prevalence of feeding difficulties objectives · pdf filemy baby is not eating ... lack of...

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Colin Rudolph, MD, PhD

Vice-President, Global Medical Affairs & Chief Medical Officer Mead Johnson Nutrition

Conflict of Interest

• Employed by Mead Johnson Nutrition

• Board Member- POPSICLE

25% - 45% in children with normal development

33%-80% in children with developmental delays or chronic disease

Prevalence of Feeding Difficulties

To provide guidance on:

When to worry

When to refer

Where to refer

an infant or toddler with concerns about feeding

Objectives

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My baby is not eating…

When did the problem start?

Acute onset in previously well

infant/child

Neurologic

Infection

Cardio-pulmonary

Metabolic

Other

Chronic problem

Subdural Hematoma

Meningitis

Cerebrovascular Event

Botulinum Toxin

Myasthenia Gravis

Guillain-Barre Syndrome

Arnold Chiari Malformation

Increased ICP

Vitamin A toxicity

Drug Tardive dyskinesia

Urinary Tract Infection

Bacteremia/Sepsis

Meningitis

Otitis Media

Hepatitis

Gastroenteritis

Pancreatitis

Esophagitis- Candida/Herpes

Neurologic Infection

Congestive Heart Failure

Pneumonia

Epiglotitis

Uremia

Hypercalcemia

Hypocalcemia

Hypomagnesiemia

Toxins

Cardio-pulmonary

Metabolic

Other

Foreign Body

Evaluation for Acute Changes in Feeding

• History and Physical Exam

– Is this infant sick? Directed laboratory exam

• Head MRI/CT?

• Sepsis work-up?

• Metabolic panel?

• No clear pathology

– Rule out Foreign Body

• UGI (water-soluble contrast)

• Upper endoscopy

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My baby is not eating…

When did the problem start?

Acute onset in previously well

infant/child

Neurologic

Infection

Cardio-pulmonary

Metabolic

Other

Chronic problem

Presentations of Feeding Disorders

Inadequate growth due to inadequate intake

Inefficient feeding (prolonged time for each meal)

Delayed progression of normal feeding skills

(intake of pureed, chewing, etc)

Recurrent respiratory disease

Causes of Inadequate or Inefficient Intake

Decreased appetite drive

Disordered parent-child interaction

Inadequate suck/swallowing skills

Learned aversion due to pain or discomfort following feeds

Popsicle Queries

• Does your baby/child let you know when he is

hungry?

• Do you think your baby/child eats enough?

• Does your baby usually like to be fed?

• Do you enjoy feeding time with your baby/child?

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ARC

POMC/

CART

AgRP/

NPY

Leptin

Appetite Appetite

Inhibition Stimulation

Environmental factors

(neglect, maternal depression) - +

Inflammatory

mediators

(TNFα)

-

Vagus -

Visceral

Pain

Medications

- +

Ghrelin +

CCK

Insulin

PYY

- +

Parent-Child Interactions

• Providing Food

• Positive Reinforcement

• Modeling Behaviors

• Is poor growth due to

“neglect” or “organic

factors”?

-Temperment

-Skills -Temperment

-Skills

Disordered parent-child interactions

“Feeding Traps”

Reinforced negative behaviors

Force feeding, food hunts, short-order cooking

Failure to set appropriate limits

grazing, multiple feeding environments, TV

Not attending to positive behaviors

ignoring child’s cues

Projecting parental food preferences

I don’t like it, therefore you won’t like it

“Infantile Anorexia”

• Infants characterized by: – refusal to eat adequate amounts of food for at least 1 month

– onset of the food refusal under 3 years of age, most commonly during the

transition to spoon- and self-feeding

– failure to communicate hunger signals, lack of interest in food, but strong

interest in exploration and/or interaction with caregivers

– significant growth deficiency

– no evidence that the food refusal followed a traumatic event or is associated

with an underlying medical illness.

Chatoor I et al, Pediatrics 2004;113:e440

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Consequences of “Infantile Anorexia”

Compared to

• Picky eaters – Persistent refusal to eat all types of food or certain

types of food to cause concern to parents

– No growth deficiency

• Healthy eaters – No food refusal or concerns

– No growth deficiency



• Although toddlers with infantile anorexia exhibit growth

deficiency, they performed within the normal range of

cognitive development

• The MDI scores of toddlers with infantile anorexia and that

of the normal weight picky eaters were, respectively, 11 and

14 points below that of the healthy eaters without feeding

problems

• Higher socio-economic status, maternal education, and

feeding reciprocity were related to higher MDI scores

• Higher levels of conflict and control struggles during feeding

interactions and maternal intrusiveness during play

interactions were related to lower MDI scores



• Causality of this disorder remains unclear – Underlying cognitive issues or mild skill deficits may make establishment of

normal feeding relationship more problematic

– Parental worry over the effect of poor weight gain on development may lead

to coercive feeding which intensifies parent-child conflicts and impacts

development


-Temperment

-Skills

-Cognition

-Temperment

-Skills

-Cognition

Wolfson Screening Criteria for Behavioral

Causes of Infant Feeding Refusal

• Evaluated infant and parent behavior patterns or symptoms to

distinguish organic or behavioral causes or infant feeding refusal

– Infantile feeding disorder- Symptoms before age 2, persistent food aversion longer

than 1 month, and a response to behavioral intervention (n=83)

– Organic group (diagnosis of GERD, Milk Allergy, Nutritional FTT) responded to

medical or nutritional therapy alone (n=68)

• Poor intake, poor weight gain, or vomiting did not discriminate between

“organic” and “nonorganic” causes.

• Factors indicating the presence of a behavioral cause included:

– food refusal (p<0.0001)

– food fixation (p<0.0001)

– abnormal parental feeding practices (p<0.0001)

– onset after a specific trigger (p<0.0001)

– presence of anticipatory gagging (p<0.0001)

Levy Y et al, J Pediatr Gastroenterol Nutr 2009:48-355-62

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More Popsicle Queries

• Do you often have to do anything special to help your

baby eat?

• Does your baby/child do any of the following when you

feed him?

– Refuses to eat

– Does not swallow

– Turns away from the breast/bottle/cup

– Gags, coughs, chokes

– Arches his body

– Cries/Tantrums

– Vomits after eating

Evaluation and Management of Possible

Behavioral Issues Impacting Feeding


– Query for underlying pathology since behavioral

issues may result from physical disorders

– Query for potential signs of behavioral factors

especially “anticipatory gagging”, onset after a

trigger

• No clear pathology

– Consider referral to psychologist/feeding team with

expertise in evaluating and treating behavioral

disorders.

– If not progressing with behavioral treatment,

reconsider other contributing factors

Evaluation and Management of Possible

Behavioral Issues Impacting Feeding

• Nutritional intervention (ng/gt) may be

advisable but there are no uniformly agreed

upon criteria (Wght for Height >2SD below

normal?)

• Often infants stop eating when supplemental

nutrition is provided and their hunger drive is

suppressed

• Follow-up on FTT infants shows they remain

small, and no study shows that intervention

alters long-term outcomes.

Popsicle Queries

• Skills limit the ability to ingest normal amounts

– Do you feed your baby more often than every two

hours?

– Do you think your baby eats enough?

– How long does it usually take to feed your baby?

• <5min; 5 to 30 min; >30 min

– Does your baby

• Turn blue, become limp or worn out before the end of

feedings, falls asleep before the end of feeing, make loud

breathing noises during/after feeding, etc….

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Causes of inadequate suck/swallow skills

Anatomic disorders

Poor coordination of suck-swallow-breathing sequence

Neurologic disorders

Oropharyngeal

Generalized

Inadequate experience during critical sensitive periods of development

Infant Adult

Mechanics

of infant

sucking Pistonlike movement of tongue and jaw produce negative

pressure

Nipple seal with lips and facial muscles


Anatomic disorders



Oropharyngeal

Generalized


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Examples of anatomic disorders

• Cleft lip and palate

• Mass such as Lingual tonsil

• Laryngeal cleft

• Tracheo-esophageal fistula

• Esophageal stenosis, web or ring

• Choanal atresia or stenosis


Anatomic disorders



Oropharyngeal

Generalized


Milk flow

Expired CO2

Relationship of breathing and swallowing

in normal newborn infant

Infant coordinates suck-swallow-breath sequence

Respiration ceases during swallowing

In children with tachypnea (due to pulmonary, cardiac or neurologic disease) coordination is often poor


Anatomic disorders



Oropharyngeal

Generalized


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Popsicle Queries

• Does your baby usually turn to take the breast or

bottle into the mouth? (rooting reflex)

• Do you usually hold your baby in your arms when you

feed him? (tone)

• Does your baby (after 9mo) sit up to eat?

• Does your child (over 15mo) pick up food with his

fingers?

• How long does it usually take to feed your baby?

• Do you often have to do anything special to help your

baby eat?

Neuromuscular disorders

Generalized

Myasthenia gravis

Muscular dystrophy

Congenital myopathies

Cerebral palsy

Polymyositis or Dermatoyositis

Infant botulism

Guillan-Barre

Oropharyngeal

Arnold-Chiari Malformation

Bulbar atresia

Ocular-Pharyngeal Dystrophy

Brain Stem Tumor

Drug-Tardive Dyskinesia

Moebius Syndrome

Cricopharyngeal achalasia

Other disorders associated with feeding

difficulties

Familial Dysautonomia

Prader-Willi

Hypothyroidism

Trisomy 18 & 21

Velocardiofacial syndrome

Rett syndrome

Evaluation for Neurologic Issues

Impacting on Feeding


– h/o or suspicion of seizures?

– Family history of developmental delays?

– Prematurity?

– Careful neurologic exam

• Consider speech pathology and/or

physical/occupational therapy referral

• Consider video-fluoroscopic swallowing

study

• Consider genetic/metabolic studies

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Inadequate oropharyngeal skills

Anatomic disorders


Neurologic disorders Oropharyngeal

Generalized


Critical Sensitive Periods for Development

The infant nervous system is programmed to acquire certain skills at specific times in development.

Skill acquisition at these “critical sensitive periods” is relatively effortless

Later skill acquisition is difficult

Infant Behavior and Learning

1937- Lorenz observed that young chicks “imprint” on the first brightly colored object they encounter and attempt to maintain proximity to that object.

Imprinting would not occur after 25 hours of age

• Deprivation of visual input at critical periods results in a lack of development of associated visual cortex

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Mechanical Skill Acquisition

Experiment: Post-weaning mice fed a soft-powdered diet versus the usual pelleted-hard diet

Result: Fewer synapses developed in the hippocampus and parietal cortex.

As adults, the spatial learning ability (tested in 8 arm radial maze) of the soft-diet fed group was reduced compared to the pelleted-hard diet fed group

Yamamoto & Hirayama, Brain Res 2001;902:255

Causes of Inadequate or Inefficient Intake

Decreased appetite drive

Disordered parent-child interaction

Inadequate suck/swallowing skills

Learned aversion due to pain or discomfort following feeds

Learned Aversions Learned aversion due to pain or

discomfort following feeding

Pharyngo-esophageal

Inflammation

Candida

Herpes

Crohn’s

Behcet’s

Caustic Burns

Reflux esophagitis

Eosinophilic esophagitis

Other gastrointestinal disorders

Achalasia

Foreign Body

Esophageal stricture

Peptic ulcer disease

Biliary tract disease

Dumping syndrome

Gastroparesis

Severe constipation

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Presentations of Pediatric Feeding Disorders


Prolonged time for feedings (but provides adequate calories for growth)


(textures, variety, etc)


Popsicle Queries

• How long does it take to feed your baby/child?

– <5min; 5-30min; >30 min (20-30 min is normal)

• Do you feed your baby more than every two hours?

• Do you often feed your child during the night?

• Do you think your baby/child eats enough?

• Does your baby often do any of the following when you

feed him?

– Refuses to eat, does not swallow, becomes limp or

worn out before the end of feeding

Prolonged time for feedings

Can be due to:

Inefficient feeding, inadequate skills

Behavioral feeding disorder

Parental-Child interaction issues

Underlying disorder causing discomfort

Evaluation of Prolonged Feeding Time



physical/occupational therapy referral (can

the infant/child eat more efficiently?)

• If skills appear appropriate, consider

behavioral therapy and/or multidisciplinary

feeding team referral

• May consider further diagnostic evaluation

including VSS and/or upper endoscopy

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Popsicle Queries

• Age specific questions:

– 9-11mo

• Is giving your baby new solid foods going well

• Does your baby eat a variety of foods?

• Does your baby usually like having things in or near his mouth?

– 12-14mo

• Does your child eat a variety of food textures?

– 15mo and older

• Most of the time, do you give your child the same food the family

eats?

• Does your child pick up food with his fingers?

• Does your child drink from a cup?

Evaluation of Delayed Progression of

Textures



occupational therapy referral

• If skills appear appropriate consider

anatomic abnormality (esophageal ring,

web) Esophagram?

• Consider Eosinophilic Esophagitis

especially if child otherwise normal or FH

of atopy Upper endoscopy with biopsy

Management strategies when intake is

inadequate include:

Nutrition guidelines

Amounts & types of food

Alterations of food Texture, Taste,

Caloric density Changes in route of

nutrition/hydration NG, Gastrostomy,

GJ

Changes in feeding schedule & pacing

Utensil changes

Position & posture changes

Oral sensorimotor program with food

Nonnutritive oral sensorimotor program

Behavioral Therapies

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Popsicle Queries

• Does your baby do any of the following

when you feed him?

– choke, cough, gag

– make loud breathing noises

– turn blue

• No questions on recurrent pneumonia or

asthma- these are for the MD

Recurrent

Pneumonia

• Defined as 2 pneumonia episodes in 1 yr or 3 episodes overall

• Retrospective review of 2,952

pneumonia admissions over 10 yrs

• 238 were recurrent pneumonia

Owayed AF et al, Arch Pediatr Adolesc Med, 2000

Evaluation of Infant or Child with Recurrent

Pneumonia

Aspiration with swallow

48% Respiratory tract anomalies

8%

Immune disorder 14% GER 6%

Cong Heart disease 9% Unknown 8%

Asthma 8%

Owayed AF et al, Arch Pediatr Adolesc Med, 2000

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Evaluation of Recurrent Respiratory Disease


• Rule out anatomic disorders (tracheo-

esophageal fistula or laryngeal cleft)

• Evaluate for aspiration (VSS, FEES,

Bronchoscopy with lavage, Chest CT?)

• Consider trial of nasogastric or nasojejunal

feeds

Conclusions

Feeding disorders present in various manners and determining the underlying cause can be difficult

A parent questionnaire screens for abnormalities but often does not provide help in identifying the underlying cause of feeding difficulties

Behavioral, anatomic, and physiologic disorders often coexist, complicating diagnosis and management such that a interdisciplinary approach to diagnosis and management is helpful

prevalence of feeding difficulties objectives · pdf filemy baby is not eating ... lack of...

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