Research review

Tharner, A., Jansen, P., Kiefte-de Jong, J., Moll, H., Hofman, A., Jaddoe, V. , Tiemeier, H., and Franco, O. Bidirectional Associations between Fussy Eating and Functional Constipation in Preschool Children, J Pediatr 2015;166:91-6

picky eating affects constipation through poor diet quality, it also can be hypothesized that constipation and the related abdominal pain are involved in the development of fussy eating.

Up to 50% of preschool children are “fussy” or “picky” eaters
Fussy eaters consume less green vegetables and fruits, foods high in dietary fibers and vitamins and eat more unhealthy foods with high sugar, salt, and/or fat content (ready-to- eat-meals and snacks).
This poor eating pattern can lead to weight gain and essential nutrient deficiencies.

Childhood constipation

affects up to 30% of children in Western countries.
affects the quality of life of affected children/families (school attendance, peer group activities, and friendships.)
In the US, the annual cost of treatment of constipation in the general pediatric population is estimated at $3.9 billion.
The vast majority (90%-95%) of constipation etiology of functional likely multifactorial, involving genetic influences, behavioral factors such as physical activity, and dietary factors.

Taylor, C., Wernimont S., Northstone, K, Emmett, P. Picky/fussy eating in children: Review of definitions, assessment, prevalence and dietary intakes Appetite 95 (2015) 349e359

Picky eating and food neophobia (reluctance to eat or avoidance of new foods) can lead to concern about the nutrient composition of some children’s diets
The development of picky eating may be affected by multiple (pressure to eat, personality, and parental feeding styles)
Picky eating appears to affect girls and boys equally
There is no single widely accepted definition of picky eating, although most definitions include an element of restricted intake of familiar foods
Several studies have identified associations of picky eating with intakes of particular food groups. A strong association was found between the mother’s liked and disliked food items and those of the child, as well as the frequency of consumption of those items

Edwards, S., Davis, A., Bruce, A., Mousa, H., Lyman, B., Cocjin, J., Dean, K., MS, Ernst, L., Almadhoun, O., Hyman, P. Caring for Tube-Fed Children: A Review of Management, Tube Weaning, and Emotional Considerations. Journal of Parenteral and Enteral Nutrition Volume XX Number X Month 201X 1–7

Enteral feeding (delivering nutrition through a tube or other device) is necessary when children are unable or unwilling to ingest sufficient nutrition to maintain adequate body composition and growth, but there is no problem with digestion.
Approximately 4 in 100,000 children require enteral feeding

The multidisciplinary approach is recommended (pediatric gastroenterologist, psychologist, dietitian, occupational therapist, and speech-language pathologist)
Feeding treatment programs have used both bolus and continuous feeding schedules successfully.
Before tube weaning: many behavioral and physical characteristics must be present (ability of the child to sit at a table, accept a bite, and adhere to the concept of structured mealtimes)
Diagnosis and treatment of underlying chronic illness are an important part of assessing a child for readiness to wean off of tube feedings.
There may be a sensitive period of oral-motor feeding skill acquisition, during which it is very important that children are exposed to tasks requiring these skills. Age and degree of exposure to oral feeding experiences may affect prognosis for success with weaning of tube feeding.

Recommendations

Tube-fed children should be treated with a multidisciplinary approach.
Blenderized diets, ideally under supervision of a healthcare professional, should be considered for tube- fed children who have difficulty with formula.
An overnight continuous tube-feeding schedule should be considered for children who eat orally and need to increase overall calorie consumption.
A combination of caloric reduction of tube feedings and behavioral modification should be used to facilitate tube weaning.
Assessment of the parent-child interaction should be a significant part of treating the tube-fed child.
Treatment of pain should be considered as part of a comprehensive feeding program.
Skills that teach chewing and promote oral intake should be initiated early to promote a shorter duration of tube feeding.

Van Tilburg, M., Hyman, P., Walker, L., Rouster, A., Palsson, O., Min Kim, S., , and Whitehead, W. Prevalence of Functional Gastrointestinal Disorders in Infants and Toddlers . Vol. 166, No. 3 March 2015

current findings suggest that FGIDs are common in US infants and toddlers group
associated with lower quality of life and increased medical consultation
most common FGIDs in infants were regurgitation and colic
most common FGIDs in toddlers (ages 2-3) are functional constipation and functional diarrhea.

Silverman, A. Interdisciplinary Care for Feeding Problems in Children. Nutrition in Clinical Practice , Volume 25 Number 2 April 2010 160-165

This article describes a biobehavioral approach for the assessment and treatment of feeding disorders.
Feeding problems disrupt the acquisition of age-appropriate feeding habits.
Feeding problems may include: food refusal, disruptive mealtime behavior, rigid food preferences, suboptimal growth, and failure to master self-feeding skills commensurate with the child’s developmental abilities.
Prevalence: 25%-45% of children in the general population, one-third of children with developmental disabilities, and in up to 80% of children with severe or profound mental retardation.
Generally, younger children have more feeding problems than do older children. However, the general trend is for early feeding problems to persist over time.
the prevalence of feeding disorders is expected to increase
Many children present with mixed causes that include behavioral, physiological, and developmental factors.
treatment may be provided by a variety of healthcare professionals from medicine, psychology, speech–language pathology, nutrition, and other specialties
few medical centers offer interdisciplinary clinics, frequently resulting in difficulties in coordination of care and potentially resulting in suboptimal treatment outcomes.
Even when a child’s medical status, oral motor status, and nutrition status have stabilized, feeding difficulties frequently continue.
Considerable evidence supports the use of behavioral approaches in the treatment of feeding disorders.
Behavioral treatment goals include decreasing behavioral problems at meals, decreasing parent stress at meals, increasing pleasurable parent– child interactions at meals, increasing oral intake or variety of oral foods, advancing texture (eg, moving from purees and smooth foods to chewable solids), and increasing the structure and routine of meals.
intensive treatment (day treatment or inpatient care) is warranted: when the feeding disorder is severe or complex (outpatient treatment not likely to be effective)

Najib, K., Moghtaderi3, M., Karamizadeh, Z., Fallahzadeh, E. Beneficial Effect of Cyproheptadine on Body Mass Index in Undernourished Children: A Randomized Controlled Trial, Iran J Pediatr; Vol 24 (No 6), Dec 2014

Cyproheptadine hydrochloride (CH) is a first-generation antihistamine which is used as an appetite stimulant.

cyproheptadine promotes increase in body mass index in children with mild to moderate undernutrition after four weeks treatment.
The probable mechanisms for appetite- stimulating effect of this drug including constant increased energy intake through more desire to eating and stimulation of grow hormone secretion by deep sleep induction .
The most frequent adverse reaction to protocol regimen was sleepiness

Dodrilla, P and Gosa, M. Pediatric Dysphagia: Physiology, Assessment, and Management. Ann Nutr Metab 2015;66(suppl 5):24–31

Swallowing difficulties can effect pulmonary health and nutritional intake.

It is estimated that swallowing difficulties occur in approximately 1% of children in the general population, though the incidence rate is much higher in some clinical populations.
Oropharyngeal dysphagia should be considered in the differential diagnosis of any young child who presents with unexplained respiratory complications.
given the high rates of silent aspiration in the pediatric population, several studies in the literature question a clinician’s accuracy for predicting airway compromise based on clinical observation alone
Common instrumental assessment for children suspected of dysphagia includes videofluoroscopic swallow study and fiberoptic endoscopic evaluation of swallow.
Common management strategies include the use of thickened fluids for children with demonstrated aspiration of thin fluids.
Significant improvements in both swallow function and sensory testing following GERD treatment have been shown in the literature (suggesting that GERD may result in decreased laryngopharyngeal sensitivity)
insufficient evidence to determine the effects of oral motor exercises on children with dysphagia.
review investigating therapy interventions for dysphagia in children with neurological impairment- show insufficient evidence regarding the effectiveness of any particular type of swallowing therapyLiterature review of using thicker liquids reveals that it can reduce the risk of laryngeal penetration and aspiration but also increase the risk of post-swallow residue in the pharynx
neurologically intact child, many clinicians advocate that an assessment of the upper airway should be performed to assess for structural malformations