Feeding Problems in Children: Clinical Presentation, Etiology, and Behavioral Management (copy)

Introduction and Definition of Feeding Problems

• Conceptual Overview: In the study of childhood nutritional disorders, significant focus is often placed on metabolism and malnutrition, but the clinical entity of feeding problems remains relatively overlooked despite its documented frequency since the early $1900\text{s}$.

• Formal Definition: A feeding problem is defined as the inability or refusal to eat certain foods due to neuromotor dysfunction, obstructive lesions, psychological factors, or a combination of these elements.

• Clinical Status: It is categorized as a symptomatic clinical entity rather than a specific disease.

Incidence and Statistical Prevalence

• General Pediatric Population: Kanner estimates that at least $\frac{1}{4}$ ($25\%$\text{)} of children exhibit feeding difficulties.

• Historical Data:

  • Tilson (1929): Reported an incidence of $28\%$ among preschool children.

  • Bartlett (1928): Noted an incidence of $23\%$ among nearly $1,500$ patients in a pediatric clinic.

• Specialized Populations: Feeding problems are more frequent in handicapped children. Data from the Georgetown University Affiliated Program for Child Development (GUAPCD) between $1971$ and $1973$ showed that $33\%$ of patients in the Nutrition Division exhibited such problems.

• Other Centers: Reports indicate an incidence range of $13\%$ to $33\%$ in nutrition divisions. A Massachusetts survey of five state institutions found that one in three patients suffered from difficulty in chewing or swallowing.

• Specific Clinical Breakdown (GUAPCD Sample of $500$ patients):

  • Prolonged subsistence on pureed foods: $27.3\%$

  • Difficulty in sucking, swallowing, or chewing: $24.1\%$

  • Bizarre food habits (e.g., eating salt by the spoonful, drinking juice by the gallon): $23.4\%$

  • Multiple food dislikes: $11.1\%$

  • Delay in self-feeding: $8.0\%$

  • Mealtime tantrums: $6.1\%$

Classification and Etiological Factors

• Classification Challenges: Palmer et al. (1975) noted a lack of a formal classification system in literature, with most etiology focusing on individual problems rather than the whole clinical entity.

• Dysphagia Causes (Illingworth):

  1. Gross Congenital Anatomical Defects: Defects of the palate, tongue, mandible, pharynx, larynx, esophagus, and thorax.

  2. Neuromuscular Causes: Delayed maturation, cerebral palsy (CP), muscular dystrophy, pharyngeal incoordination, bacterial/viral infections, and specific syndromes such as Cornelia de Lange\'s.

  3. Acute Infective Conditions: Conditions such as stomatitis.

• Sensitive Periods: Illingworth and Lister proposed a critical or sensitive period for introducing solids around $6$ to $7\,\text{months}$. Missing this window can lead to long-term feeding difficulties.

• Behavioral Mismanagement: Identified as a primary etiological factor. Mohr (1928) emphasized the emotional relationship between mother and child. Kanner identified three principal factors:

  1. Culturally imposed mechanization and overregulation of feeding.

  2. Obsessive and coercive maternal overprotection.

  3. Infantile response to maternal attitudes.

• Nutritional Misconceptions: Schwartz (1958) cited "pseudoscientific knowledge" regarding nutritional requirements during periods of decelerated growth as a cause. Additional factors include early weaning, high-tension mealtime atmospheres, and constant nibbling.

• Handicapped Context: Parental guilt may lead to overcompensation through forcing larger-than-necessary amounts of food.

• GUAPCD Causal Statistics (1971–1975):

  • Neuromotor Dysfunction: $73.5\%$

  • Behavioral Mismanagement: $21.3\%$

  • Mechanical Obstructions: $5.2\%$

A Behavioral Approach for Management: Applied Behavior Analysis (ABA)

• Management Philosophy: While minor temporary complaints can be ignored, treated feeding problems must be distinguished from those with dangerous outcomes (e.g., severe malnutrition, growth retardation). Conventional parental methods (masking food, withholding dessert) are often inconsistent and disappointing.

• Interdisciplinary Requirement: Effective management requires an integrated approach involving pediatricians, nutritionists, surgeons, therapists (occupational, speech), neurologists, dentists, and psychologists.

• Components of ABA:

  • Evaluation: Identification of behavioral excesses (overeating), deficits (lack of self-feeding skills), or inappropriate stimulus control (snacking at bedtime).

  • Baseline Data: Includes nutritional/developmental evaluation and mealtime observations to specify target behaviors and identify potential reinforcers.

  • Treatment Sessions: Conducted usually on an outpatient basis (e.g., during noon meals). Sessions typically last $30\,\text{minutes}$ to $45\,\text{minutes}$. Objectives are stated behaviorally to measure effectiveness.

  • Therapist Role: Initially, a qualified professional (psychologist, nutritionist) executes the plan, using tangible or social rewards for each bite. Tasks are broken into small, simple steps.

  • Reinforcement Schedule: Moves from a $1:1$ ratio to $2:1$ or higher, eventually using the meal itself as a reinforcer. Nutritionally undesirable items (e.g., potato chips) may be used initially but are phased out for cheese or social praise (e.g., "good boy").

  • Parental Integration: Parents must learn techniques via videotape monitors and eventually take the therapist\'s place in sessions to ensure home continuation.

  • Follow-up Progression: Termination depends on objective achievement. Follow-up intervals: weekly, monthly, half-yearly, then yearly.

Feeding Problems Due to Neuromotor Dysfunction or Mechanical Obstruction

• Major Groupings of Abnormalities (Illingworth):

  1. Mechanical/Gross Structural: Cleft palate, submucous cleft, macroglossia, micrognathia, Pierre Robin syndrome, hypoplasia, and defects of the pharynx, larynx, esophagus, and thorax.

  2. Neuromuscular: Delayed maturation, cerebral palsy, bulbar/suprabulbar palsy, Möbius syndrome, pharyngeal incoordination, muscular dystrophy, Cornelia de Lange\'s, Prader-Willi syndrome, rumination, and tongue thrusting.

  3. Acute Infective: Stomatitis and esophagitis.

• Prognosis Factors: Dependent on the degree of physiological dysfunction and the child\'s mental ability. Congenital abnormalities increase the risk of mental retardation.

• Complications: Pseudoretardation may occur due to long-term maternal separation or missing sensitive periods for solid food introduction.

Normal Development of Oral Reflexes and Feeding Skills

• Developmental Pattern: Proceeds from general to specific. Birth behavior is controlled by primitive spinal and brain stem reflexes (involuntary). These are replaced by higher-order midbrain and cortical functions (voluntary control like sitting, standing, walking).

• Primitive Reflexes (Table 13-II):

  • Sucking Reflex: Present at birth; typically diminishes by $3$ to $5\,\text{months}$. If it persists in its primitive form, it may interfere with voluntary chewing.

  • Rooting Reflex: Head turns toward tactile stimulus near the mouth. Usually disappears between $3$ and $5\,\text{months}$.

  • Bite Reflex: Elicited by gum stimulation; disappears by $3$ to $5\,\text{months}$. A hyperactive bite (clamping) interferes with feeding.

  • Gag Reflex: Present at birth; persists through life. It prevents food from entering the windpipe but must weaken enough to allow solids at around $7\,\text{months}$.

  • Protrusion Reflex: Pushing food out when placed on the anterior third of the tongue. Persistence after $4\,\text{months}$ delays solid food introduction.

Specific Feeding Impairments and Abnormalities

• Tongue Problems: Tongue thrusting can persist for years, mashing food against the roof of the mouth rather than moving it laterally. Restricted movement can cause high palates or narrow jaws in CP children.

• Lip Control: Poor contraction of lip muscles results in drooling and inability to seal around spoons or cups.

• Chewing: Requires rotary jaw motion rather than vertical up-and-down motion. Insufficient mastication impairs digestion and absorption.

• Stability and Reflex Interference:

  • Lack of head and trunk stability makes hand-to-mouth patterns impossible.

  • Asymmetrical Tonic Neck Reflex (ATNR): Occurs when the head turns to one side, causing spontaneous extension of the arm on that side, preventing it from reaching the mouth.

Comprehensive Assessment of Feeding Abilities

• Mueller Prespeech and Feeding Evaluation (Table 13-III):

  1. Facial Expression: Check for flaccidity or exaggerated grimacing under stimulation (common in CP).

  2. Feeding Reflexes: Systematic testing of rooting, suck/swallow, bite, and gag reflexes.

  3. Feeding Behavior: Evaluation of lip seal, negative pressure during sucking, and mandibular movement during swallowing.

  4. Digital Stimulation Response: Normal oral musculature should remain relaxed. CP children may exhibit hyperextension or startle responses.

  5. Dental Development: Assessment of occlusion, palate shape, caries, and gum health (glosstitis, cheilosis, stomatitis).

  6. Jaws: Assessment at rest and during motion.

  7. Lips: range of gross and fine movements (kissing, pursing).

  8. Breathing: Assessment of regularity and whether the child is a nose or mouth breather.

  9. Voice: Evaluation of pitch, range, volume, and intonation.

Facilitation Techniques for Specific Feeding Difficulties

• Oral Facilitation General Rules: Start internal mechanism, proceed outward. Sequence: Jaw stability $\rightarrow$ Tongue lateralization $\rightarrow$ Lip closure.

• Sucking Technique: Vibrate the orbicularis oris muscle followed by stretch pressure (pushing upper lip up, lower lip down). Bottles should have holes allowing liquid to drop at $2\,\text{drops/min}$. Straws should be $\frac{1}{8}\,\text{in}$ in diameter.

• Swallowing Technique: Vibrate laryngopharyngeal musculature from chin to sternal notch. Stroking upward under the chin provides a stimulus for the tongue to move. Head should be slightly downward.

• Gag Inhibition: Use the ball end of a swizzle stick to "walk back" on the midline of the tongue with pressure. Repeat $5$ to $7$ times. For hyperactive bite, use a plastic-covered metal spoon; do not use plasticware that might break.

• Tongue Management:

  • Thrust: Vibrate under the chin with teeth closed. Pulling on the tongue with gauze (Down\'s syndrome technique) helps retraction.

  • Lateralization: Press swizzle stick against lateral surfaces. Place food in the corners of the mouth by molars to encourage movement.

  • Elevation: Lightly touch the roof of the mouth with a fiber brush; the tongue will rise to the spot.

• Jaw Stability: Vibrate masseters, pterygoids, and temporalis muscles for $5\,\text{seconds}$ each, followed by stretch pressure. For a retracted jaw, push in on the jaw and vibrate the zygomatic arch.

• Chewing: Place food bits between back teeth. Increase texture gradually: soft potatoes $\rightarrow$ orange sections $\rightarrow$ raw carrots. Using a mirror can provide visual feedback.

Progression to Independent Feeding and Assistive Devices

• Sitting Balance: Optimal position is $90^\circ$ hip flexion with feet supported (Fig. 13-4). The therapist should work from the nondominant side or behind.

• Finger Feeding: Initiated when the child can put hands to mouth. Beneficial foods: crackers, cheese cubes, fruit slices.

• Cup Drinking: Introduce several months before weaning. Assist with lip closure by placing a forefinger horizontally across the upper lip (Fig. 13-5).

  • Specialty Cups:

    1. Wonder-flow: Nylon glass with spout and flow-control knob for supine drinking.

    2. Weighted base: Prevents tipping.

    3. Two handles: For better grasp.

    4. Adjustable glass holder: Pliable plastic-coated handle for custom hand fit.

• Spoon Feeding: Prerequisites include hand-to-mouth patterns and ability to swallow without choking. Recommended foods: peanut butter, mashed potatoes, applesauce.

  • Specialty Spoons:

    1. Swivel handled: Keeps spoon level despite hand rotation.

    2. Iced tea/Extension: For children unable to bend/extend elbows.

    3. Built-up handles: Using foam rubber, wooden spools, or masking tape.

    4. Bent handle: Provides a more secure grasp.

• Adaptive Kitchenware: Bowls with high sides for scooping. Stability achieved via suction cups, velcro, masking tape, or "clay as anchor" (Fig. 13-8).