I want to thank Dr. Piazza for giving permission to repost this article.It was originally printed in Paradigm Magazine, • Fall 2000, pg. 8-9. It’s one of my favorites. Krisi
“Don’t worry, she’ll eat when she gets hungry” is the common assumption of most practitioners working with pediatric populations.
Even though this adage applies to the majority of infants and toddlers, there is a significant minority of children that, without intervention, would become malnourished, dehydrated and in some cases would die. These children have feeding disorders, a complex and poorly understood problem that has received increasing attention in research literature and the general media.
What is a Feeding Disorder?
Feeding disorders consist of a heterogeneous set of problems characterized by the ways that they cause significant stress to the family.1 The most frequently occurring types are:
• failure to maintain weight or grow
• failure to eat a sufficient variety of foods to maintain nutritional status
• dependence on alternative nutrition such as tube or bottle feedings
• inappropriate mealtime behaviors
The behaviors that characterize feeding disorders reflect the heterogeneous etiologies of the problem. For example, medical problems such as severe gastroesophageal reflux (GER) can cause eating to be painful. Early experiences with pain during intake can cause the child to stop eating and develop behavior problems (e.g., batting at the spoon, crying) that make it difficult if not impossible for the parent to feed the child. In addition, limited experiences with oral intake often result in failure of the child’s oral motor responses to develop normally. Parents also report that their children (a) do not demonstrate hunger, (b) demonstrate aversion to or avoidance of sensory stimulation and (c) struggle with parents for control during the feeding situation. Each child is different and may present with one or several of these characteristics.
One intervention that is used commonly with children with severe food refusal or selectivity is the use of alternative supplementation (e.g., gastrostomy tube). Although such methods can be vital in improving status for children with severe failure to thrive, unfortunately, supplemental feedings may also interfere with the development of typical feeding behaviors. If tube feedings replace oral feedings, the child does not get to practice the skills required for eating, such as chewing and swallowing. Second, tube feedings may interfere with or suppress hunger and satiety cues. Thus, the child may lack sufficient internal motivation to eat or may not learn how to recognize and respond to internal cues.
Oral motor difficulties are commonly reported in children with feeding problems. These problems may be a function of inadequate development as a result of pre-mature birth or other situations. Additionally, some children demonstrate aversion to or avoidance of sensory stimulation.
Environmental factors also may play a role in either the onset or the maintenance of the feeding problem.1 For example, when a child refuses to eat by crying or batting at the spoon, caregivers often will end the meal, try to calm the child or coax the child to eat. In some cases, the caregiver, in desperation to get the child to eat something, will give the child a more preferred food if the child refuses to eat a less preferred food. Even though these techniques are meant to improve the situation, they may actually exacerbate the problem. That is, the child learns that additional payoffs in the form of increased parental attention or avoidance of non-preferred foods are available in response to inappropriate mealtime behavior or food refusal.
What is the Prevalence of Feeding Disorders?
The reported prevalence of pediatric feeding disorders varies. About 25 percent of typically developing children display some difficulties around mealtime. However, the number of children requiring treatment for feeding problems is probably between one and five percent.
How do you Assess and Treat a Feeding Disorder? Feeding disorders are not the result of a single etiology, treatable by a single professional, but they represent a complex interaction among a variety of factors, warranting treatment by an interdisciplinary team.
Team members should include professionals that may provide input into the assessment and treatment of the feeding problem, such as gastroenterology, behavioral psychology, occupational and/or speech therapy, nutrition and social work.2 Critical program components include (a) evaluation of physiological problems that may contribute to the feeding difficulties, (b) determination of the safety for oral feedings, (c) intervention with respect to oral motor deficits or sensitivities, (d) monitoring the child’s intake to ensure a balance between adequate calories, growth and weight gain and (e) assessment of the family’s ability to carry out an intervention program.
The behavioral assessment of feeding disorders consists of gathering information provided by caregivers regarding the history of feeding difficulties, performing direct observations of the child in the eating situation, manipulating the various environmental conditions that possibly contribute to the feeding problems and conducting food, texture or toy preference identification.1, 2
Direct observations of the child in a typical mealtime setting allows the team to observe both the child’s and the caregiver’s behavior during the meal. Direct observation of parent and child behavior during the meal assists in the development of hypotheses as to why the feeding problems are occurring. Hypotheses can be tested using functional analyses designed to identify why a child does not eat or what environmental factors might contribute to food refusal or inappropriate mealtime behavior.4
Analog functional analyses have been used to assess a variety of inappropriate behaviors and have become the “gold standard” in the treatment of behavior disorders. Formal assessment of inappropriate mealtime behaviors via functional analyses improve our understanding of why food refusal behaviors occur during mealtimes and help us select individualized treatments directly related to the function of the inappropriate behavior. For example, if the results of the functional analysis suggest that the child engages in inappropriate behavior to gain access to preferred foods (i.e., the child refuses to eat peas so mom will make a peanut butter and jelly sandwich), then an indicated treatment would be to present a piece of a peanut butter and jelly sandwich following consumption of peas. A different treatment would be prescribed if the results of the functional analysis indicated that the child refused food to obtain caregiver attention. In this case, the indicated treatment would consist of providing the child with attention for eating and minimizing attention for refusing food. Specific techniques are used when the child refuses to allow any food or liquid to enter his or her mouth. These techniques are known as escape extinction procedures and include providing cues to the child to open his or her mouth (e.g., touching the spoon to the child’s lip or providing a gentle prompt to the mandibular joint), thereby increasing opportunities for the child to accept and swallow food. Finally, “fading” is a technique that involves exposing the child to various aspects of the feeding situation in a gradual manner. For example, the child might be presented with an empty spoon. Once the child is opening his or her mouth consistently when the empty spoon is presented, food or liquid can then be added onto the spoon in increasing amounts.
Where do Parents Fit In?
The caregiver is one of the most crucial aspects for the generalization and continued success of any feeding program.1 Generalization can be enhanced by implementing the treatment in settings in which eating behaviors are expected to occur (e.g., at home and school). Caregivers should be given the opportunity to implement the treatment in the presence of the therapist and alone in order to determine how well the interventions carry over from one environment to another. Also, caregivers must be trained not only in how to implement the feeding treatment, but also in the reasons why a treatment package has been designed. Including the caregivers in all parts of the assessment and treatment process can increase each care- giver’s investment in the final treatment. Parent or caregiver training can be implemented in a variety of ways, including direct observation, role playing with the therapist, discussion, handouts, verbal feedback, videotape review and in vivo training. In order to continue the gains made in a feeding program, the effective implementation of the treatment by all relevant caregivers is paramount. Data can be recorded on the parent’s accuracy of the intervention, thereby ensuring that procedures are carried out with the level of fidelity needed to maintain treatment gains. Caregivers need to understand that there is no quick fix to a feeding problem, no substitute for consistent implementation of the program.
Summary In short, pediatric feeding disorders are a complex mix of medical, oral motor and behavioral issues. Furthermore, each of these factors may contribute in varying degrees to the initiation and maintenance of the feeding disorder. Therefore, an inter- disciplinary model is the most comprehensive method for assessing and treating pediatric feeding problems, and behavioral approaches can contribute substantially to the interdisciplinary treatment of these problems.
Cathleen C. Piazza, Ph.D.
Director, Pediatric Feeding Disorders Program
Professor, University of Nebraska Medical Center’s
Munroe-Meyer Institute and Department of Pediatrics
985450 Nebraska Medical Center, Omaha, NE 68198-5450
- Shore, B.& Piazza, C. Pediatric Feeding Disorders. In E.A. Konarski, J.E. Favell, & J.E. Favell (Eds). Manual for the Assessment and Treatment of the Behavior Disorders of People with Mental Retardation, (1997).
- Babbitt, R.L., Hoch, T.A., Coe, D.A., Cataldo, M.F., Kelly, K.J., Stackhouse, C., & Perman, J.A. Behavioral assessment and treatment of pediatric feeding disorders. Developmental and Behavioral Pediatrics, vol. 15 (4), pgs. 278-291, (1994).
- Jenkins, J. & Milla, P. Feeding problems and failure to thrive. In N. Richman & R. Lansdown (Eds.). Problems of Preschool Children. John Wiley & Sons Ltd, pgs. 151- 172, (1988).
- Iwata, B.A., Dorsey, M.F., Slifer, K.J., Bauman, K.E., & Richman, G.S. Toward a functional analysis of self-injury. Analysis and Intervention in Developmental Disabilities, vol. 2, pgs. 3-20, (1982).
We would like to thank the online magazine Paradigm for permission to reprint this article in the Pediatric Feeding and Dysphagia Newsletter and Dr. Piazza for permission to post this article. Paradigm is a free online magazine from Three Springs Adolescent Treatment Programs.