There are many reasons that infants and children develop feeding problems. Many of these children have a history of prematurity, neurological dysfunction, respiratory issues, gastrointestinal dysfunction, and learned patterns of behavior as well as other issues. Research supports that a significant number of children have feeding difficulty related to their GI dysfunction.

 

• Hyman PE. (1994) Gastroesophageal reflux: one reason why baby won’t eat. J Pediatr. Dec;125(6 Pt 2):S103-9.

• Fishbein M¹, Branham C, Fraker C, Walbert L, Cox S, Scarborough D. (1993) The incidence of oropharyngeal dysphagia in infants with GERD-like symptoms. JPEN J Parenter Enteral Nutr. Sep;37(5):667-73. doi: 10.1177/0148607112460683. Epub 2012 Sep 18.

• Rommel N¹, De Meyer AM, Feenstra L, Veereman-Wauters G. (2003) The complexity of feeding problems in 700 infants and young children presenting to a tertiary care institution. J Pediatr Gastroenterol Nutr. Jul;37(1):75-84.

• Field D¹, Garland M, Williams K. 2003 Correlates of specific childhood feeding problems. J Paediatr Child Health. May-Jun;39(4):299-304.

Working closely with your child’s medical team or referring physician can improve their “gut comfort” which will improve their response to feeding therapy. It’s important for feeding therapists to recognize the effects of GI issues on our feeding patients.

The child’s response to therapy techniques will be better if the child feels better!

• improving variety and volume of intake

• ease and efficiency of eating

• comfort with eating

• desire to eat

• response to oral motor-sensory therapy

What types of GI disorders contribute to feeding disorders and how do they present?

 

Constipation:

Definition: “Delay or difficulty in defecation, present for 2 or more weeks, is a common pediatric problems encountered by both primary and specialized medical providers.”

From:

Evaluation and Treatment of Constipation in Infants and Children: Recommendations of the North American Society for Pediatric Gastroenterology, Hepatology and Nutrition

Presentation: Constipation can slow motility, cause pain or discomfort and can increase gastroesophageal reflux. Children may present with gas, bloating, crying with/after eating, complaints of stomach pain, poor appetite, volume limiting, grazing, picky eating, food refusal and aversive feeding behavior.

Therapist questions to ask: Ask caregivers about stooling including how often the child goes, ease of going (straining?), size of stool, consistency of stool (hard/soft, formed or soft).

Intervention: The goal is to achieve daily stooling to keep the digestive system moving. There are different strategies that may be used by the physician or nurse practitioner that may include a “clean out” if necessary to eliminate stool that is backed up as well as hydration, fiber, stool softeners, laxatives, and dietary changes.

 

Gastroesophageal Reflux Disease (GERD)

Definition: “GER is the passage of gastric contents into the esophagus with or without regurgitation and vomiting. GER is a normal physiologic process occurring several times per day in healthy infants, children, and adults. Most episodes of GER in healthy individuals last < 3minutes, occur in the postprandial period, and cause few or no symptoms. In contrast, GERD is present when the reflux of gastric contents causes troublesome symptoms and/or complications. Every effort was made to use these 2 terms strictly as defined.”

From:

Pediatric Gastroesophageal Reflux Clinical Practice Guidelines: Joint Recommendations of the North American Society for Pediatric Gastroenterology, Hepatology, and Nutrition

(NASPGHAN) and the European Society for Pediatric Gastroenterology, Hepatology, and Nutrition (ESPGHAN)

Presentation: GERD can cause eating to be painful and contribute to learned association between eating and discomfort. Children may present with a variety of symptoms:

• stomach/GI: vomiting (during or after meals, or possibly later), spitting up, audible regurgitation, reswallowing, burping, complaints of stomach pain, throat clearing

• eating: solid food dysphagia, food refusal, picky eating, volume limiting, grazing, texture refusal, gagging, oral hypersensitivity, irritability with meals, preference for drinking water, preference for eating standing up, arching, hyperextension, and aversive feeding behavior. Choking and gagging on food and liquids.

• ENT/pulmonary: chest or nasal congestion after eating or in the morning, reactive airway issues, pneumonia, hoarse vocal quality, otitis media
  

• other: irritability, poor sleeping, bad breath, poor weight gain, sweating, poor weight gain

Therapist questions to ask: Ask caregivers about hard and soft signs of reflux (mentioned above). Use your case history to identify GER issues versus other symptoms of constipation, EoE, and allergy/intolerance. Ask lots of questions.

Intervention: reflux management can include:

• formal evaluation with testing (common: upper GI x-ray, pH probe, gastric emptying test, endoscopy, manometry)

• behavioral modifications (swaddling, position changes, calming and soothing techniques)

• medical management (medicines for acid blockage, motility, pain, tube feeding)

• nutritional management (formula changes, volume and rate changes)

• surgical intervention (nissen fundoplication).

 

Eosinophilic Esophagitis (EoE)

Definition: is an allergic/immune condition that involves inflammation or swelling of the esophagus. In EoE, large numbers of white blood cells called eosinophils are found in the tissue of the esophagus.

From:

The American Academy of Allergy, Asthma & Immunology (AAAAI)

Eosinophilic Esophagitis Home

Presentation: may include poor weight gain (failure to thrive), refusal to eat, vomiting often occurring with meals, heartburn, difficulty swallowing (dysphagia), pain or discomfort with swallowing (odynophagia), food becoming lodged within the esophagus (food impaction), cough or chest, throat, or abdominal pain.

The symptoms of EoE vary with age.

• infants and toddlers: food or poor growth

• School-age children: abdominal pain, trouble swallowing or vomiting

• Teenagers and adults: difficulty swallowing, food impaction

Therapist questions to ask: Ask caregivers questions to tease out reflux issues vs. EoE. Ask about history of allergy including eczema, hives, rashes. Ask about parents and siblings history with eating. Poor improvement on reflux management may be an indication that EoE needs to be evaluated for (note: adequate GER management may involve trials on different medications).

Intervention: Diagnosis involves endoscopy and biopsy. Some centers will treat for GERD first and if the child does not show improvement then will scope (EGD) to assess for esophagitis including biopsy to identify EoE. Treatment many vary across institutions but often includes swallowed steroids to reduce inflammation, allergy testing, dietary changes to eliminate food triggers, and periodic endoscopy to assess improvement.

 

Gastroparesis:

Definition: a condition where the stomach contracts less often and less powerfully, causing food and liquids to stay in the stomach for a long time. Gastroparesis can be caused by viral infections, scar tissue, previous stomach surgery, some medications, neurologic problems, and endocrine problems including diabetes, adrenal problems, and thyroid disease. However, in as many as 60% of children with gastroparesis, the cause is not known.

From: Nationwide Children’s hospital
Presentation: Symptoms of gastroparesis can include volume limiting (feeling full after only a few bites), grazing, poor appetite, bloating, excessive burping or belching, nausea, vomiting, weight loss due to inability to eat, abdominal pain

Therapist questions to ask: Ask about feeding schedule and patterns. Children with slow emptying often graze, volume limit, or have poor appetite.

Intervention: May involve testing (upper GI x-ray, gastric emptying scan, endoscopy), medication (for reflux or motility, pain, nausea, constipation management), nutritional changes (predigested formulas, smaller meals more often, changes in rate and volume if tube fed).