletion (q21.3q31)Globus sensationEpidermolysis bullosa dystrophica

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16Radiographic studies

To detect anatomic or structural abnormalities ( strictures, fistulas, masses, et al) standard upper GI contrast studies using barium suspension

To image of the coordination of movement of a bolus through the oropharynx and esophagus VSS (videofluoroscopic swallowing study)17Therapeutic approachCareful evaluation of potential causesImprove efficiency and safety of feedingsChanging textures, bottle/utensils, alignment of the head, neck and bodyEnteral feeding by nasogastric or gastrostomyImprove feeding skills18FEEDING PROBLEM 19ImplicationEXCESS NUTRITIONFEEDING PROBLEMDEFICIENCYPRIMARYSECONDARYTISSUE DEPLETIONBIOCHEMICAL LESIONCLINICAL SIGNS20EPIDEMIOLOGYMild feeding problems: not always hungry/eating small amounts/picky eating/strong preferencesHealthy toddlers, early school age 25-40%21EpidemiologySerious feeding problems: All children 3-10%/Children developmental disability 33% (mental retardation, prematurity, organic dis)22DEFINISI

Samsudin : masalah makan adalah bila anak hanya mampu menghabiskan kurang dari 2/3 dari jumlah makanannya sehingga kebutuhan nutrien tidak terpenuhi.

Palmer : masalah makan adalah ketidak mampuan untuk makan atau penolakan terhadap makanan tertentu sebagai akibat disfungsi neuromotorik, lesi obstruktif, atau faktor psikososial yang mempengaruhi makan, atau kombinasi dua atau lebih penyebab tersebut.

23Definisi yang lainKekurangan dalam semua aspek mengkonsumsi makanan yang menyebabkan gizi kurang, pertumbuhan yang jelek, waktu makan yang menimbulkan stres baik untuk anak maupun yang momong24Most common feeding problems in young children (Kerwin 1999)Inappropriate mealtime behaviours (e.g., temper tantrums, throwing food)Lack of self-feedingFood selectivity (eating only a few foods)Failure to advance textures from puree to table foodFood refusal (not accepting any or only smell quantities of food)Oral sensorimotor immaturity or dysfunctionAspiration or swallowing problemsFrequent gagging or vomiting 25Angka KejadianLaporan GUAPCD adalah sbb :

Hanya mau makanan lumat/cair27.3%Kesulitan menghisap, mengunyah, menelan24.1%Kebiasaan makan yang aneh/ganjil 23.4%Tidak menyukai banyak macam makanan 11.1%Keterlambatan makan mandiri 8.0%Mealtime tantrums 6.1%

26Angka KejadianPenelitian anak prasekolah usia 4 6 tahun di Jakarta, kesulitan makan sebesar 33.6% 44.5% diantaranya menderita malnutrisi ringan-sedang79.2% telah berlangsung lebih dari 3 bulan.27Penyebab kesulitan makan (Samsudin)Faktor organikFaktor NutrisiFaktor psikologikFaktor psikiatrik28Faktor organikKelainan pada rongga mulutKelainan bagian lain saluran cernaKelainan organ tubuh lainPenyakit metabolik 29Faktor Nutrisi :

Bayi konsumer pasif

Anak konsumer semi pasif/ semi aktif

Pemenuhan kebutuhan nutrisi masih bergantung pada orang lain.Pada bayi & anak terjadi perubahan pola makan dari makanan bayi ke makanan dewasa, seringkali secara sinergis menimbulkan masalah makan yang dapat mengakibatkan terjadinya defisiensi nutrien dan malnutrisi, yang bisa menurunkan nafsu makan sehingga asupan makanan lebih berkurang lagi.30Faktor Psikologik :

Mekanisme beban sosiokultural serta aturan makan yang ketat/berlebihan

Sikap ibu yang obsesif dan memaksa akibat overproteksi

Respons infantil terhadap sikap ibu 31Faktor psikiatrikInfancy/early childhoodPicaRumination disorder32Infancy/early childhoodPersistent failure to eatFailure to thrive (> 1 month)No gastrointestinal/medical causeNo lack of food supplyBefore 6 years33PicaPersistence eating nonnutritive substances (> 2 months)Inappropriate for development levelNo part of culturally sanctioned practiceCan be during course of mental retardation, pervasive, developmental disorder, but needs independent attention34Rumination disorderRepeated regurgitation, rechewing food (> 1 month)No gastrointestinal/medical courseNot confined to the course of anourexia of bulimiaCan be during course of mental retardation, pervasive developmental disorder but need independent attention35Masalah makan tahun pertamaKurang makan, bayi gelisah, menangis dan BB kurang

Kelebihan makan baik kualitatif/kuantitatif

Regurgitasi dan muntah, 6 bln pertama wajar

Diare/tinja lembek. Tinja ASI lebih lembek

Konstipasi, bisa karena cairan/ makanan kurang

Kolik,biasa terjadi sampai usia 3 bulan36Faktor risiko terjadinya masalah makanBayi/anak dengan GERBayi kurang bulan dan berat lahir rendah terutama dg intubasi lamaBayi dg komplikasi pada masa neonatal mis intubasi lama yang mengakibatkan reflex muntah berlebihan, bahkan tidak bisa makan sama sekaliBayi dengan displasia brokopulmuner, CHD, nerologik dll 37Masalah makan masa anakKecepatan tumbuh rata - rata melambat

Nafsu makan bervariasi

Suka/ tidak suka makan cepat berubah

Lambung masih kecil

Anak tidak pernah membuat dirinya kelaparan

Anak tidak boleh dipaksa makan

Suplementasi vitamin/ mineral tak perlu38Tatalaksana masalah makanMencakup 3 aspek yaitu :

Identifikasi faktor penyebab

Evaluasi tentang dampak yang telah terjadi

Upaya perbaikan : a. nutrisi b. faktor penyebab 39Upaya yang dilakukan adalah :

Atasi faktor penyebab (organik, infeksi, psikologik, dll)

Atasi dampak yang telah terjadi (malnutrisi, defisiensi nutrien tertentu, dll)

Upaya nutrisi : perbaiki/ tingkatkan asupan makanan

Re-edukasi tentang perilaku makan

Fisioterapi bagi anak yang mengalami kesulitan mengunyah/ menelan 40Meningkatkan komposisi kalori pada formula bayiFormula disajikan dalam konsentrasi yang lebih tinggi yi dg air kurang dari yang dianjurkanTambahkan glukosa polimer 23 kcal/sendok teh, minyak jagung 8,4 kcal/ml 41Pada anak lebih dari 1 tahunGunakan formula tinggi kalori yi 1 kcal/mlTambahkan suplemen bubuk pada susu42BEGIN HEREAlways Hungry?2. Breastfed?3. Bottle fed or sore mouth?Go to Question 5Breast milk insufficient or sore mouthBottle nipple CLOGGED or too small or mouth soreCorrect the nipple problemSee above if mouth soreSYMPTOMSDIAGNOSISSELF - CAREYESNONONOYESYES4. Fall asleep after feel from breast or bottle?Common for younger infants,but must decrease as baby growsYES Mother drinks enough fluids If sores or white patches in babys mouth, see doctorSee doctor to check babys growth and weight gainNext Page43SYMPTOMSDIAGNOSISSELF - CARE5. Cry after Feeding? 6. Throwing up with forceful vomiting? YES7. Lot of gas and stomach discomfort? 8. Severe crying after meal? NONONONOGo to question 9NOPYLORIC STENOSISLACTOSE INTOLERANCECOLIC?Contact doctorSwitch to a non-cows-milk?See doctorNext PageYESYESYES44SYMPTOMSDIAGNOSISSELF - CARE9. Little interest in food Or slow weight gain? 10. Bowel movements loose/ Feel-smelling after the feedings NONOFor more information, please consult your doctor.If you think the problem is serious, call right awayDEVELOPMENTAL PROBLEM? Allergy or more severe intolerance(LACTOSE INTOL or CELIAC DIS) YESYESSee your doctor See your doctor NO45Preventing feeding problemsTeach to feed him self as early as possibleProvide with healthy choicesAllow experimentationAs long as your child is growing normally, probably little to worry aboutAvoid giving large amount which have little nutritional valueMeal time should be enjoyable and pleasant46Childhood Obesity47DefinitionsObesityExcessive deposition of adipose tissue

OverweightWeight in excess of the average for height lean body mass or adipose tissue or both48Clinical ManifestationsRound face, double chinIncreased truncal fat deposition GynecomastiaPendulous abdomen and white/purple striaeBuried penisTall for age & Early menarcheGenu valgum

49Clinical manifestations

50Clinical manifestations

51Anthropometric MeasurementBMI 95th percentile % Ideal Body Weight (IBW) 120%Triceps Skinfold 85th percentileFat distribution patterns (waist-hip-ratio)< 0.8 gynecoid type (feminine type)> 0.8 android type (masculine type) 52

53CausesPositive energy balance ( 95%)Excessive caloric intakeDecreased physical activityDecreased resting metabolic rateMedical causes ( 95th WeightmaintenanceComplications -Complications + : mild hypertension, insulin resistance, dyslipidemiaWeight loss63Recommended Treatment Algorithm7 years of age / olderBMI 85th 95thBMI95thComplications -Complications +Weight maintenanceWeight loss64Preventing Obesity: Tips for Parents

65Components of a Successful Weight Loss Plan

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THANKYOU67

PRIVATE Respect your child's appetite: children do not need to finish every bottle or meal.

Avoid pre-prepared and sugared foods when possible.

Limit the amount of high-calorie foods kept in the home.

Provide a healthy diet, with 30 percent or fewer calories derived from fat.

Provide ample fiber in the child's diet.

Skim milk may safely replace whole milk at 2 years of age.

Do not provide food for comfort or as a reward.

Do not offer sweets in exchange for a finished meal.

Limit amount of television viewing.

Encourage active play.

Establish regular family activities such as walks, ball games and other outdoor activities.

PRIVATE ComponentComment

Reasonable weight-loss goalInitially, 5 to 10 lb, or a rate of 1 to 4 lb per month.

Dietary managementProvide dietary prescription specifying total number of calories per day and recommended percentage of calories from fat, protein and carbohydrates.

Physical activityBegin according to child's fitness level, with ultimate goal of 20 to 30 minutes per day (in addition to any school activity).

Behavior modificationSelf-monitoring, nutritional education, stimulus control, modification of eating habits, physical activity, attitude change, reinforcements and rewards.

Family involvementReview family activity and television viewing patterns; involve parents in nutrition counseling.