Feeding Across the Lifespan Conference 7/14-15/17

Feeding Across the Lifespan

Nationwide Children’s Hospital, Columbus, OH

My colleague and I attended a wonderful conference last weekend in Columbus, OH hosted by Nationwide Children’s Hospital. There was so much information from the medical, nutritional and therapeutic perspectives. I regret I couldn’t summarize everyone’s presentation but here are some of the highlights.

Pre conference Business Meeting for The Pediatric Feeding Consortium

The day before the conference, The Pediatric Feeding Consortium held its  bi-yearly business meeting. This is a multi-disciplinary group of professionals involved in the care of children with feeding disorders working on becoming an International professional organization. I highly recommend joining this group.

• To Join: email Sherri Cohen, MD at COHENS@email.chop.edu. Please email Sherri your name, your profession, and where you work.
• Next meeting  will be January 2018 in  Orange County, CA hosted by the feeding team from Children’s Hospital Orange County

Highlights from the conference:

Relationships among preterm infant feeding and neurobehavioral outcomes Presenter: Rita Pickler, PhD, RN, FAAN 

Discussed feeding readiness with preterm infants.

• A cochrane  review in 2016 on responsiveness to feeding showed a small weight gain associated with infant driven feeding but longer time to get to full oral feeds. Results showed low data support so there were no recommendations from the review.
• Cochrane review on oral stim reported poor quality studies and again no recommendations made.

She discussed feeding readiness and the importance of maturity and experience .

• Maturity and feeding experience interacted to affect oral feeding performance; maturity depends on experience and experience depends on maturity.
• how little opportunity some parents have to orally feed prior to taking a baby home.
• The single biggest predictor of out come is length of stay in NICU. The longer the stay, the worse the outcome.
• cue based feeding- should be done either all the time or not at all. Doesn’t make sense to only try 2x/day from neuro-developmental perspective.

Dr. Pickler discussed a study that looked at the tactile component of feeding. Nursing held the babies for  every feeding and gave infant opportunity to feed, if the baby did not feed, they were held for gavage and oral feedings.

Results showed:

• babies with most tactile /hands on w/gavage- achieved full oral feeds sooner even though intervention started with holding through gavage feeding. power of touch.
• how this effects oral development. improved alertness and orientation , improved cognitive score on bailey scale.
• Feeding is neurologically driven. MRI: more connectivity in brain seen in infants with patterned feeding experience.
• mouse studies- never eaten, no connectivity in the brain.

Unique Considerations when Treating Feeding Disorders in School-age Children with Autism Spectrum Disorder
Presenter: Jon Wilkins, PhD

• Rate of feeding difficulties (broadly defined): 70-90% across different studies (Volkert & Vaz, 2010)
• common: food selectivity, restrictive eating, disruptive, overeating

Treatment barriers:

• Rigid behavior, need for sameness, sensory differences, low motivation, poor hunger cues, anxiety, GI issue

Treatment strategies: ABA as applied to feeding

• Many children w/ASD are visual learners. Provide instructional support- with a visual schedule, using a social story (3rd person narrative script) to increase expectations and reward
• Provide gradual exposure with non preferred foods –  sets child up for success with small achievable goals, create exposure to food
• Behavioral contract – establish rules with meal time, parent , child, therapist sign
• Implement structure- Scheduling meals and snacks and  length of meals.

Alan Silverman, PH. D, Children’s Hospital of Wisconsin Feeding Program: Rapid tube weaning program

Inpatient Program criteria:

• The child is unable to grow without tube and has failed standard treatment  care
• Child has been cleared by therapist for oral/swallow skills
• Program is not  for advancing oral skills but for tube weaning

Program: “Nutrition before oral feeding”

• Length of stay is 10-14 day where medical team including RD carefully tracts nutritional parameter and Supplemental feedings are stopped to promote hunger .
• Psychologists feed 3 meals per day, psychologist, 7 days per week
• Strict measuring  of foods and liquids
• RD monitors calorie intake, weight, hydration
• weight/height admission, every morning. Child can’t lose more than 5% of body weight
• Established labs, nutrition and calorie goals – urine specific gravities for dehydration, blood glucose, ketones. fluid given if needed.
• Dr. Silverman stressed this program is done with inpatient admission only.
• follow children after finishing program, don’t take tube out until child can grow without tube.

Risks for appetite manipulation

• dehydration
• acute malnutrition
• acute anorexia secondary to ketoacidosis,
• acute hypoglycemia

• some children need a g-tube to grow and thrive. sometimes with better nutrition, hunger improves.
• Periactin- can be good for gastric accommodation and vomiting. safe to use above 1, under 1 need team eval first to determine if to can be successful

Cognitive Behavioral Feeding Therapy for Older Children and Adolescents Presenter: Parker Huston, PhD
Adapting Behavioral Strategies to Complement Feeding Therapy
Presenter: Elizabeth Halpin, MHS, OTR/L & Rob Dempster, PhD 

Cognitive behavioral treatment for older children and adolescents

• in cognitive theory: perception is more important than reality.
• behavior- goal long term change, coping skills to treat negative pattern

Use of motivational interviewing- move child from ambivalence state to make positive decision

Whats in this for me? Therapist help to  identify goals

• what would be in it for you if you changed your eating behavior
• affirm and support change
• reflecting on past experience then summarize
• change is a process

ARFID-not body image related, lack of interest in eating, in conjunction with sensory eating issues.

• eating is a behavior, impacted by mood and cognition, negative feedback loop, leads to avoidance
• During food trials- use tracking sheets, this system is helpful for the older child.
• different brands of the same food counts as different foods
• branching techniques- work on different forms of preferred foods, new brands
• teaching coping strategies that will serve them in the long term

Behavioral strategies

• Establish clear goals and expectations
• make goals small and build on progress
• Use of a timer for clear end to session
• can rotate food around a plate
• keep going in face of negative behaviors – behaviors at 1 meal does not mean you are doing the wrong thing
• work  with family to figure out plan to carry over at home
• have family practice in session
• when/how often practice, parents should describe plan.
• family needs to have some successes
• family/child needs sort term and long term goal

consult with Psychology- help with difficult behaviors, intense general anxiety/oppositional behavior

Transitioning Feeding Treatment from Children to Young Adults
Presenters: Marcia Cox, MHS, OTR/L, SCFES & Dennis Cleary, MS, OTD, OTR/L 

• Discussed transitioning treatment into adulthood
• staff training in residential facilities
• Risk of choking in this population

Approaches to Feeding Difficulties in Infants in the NICU
Presenter: Ish Gulati, MD

Dr. Gulati discussed medical, nutritional, and therapeutic strategies used in feeding assessment and treatment. He described Nationwide children’s Hospital’s approach to GI dysmotility and GERD leading to Dysphagia

• poor gastro-duodenal coordination can delay transit
• GERD like symptoms can be non specific
• Swallowing disturbances can be due to heterogeneous causes
• 37-40% of infants and children that received feeding difficulty assessment were born prematurely. Lefton-Greif. Phys Med Rehabil Clin N Am 2008
• 3.5 % of all newborns had feeding problems, 3 -fold more if born < 37 weeks, and 7-fold more if born VLBW (very low birth weight). Motion et al. Ambulatory Child Health 2001
• Targeted approach: early oral stimulation, cue based feeding
• Diagnosis and management approach includes:

• Gastro-Intestinal (Poor motility-Residuals)
• Gastro-esophageal junction (GERD)
• Oro-Pharyngo-Esophageal (Dysphagia)