Mehta P, Furuta GT, Brennan T, Henry ML, Maune NC, Sundaram SS, Menard-Katcher C, Atkins D, Takurukura F, Giffen S, Pan Z, Haas AM. Nutritional State and Feeding Behaviors of Children With Eosinophilic Esophagitis and Gastroesophageal Reflux Disease. J Pediatr Gastroenterol Nutr. 2018 Apr;66(4):603-608. doi: 10.1097/MPG.0000000000001741.
This study compares growth, nutrition, and feeding behaviors in children with GERD and EoE. Vitamin D intake was below the RDI in GERD subjects. EoE subjects’ intake was below RDI of Vitamin D and calcium. GERD and EoE groups both had normal intake of calories, carbohydrates, proteins, fats, and iron, and normal serum ferritin, prealbumin, parathyroid hormone, and Vitamin D. Behavioral Pediatric Feeding Assessment Scale problem and frequency scores were similar in GERD and EoE subjects but were higher than those of healthy controls. EoE subjects on food allergen restriction diets had significantly less feeding dysfunction than those on regular diets. As a selected group of children with uncomplicated GERD or EoE were without nutritional deficiencies but had maladaptive feeding, providing anticipatory guidance to minimize mealtime challenges, monitoring for improvement, or referring to a feeding therapist, may be beneficial. A trial of food allergen restriction may provide additional benefit for those with EoE.
Uygur O1, Yalaz M1, Can N1, Koroglu OA1, Kultursay N1.Preterm Infants May Better Tolerate Feeds at Temperatures Closer to Freshly Expressed Breast Milk: A Randomized Controlled Trial. Breastfeed Med. 2019 Feb 5. doi: 10.1089/bfm.2018.0142. [Epub ahead of print]
Feeding intolerance is one of the most frequent problems among preterm infants. These infants are fed with expressed breast milk or preterm formulas of which the temperature is not routinely measured. In this study, we aimed to examine the effects of feeds with warm milk versus room temperature milk in preterm infants. In total, 80 preterm infants (group 1 fed with milk at 22-24°C, n = 40; group 2 fed with milk at 32-34°C, n = 40) were prospectively included in the study. There was a slight decrease in gastric residual frequency in infants fed with breast milk in group 2. Apnea was significantly more frequent in group 1, and these infants needed more anti-reflux treatment. According to our results, warming enteral feeds close to body temperature are encouraging especially due to the decrease in gastric residual frequency, apnea of prematurity, and need for anti-reflux treatment. More studies may confirm the positive effect of warm enteral feeds on feeding tolerance in preterm infants.
Pavithran J1, Puthiyottil IV1, Narayan M1, Vidhyadharan S1, Menon JR1, Iyer S1. Observations from a pediatric dysphagia clinic: Characteristics of children at risk of aspiration pneumonia. Laryngoscope. 2018 Dec 24. doi: 10.1002/lary.27654. [Epub ahead of print]
The clinical variables that are predictive of aspiration pneumonia are not clear in the pediatric population. This study was conducted in order to identify the demographic, clinical, and radiological risk factors for the development of aspiration pneumonia in children referred to the dysphagia clinic. A retrospective analysis of medical records of 88 children referred to the dysphagia clinic who had undergone videofluroscopic swallow study (VFSS). Oropharyngeal dysphagia was found in 61.3% (54 of 88). Incidence of aspiration pneumonia was 39.8% (35 of 88). Respiratory symptoms such as cough, choking, excessive secretions, and pharyngeal dysmotility other than aspiration in VFSS were not predictors of pneumonia. Infants and children with laryngotracheal anomalies, demonstrable aspiration in VFSS, and major cardiac illness are at risk of presenting with aspiration pneumonia. Whether gastroesophageal reflux disease (GERD) or esophageal dysmotility are causative of aspiration in the rest of the population needs to be investigated by future prospective studies.
Park J1, Thoyre SM2, Pados BF1, Gregas M3. Symptoms of Feeding Problems in Preterm-born Children at 6 Months to 7 years Old. J Pediatr Gastroenterol Nutr. 2018 Dec 14. doi: 10.1097/MPG.0000000000002229. [Epub ahead of print]
Describe symptoms of feeding problems in children born very preterm (<32 weeks gestation) and moderate to late preterm (32-37 weeks gestation) compared to children born full-term; explore the contribution of medical risk factors to problematic feeding symptoms. Compared to children born full-term, both very preterm and moderate to late preterm born children had significantly higher scores on the PediEAT total scale and all four subscales. More severe symptoms were noted in very preterm children, particularly in the areas of Physiologic Symptoms and Selective/Restrictive Eating. Among preterm children, all 11 medical factors were found to be associated significantly with increased symptoms of feeding problems. Compared to children born full-term, preterm born children demonstrated greater symptoms of feeding problems regardless of their current age, suggesting children born preterm may require more careful monitoring of feeding throughout childhood.
Raol N1, Schrepfer T2, Hartnick C3. Aspiration and Dysphagia in the Neonatal Patient. Clin Perinatol. 2018 Dec;45(4):645-660. doi: 10.1016/j.clp.2018.07.005. Epub 2018 Sep 18.
Dysphagia and aspiration are commonly encountered problems in the neonatal population. It is often multifactorial in nature and management should be tailored to the individual patient. Multiple causes should be considered, including anatomic abnormalities, neurologic/developmental delay, cardiopulmonary disease/infection, and gastroesophageal reflux disease, in addition to those cases where a definitive reason may not be identified. Management should be multidisciplinary in nature and surgical intervention may be indicated in certain populations of patients. Here, we discuss the presentation, workup, and management of the neonatal patient with dysphagia and aspiration.
Lenfestey MW1, Neu J2. Gastrointestinal Development: Implications for Management of Preterm and Term Infants. Gastroenterol Clin North Am. 2018 Dec;47(4):773-791. doi: 10.1016/j.gtc.2018.07.005. Epub 2018 Sep 28.
The gastrointestinal (GI) system provides digestive, absorptive, neuroendocrine, and immunologic functions to support overall health. If normal development is interrupted, a variety of complications and disease can arise. This article explores normal development of the GI tract and specific clinical challenges pertinent to preterm and term infants. Specific topics include abnormal motility, gastroesophageal reflux, current feeding recommendations for preterm infants, effects of parenteral nutrition, and the relationship between the GI tract and the immune system.
Inage E, Furuta GT, Menard-Katcher C, Masterson JC. Eosinophilic esophagitis: pathophysiology and its clinical implications. Am J Physiol Gastrointest Liver Physiol. 2018 Nov 1;315(5):G879-G886. doi: 10.1152/ajpgi.00174.2018. Epub 2018 Sep 13.
Classically, eosinophilic esophagitis is an antigen-mediated chronic disease distinct from gastroesophageal reflux disease. It is characterized clinically by feeding dysfunction, dysphagia, and reflux-like symptoms. Histologically, eosinophilic esophagitis is identifiable by a dense epithelial eosinophilic infiltrate. Here, we review the clinicopathologic diagnostic criteria and our understanding of eosinophilic esophagitis as an allergic disease with genetic and immunological components. We present studies defining the importance of the epithelial barrier and the concept of barrier dysfunction as an initiating or perpetuating factor for this disease. We discuss the relationship between the symptoms of dysphagia and feeding dysfunction, our current knowledge of the underlying pathophysiologic mechanisms, and advances in clinical assessment of esophageal distensibility and narrowing in eosinophilic esophagitis patients. Finally, therapeutic implications relating to the advances that have led to our current understanding of the pathophysiology of eosinophilic esophagitis are explored.
Romano C, Dipasquale V, Gottrand F, Sullivan PB. Gastrointestinal and nutritional issues in children with neurological disability. Dev Med Child Neurol. 2018 Sep;60(9):892-896. doi: 10.1111/dmcn.13921. Epub 2018 May 27.
Neurological disability is often associated with feeding and gastrointestinal disorders leading to malnutrition and growth failure. Assessment of nutritional status represents the first step in the clinical evaluation of children with neurological disability. The European Society of Gastroenterology, Hepatology, and Nutrition (ESPGHAN) recently issued a consensus statement on gastrointestinal and nutritional management in children with neurological disability. Here we critically review and address implications of this consensus for clinical practice, including assessment and monitoring of nutritional status, definition of nutritional requirements, diagnosis and treatment of gastro-oesophageal reflux disease, and indications for and modalities of nutritional support. There is a strong evidence base supporting the ESPGHAN guidelines; their application is expected to lead to better management of this group of children. Assessment of nutritional status in children with neurological disability should include the evaluation of body composition. Standard polymeric formula via gastrostomy tube is an effective, long-term nutritional intervention. Tube feeding should be started early, before the development of malnutrition.
Salvatore S, Savino F, Singendonk M, Tabbers M, Benninga MA, Staiano A, Thickened infant formula: What to know. Vandenplas Y5. Nutrition. 2018 May;49:51-56. doi: 10.1016/j.nut.2017.10.010. Epub 2018 Feb 26.
The indications, properties, and efficacy of different thickening agents and thickened formulas on regurgitation and gastroesophageal reflux in infants were reviewed. PubMed and the Cochrane database were searched up to December 2016. Based on the literature review, thickened formulas reduce regurgitation, may improve reflux-associated symptoms, and increase weight gain. However, clinical efficacy is related to the characteristics of the formula and of the infant. Commercial thickened formulas are preferred over the supplementation of standard formulas with thickener because of the better viscosity, digestibility, and nutritional balance. Rice and corn starch, carob bean gum, and soy bean polysaccharides are available as thickening agents. Hydrolyzed formulas have recently shown promising additional benefit. Thickened formulas reduce the frequency and severity of regurgitation and are indicated in formula-fed infants with persisting symptoms despite reassurance and appropriate feeding volume intake.
Vetter-Laracy S, Osona B, Roca A, Peña-Zarza JA, Gil JA, Figuerola J. Neonatal swallowing assessment using fiberoptic endoscopic evaluation of swallowing (FEES). Pediatr Pulmonol. 2018 Apr;53(4):437-442. doi: 10.1002/ppul.23946. Epub 2018 Jan 22.
Swallowing disorders which lead to aspiration are common in premature infants with a postmenstrual age (PMA) of >36 weeks. Aspiration is often silent and the unique symptom is desaturation during feeding. The aim of this study was 1) to determine the number of prematures with desaturations during feeding due to aspiration, using Fiberoptic Endoscopic Evaluation of Swallowing (FEES); 2) to relate clinical factors and FEES findings to aspiration; and 3) to describe type and efficacy of suggested treatments.A total of 44 (71%) infants were diagnosed with aspiration and/or penetration. No relation was found to demographic or clinical data. The accumulation of saliva and residues post-swallowing were related to aspiration (P < 0.01). In 77.3% of the infants, use of a thickener seemed to reduce aspiration during FEES and was suggested as a treatment. 13.6% of infants received anti-reflux treatment after FEES and 9.1% required gastrostomy.Aspiration is very frequent in premature infants who present desaturations during feeding and FEES is a useful method for diagnosing and suggesting treatments.
Yang HR1. How to approach feeding difficulties in young children. Korean J Pediatr. 2017 Dec;60(12):379-384. doi: 10.3345/kjp.2017.60.12.379. Epub 2017 Dec 22.
Feeding is an interaction between a child and caregiver, and feeding difficulty is an umbrella term encompassing all feeding problems, regardless of etiology, severity, or consequences, while feeding disorder refers to an inability or refusal to eat sufficient quantities or variety of food to maintain adequate nutritional status, leading to substantial consequences, including malnutrition, impaired growth, and possible neurocognitive dysfunction. There are 6 representative feeding disorder subtypes in young children: infantile anorexia, sensory food aversion, reciprocity, posttraumatic type, state regulation, and feeding disorders associated with concurrent medical conditions. Most feeding difficulties are nonorganic and without any underlying medical condition, but organic causes should also be excluded from the beginning, through thorough history taking and physical examination, based on red-flag symptoms and signs. Age-appropriate feeding principles may support effective treatment of feeding difficulties in practice, and systematic approaches for feeding difficulties in young children, based on each subtype, may be beneficial
Shmaya Y, Eilat-Adar S, Leitner Y, Reif S, Gabis LV. Meal time behavior difficulties but not nutritional deficiencies correlate with sensory processing in children wit16h autism spectrum disorder. Res Dev Disabil. 2017 Jul;66:27-33. doi: 10.1016/j.ridd.2017.05.004. Epub 2017 Jun 2.
Food aversion and nutritional difficulties are common in children with autism spectrum disorder.To compare meal time behavior of children with autism to their typically developing siblings and to typical controls and to examine if sensory profiles can predict meal time behavior or nutritional deficiencies in the autism group.
Shaker M, Venter C. The ins and outs of managing avoidance diets for food allergies. Curr Opin Pediatr. 2016 Aug;28(4):567-72. doi: 10.1097/MOP.0000000000000382.
Food allergic reactions have become more prevalent and management of food allergies requires dietary avoidance of triggers that may place children at nutritional risk. Immunoglobulin E and non-immunoglobulin E-mediated food allergies lead to dietary avoidance. Although some children outgrow food allergies or become tolerant to cooked/baked versions of the allergen, many do not. Multiple food avoidance increases the risk for inadequate nutrient intake, including protein, calcium, vitamin D, and others. Multidisciplinary management of patients requires careful attention to growth, particularly height, and nutrition.Although attention to accurate diagnosis of food allergy is key, understanding nutritional risks of children with food allergies can lead to opportunities to address potential deficiencies resulting from food allergen avoidance.
Katzman DK, Norris ML, Zucker N. Avoidant restrictive food intake disorder: First do no harm. Int J Eat Disord. 2019 Jan 24. doi: 10.1002/eat.23021. [Epub ahead of print]
This opinion piece offers some considerations, both medical and psychological, for the use of nasogastric tube (NGT) feedings in the treatment of avoidant restrictive food intake disorder (ARFID) in children and adolescents. Although there is empirical support for the use of NGT feedings in the treatment of anorexia nervosa, this evidence base does not exist for the treatment of ARFID. As such, there is need to delineate pragmatic considerations in the use of this procedure. Issues of medical necessity notwithstanding, we advise that the use of this procedure be considered more cautiously due to the oral sensitivities inherent in many individuals with ARFID and the potential psychological consequences. These sensitivities may make the experience of NGT feedings particularly aversive, with the potential of creating iatrogenic conditioned food aversions. This article encourages clinicians to give careful thought and attention when considering NGT feedings in children and adolescents with ARFID.
Craig F, De Giacomo A, Operto FF, Margari M2, Trabacca A, Margari L. Association between feeding/mealtime behavior problems and internalizing/externalizing problems in autism spectrum disorder (ASD), other neurodevelopmental disorders (NDDs) and typically developing children. Minerva Pediatr. 2019 Feb 13. doi: 10.23736/S0026-4946.19.05371-4. [Epub ahead of print]
The aim of current study was to examine the nature and prevalence of feeding problems and mealtime behavior problems in children with ASD comparing to children with other neurodevelopmental disorders (NNDs) and TD children. We also investigated the impact of intelligence quotient (IQ) and/or emotional and behavioral problems on feeding and mealtime behavior problems. Children with ASD showed more feeding and mealtime behavior problems including food refusal and limited variety of foods compared with NDDs and TD children. ASD group showed more problems in mealtime behavior and parent behaviors compared to TD group. These results suggest that routine screening for feeding and mealtime behavior problems among children with ASD is necessary to prevent dietary inadequacies that may be associated with eating habits.
Schuster RC, Szpak M, Klein E, Sklar K, Dickin KL. “I try, I do”: Child feeding practices of motivated, low-income parents reflect trade-offs between psychosocial- and nutrition-oriented goals. Appetite. 2019 Jan 12;136:114-123. doi: 10.1016/j.appet.2019.01.005. [Epub ahead of print]
Although there is increased focus on behavior change programs targeting parents to promote healthy child feeding, success of these programs has been limited. To close this gap, we sought to understand parents’ goals for child feeding and their motivations, abilities, and contextual environment that challenged or enabled goal achievement, with a focus on parents’ own childhood food experiences. Low-income parents articulated and were clearly motivated to achieve both nutrition- and psychosocial-oriented goals. Salient psychosocial goals (e.g., family meals to promote family relationships, help child feel secure), often led to different child feeding practices than indicated by parents’ nutrition-oriented child feeding goals (e.g., nutritious diet, healthful relationship with food). Sometimes these psychosocial goals were in conflict with the nutrition-oriented goals; for example, some parents gave into child food preferences to avoid conflict or hesitated to introduce changes in diets of overweight children to preserve child self-esteem. Prominent contextual barriers included child preferences, life disruptions, and the inflexible time and financial restrictions of poverty. Parents exhibited awareness and motivation to achieve healthy eating goals but success was often thwarted by the salience of psychosocial goals that often motivated less-healthy practices. Thus, behavior change programs should acknowledge the value and relevance of both types of goals and help parents develop strategies to address the tensions between them.