Feeding Disorders

Diane Barsky, MD

Feeding Disorders - BASICS

• Feeding disorders: Inability to consume by mouth in quantitiy or quality nutrition which is developmentally appropriate for that child
• Dysphagia: Disorder of swallowing characterized by difficulty in oral preparation for the swallow or in moving food or liquid from the mouth to the stomach
• Aspiration: Food or fluid falling below vocal cords proceeding to lungs
• Penetration: Food or fluid remaining above vocal cords and cleared by patient through coughing to prevent aspiration

Feeding Disorders - general prevention

• Monitor weight, height, head circumference, weight for height and BMI percentiles at regular interval office visits to identify changes in nutritional status early especially in high risk populations
• Selective eater: Educate parents on age appropriate portion sizes and foods
• Provide vitamin and mineral supplementation or refer to nutritionist for complete assessment if patient at risk for deficiencies
• Developmental delay—evaluate diet and feeding skills to manipulate nutrition provided
• Ensure foods offered match developmental age if different than chronological

Feeding Disorders - epidemiology

Feeding Disorders - incidence

• 25–40% of normally developing children with feeding disorder
• 80% of children with cerebral palsy demonstrate abnormal oral motor and swallowing patterns for feeding
• 40–70% of children with medical disorders and/or developmental disabilities

Feeding Disorders - risk factors

• Congenital heart disease
• Cystic fibrosis
• Metabolic disorders
• Autism spectrum disorder
• Developmental delay
• Prolonged tube feeders (>4 weeks)
• Prematurity
• Neuromotor dysfunction
• Anatomic deformities (i.e., Pierre Robin sequence, laryngomalacia, tracheotomyal)
• GI disorders: Gastroesophageal reflux,
• Tachypnea (respiratory rate > 40 breathes per minute)
• Oral motor disorder: Inability to manipulate age appropriate diet often related incoordination of facial muscles and/or tongue
• Pharyngeal dysphagia: Inability to protect airway during swallow—may be due to anatomic abnormality or neurological dysfunction

  Voluntary food or fluid refusal due to learned fear when caregiver pushes foods or textures before the child is developmentally or medically ready, may result in maladaptive interactions at meals

Feeding Disorders - DIAGNOSIS

Feeding Disorders - signs & symptoms

• Poor linear growth
• Sucking and swallowing incoordination—infant should demonstrate 1;1:1 suck, swallow, breathe pattern when sucking from breast or bottle
• Recurrent pneumonia
• Coughing during or after feeding
• Refractory asthma
• Drooling
• Refusal to drink or eat

Feeding Disorders - history

• Medical diagnoses past and present
• Treatments in past or present, especially those aversive to face and upper body and face (i.e., suctioning, tracheostomy, intubation)
• 24-hour diet: Recall food and fluid consumed over a 24-hour period
• Previous hospitalizations, especially respiratory illnesses
• Allergies or food intolerances
• Growth history
• History of snoring or sleep apnea: May indicate adenoidal or tonsillar hypertrophy
• GI history: Stool pattern, vomiting, gagging, spitting up, pain
• Previous diagnostic testing
• Family history: GI disease, allergies, developmental delays, genetic abnormalities

Feeding Disorders - physical exam

• HEENT: Dysmorphic facial features, shape of head and sutures, facial tone, intact soft and hard palate, shape of mandible,tonsillar size, patency of nares, movement of lips and tongue, presence of stridor
• Pulmonary: Rate of breathing, use of accessory muscles for respiration, rales or wheezes
• Cardiac: Murmur and rhythm
• GI: Bowel sounds, masses, stool palpable, tenderness, distension use normal
• Neurologic: Tone, positioning, cranial nerves, gait
• Extremities: SC stores, muscle development
• Skin: Rashes, alopecia

Feeding Disorders - tests

Perform feeding observation: Watch caregiver feed child preferably thru one way observation mirror. Monitor child’s behavioral response to placement in the feeding chair and presentation of bottle, breast or cup and a variety of food types and texture, observe parental reaction to child’s behaviors, outcome of feeding behaviors.

Feeding Disorders - lab

Based on nutritional and/or developmental concerns:

• Failure to thrive: Celiac panel, CBC, comprehensive metabolic panel, lead, urine analysis, thyroid function. Other tests if suspect vitamin or mineral deficiency (i.e., zinc, iron)
• Developmental and/or genetic concerns: Chromosomes, FISH test for 22Q11 deletion, FISH test for Prader Willi syndrome, fragile X (males), serum and urine organic acids, lactate, pyruvate, CPK
• Sweat test if suspect cystic fibrosis: Failure to thrive, diarrhea and/or recurrent pulmonary infections

Feeding Disorders - imaging

• Tests indicated based on history and physical
• Suspect pharyngeal dysphagia—modified barium swallow study (MBSS) (also known as “videofluoroscopic swallow study”) evaluates swallow function and can visualize aspiration during swallow, usually performed by radiologist and speech therapist. Study visualizes function of pharyngeal muscles and structures to indicate etiology of aspiration
• Evaluate gastric emptying time, screen for postprandial reflux and aspiration related to gastroesophageal reflux
• Upper GI series: Order with patient vomiting or with delayed gastric emptying to ensure normal anatomy of esophagus, stomach and duodenum
• Chest x-ray: Determine if infiltrates or atelectasis present; right upper and/or middle lobe changes indicative of potential aspiration. Compare to previous studies to determine if lung changes chronic or improving over time
• Salivagram: Radionucleotide study to evaluate if patient aspirating their oral secretions
• Chest CT scan: Allows detection of subtle changes from silent aspiration not detectable by pulmonary exam or chest x-ray.

Feeding Disorders - diag proced-surgery

• MBSS: Speech therapist feeds a variety of textures: Thin and thickened liquid of honey and nectar consistency, thin and thick purees and chewable foods to determine safety of oral feeding. Allows visualization of oral and pharyngeal phases of swallowing. Can also determine appropriate positioning, type of infant bottles and cups which minimize the risk for aspiration. Timing of aspiration also evaluated to determine if volume and fatigue result in aspiration, patient may be safe to drink or eat for short periods of time before their swallow becomes uncoordinated and leads to aspiration.
• Fiberoptic endoscopic evaluation of swallowing (FEES): Usually performed by ENT specialist—direct visualization of airway structures and swallowing mechanism. Provides information on pharyngeal phase of swallowing but not oral phase. Best used if pharyngeal or laryngeal abnormality is suspected, tracheostomy in place and difficulty managing secretions. Can observe food or fluid falling below vocal cords resulting in aspiration
• Bronchoscopy: Visualize tracheobronchial tree and lungs, sample for lipid laden macrophages in lungs indicative of aspiration
• Endoscopy: To perform esophageal, gastric and small bowel biopsies to determine presence of eosinophilic esophagitis, celiac disease (positive or inconclusive celiac panel) or presence of gastroesophageal reflux disease

Feeding Disorders - differencial diagnosis

• Cardiorespiratory:
  • Congenital heart disease:
    • Infectious pneumonia
    • Bronchopulmonary dysplasia
• Neurological:
  • Diencephalic syndrome:
    • Congenital myopathy
    • Arnold Chiari malformation
    • Hypoxic-ischemic encephalopathy
• GI/Nutritional:
  • Gastroesophageal reflux
  • Eosinophilic esophagitis
  • Failure to thrive
  • Celiac disease
• Metabolic syndromes
• Psychological disorders:
  • Behavioral refusal
  • Psychosocial deprivation
  • Anxiety disorder
• Food allergies
• Anatomic:
  • Laryngeal cleft
  • Tracheoesophageal fistula
• Genetic disorders
• Developmental disorders:
  • Autistic spectrum disorder
  • Sensory integration disorder

Feeding Disorders - TREATMENT

• Pharyngeal dysphagia: Pulmonary referral, oral stimulation program, nothing by mouth as indicated by clinical exam and studies, initiate tube feeds, monitoring by speech therapist
• Feeding disorders are complex and should be evaluated by multidisciplinary team involving medical, nutrition, psychology, occupational therapy and speech

Feeding Disorders - initial stabilization

• Prior to initiation of treatment ensure weight gain and growth adequate
• Evaluate and treat vitamin and mineral deficiencies
• If weight for height or BMI <5% or inappropriate weight gain over 3 months consider initiation of supplemental nasogastric tube feeds
• If aspiration pneumonia suspected obtain blood cultures, chest x-ray, keep NPO, and start IV fluids and antibiotics. Measure oxygen saturation and initiate supplemental oxygen if <95%

Feeding Disorders - general measures

• Calorie counts
• Ensure adequate hydration

Feeding Disorders - diet

• Keep patient NPO if suspect aspiration until further evaluation (i.e., MBSS) can be performed
• Order diet appropriate for child’s current level of feeding skills (i.e., accepts baby food may trial pureed diet)
• If inadequate nutritional intake offer nutritional supplements, monitor calorie counts, and initiate supplemental nasogastric tube feeds if unable to meet nutritional requirements

Feeding Disorders - activity

No restrictions: Allow based on child’s developmental and medical

Feeding Disorders - nursing

• Monitor daily weight
• Document daily input and output
• Monitor vital signs including respiratory status
• Pulse oximetry as indicated
• Evaluate tolerance of supplemental tube feeds
• Offer developmentally appropriate diet in seating at structured mealtimes and snacks including nutritional supplements
• Caregiver education regarding administration of supplemental tube feeds

Feeding Disorders - special therapy

• Speech therapy: Evaluate oral motor skill and safety of swallowing mechanism, perform MBSS when indicated
• Occupational therapy: Evaluate fine motor skills, sensory processing and posture to support feeding
• Psychology: Identifies behaviors interfering with food acceptance and recommends strategies to improve oral acceptance
• Nutrition: Perform complete nutritional assessment including evaluation of growth parameters, identifying patient’s nutrition requirements and adequacy of current diet. Develops care plan to meet patient’s nutritional requirements and monitors intake and weight gain during hospitalizations

Feeding Disorders - complementary and-alternative-therapies

• Obtain listing of all supplemental vitamins, minerals, herbs, etc. parent may be providing to patient
• Investigate if parent following any special diets (i.e., casein-gluten-free diet in autistic spectrum disorder)
• Note current literature does not support special diets or excessive dosing of vitamin and/or mineral supplements in developmental disorders unless indicated in treatment of a specific metabolic disorder

Feeding Disorders - surgery

• Consider gastrostomy tube placement if anticipate tube feeding >3 months
• For gastroesophageal reflux not controlled by medication, consider bypassing stomach and feeding into intestine with jejunostomy tube or Nissen fundoplication

Feeding Disorders - medication

• Appetite enhancing medications not routinely recommended
• Medications administered to treat underlying medical condition (i.e., gastroesophageal reflux disease), refer to specific sections for treatment of identified medical issues resulting in feeding disorder

Feeding Disorders - FOLLOW UP

Appointment with multidisciplinary feeding team if available within reasonable geographic radius

Feeding Disorders - prognosis

• Nutritional rehabilitation can be achieved with tube feedings if patient monitored closely
• Patients with pharyngeal dysphagia resulting in aspiration may improve over time
• Structural abnormalities as seen with CHARGE association or subglottic stenosis may improve over 1st 2–3 years of life or require surgical intervention prior to oral feeding
• Static or degenerative neurological conditions resulting in aspiration generally do not resolve
• Patient demonstrating dysphagia during illness may improve when healthy

Feeding Disorders - patient monitoring

• Patient’s weight should be checked within 2 weeks of discharge.
• Pediatrician should monitor patients with respiratory difficulties related to aspiration every 2 weeks until stable.

Feeding Disorders - bibliography

1. Chatoor I. Feeding disorders in infants and toddlers: Diagnosis and treatment. Child Adolesc Clin N Am. 2002:11:163–183.
2. Rudolph CD, Thompson LD. Feeding disorders in infants and children. Pediatr Clin North Am. 2002;49(1):97–112.
3. Tobin S, Schumacher C, Barsky D, et al. Children’s Hospital of Philadelphia’s Pediatric and Swallowing Center: The role of our interdisciplemanry feeding team in the assessment and treatment of feeding problems. Special Focus on Nutrition. Building Block of nutrition. March 2006:1–34.

Feeding Disorders - CODES

Feeding Disorders - icd9

• V69.1 Inappropriate diet and eating habits
• 307.50 Eating disorder, unspecified

Feeding Disorders - PATIENT TEACHING-MED

See Table XX in Section VI

Book Source Details

• Book Title: The 5-Minute Pediatric Consult
• Author(s): M. William Schwartz MD; et al.
• Year of Publication: 2008
• Copyright Details: The 5-Minute Pediatric Consult, Copyright © 2008 Lippincott Williams & Wilkins.

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Copyright Details: The 5-Minute Pediatric Consult, Copyright © 2008 Williams & Wilkins.

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More About This Book: Title: The 5-Minute Pediatric Consult Authors: M. William Schwartz MD; et al. Publisher: Lippincott Williams & Wilkins Copyright: 2008 ISBN: 0-7817-7577-9

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