Assessment of Paediatric Feeding Flashcards
What is a Paediatric Feeding Disorder?
PFD is “impaired oral intake that is not age appropriate and is associated with medical, nutritional, feeding skill and/or psychosocial dysfunction.”
Compare picky eating and PFD
Picky eating:
- transient
- reduced dietary variety
- still generally meet nutritional requirements from diet
- some behavioural difficulties at mealtimes
- up to 50% of typically developing children will experience transient ‘picky eating’
- limited impact on activity participation
PFD:
- chronic
- usually don’t meet nutritional needs
- very restricted dietary variety
- ongoing food neophobia
- high frequency behavioural difficulties outside of mealtimes
- associated with considerable parental stress
- less common than picky eating
- most frequently occurs in children with a developmental or physical disability
- limits the child or family’s ability to participate in social activities
Feeding disorders in children: common presentations
Limited range of textures:
- Often reliance on ‘easy to eat foods’
- Puree, dissolvable vs. lumpy, mechanical
Limited range of foods:
< 30 foods
<10 proteins/ dairy, <10 fruit/ veg, <10 starches
Prolonged mealtime duration:
>30 mins at mealtimes, >2hrs a day spent trying to feed child
High frequency problematic behaviour at mealtimes
Parental stress related to the child’s eating patterns
How is PFD different from ARFID?
Avoidant Restrictive Food Intake Disorder (ARFID) is a diagnostic criteria in the DSM-V
Generated as a mental health diagnosis (i.e., psychiatric/behavioural)
Describes children with feeding problems without medical or feeding skills issues
Not an eating disorder (e.g., anorexia nervosa) but sits under eating disorders in the DSM-V
Given this diagnosis sits under the nutritional + psychosocial domains of PFD, children with ARFID could also be considered to have PFD
Oral phase dysphagia in children - common presentation
Oral phase
◼ Absent oral reflexes
◼ Uncoordinated suck
◼ Immature biting and chewing
◼ Poor oral preparatory skills
◼ Oral apraxia
Pharyngeal phase dysphagia in children - common presentation
Pharyngeal phase
◼ Poor suck-swallow-breath coordination
◼ Delayed swallow trigger
◼ Poor pharyngeal clearance
Oesophageal phase dysphagia in children - common presentation
Oesophageal phase
Impaired opening of the upper oesophageal sphincter (UES)
Impaired opening of the lower oesophageal sphincter (LES)
LES relaxation causing reflux
Poor motility
Risks of dysphagia
Aspiration (where material enters the airway below the level of the vocal folds)
At risk of developing respiratory disease, including pneumonia
In some cases, may need to alter or cease oral feeding
During a feed, you may observe:
- wet voice during feeds*
- wet breathing*
- cough*
- colour changes
- oxygen desaturations
- gagging
- watery eyes
- nasal flaring
- sudden state or tone changes
Apnoea
- Apnoea occurs when the airway closes and fails to reopen – there is a period where no breathing occurs
- Apnoea may occur in response to material entering the airway in young infants
- In young infants, this response is known as the laryngeal chemoreflex (may be more prevalent in premature infants)
- Apnoea is different to choking, where a solid bolus physically blocks the airway
IMPACTS of PFD
- Growth and development
- Health
- Parent stress levels
- Social participation and QOL
- Financial burden
How does PFD impact Growth and nutrition?
- Poor growth and underweight
- Overweight
- Poor nutrition
- Financial burden
How does PFD impact health?
- Chest and respiratory health
- Macro- and micronutrient deficiencies and malnutrition can cause health problems, e.g.,
- Iron deficiency anaemia
- Rickets
- Scurvy - Constipation
- Overweight/obesity may predispose children to diseases of later life e.g., Type 2 diabetes and cardiovascular disease
How does PFD impact parental stress levels?
Higher stress levels reported in:
- Children with more challenging behaviours
- Children with developmental delays
- Older children (parents of younger children tended to be defensive responders) (Silverman et al., 2020)
- Parents reported fearing for the child’s health and life, and feeling that they were starving to death
How does PFD impact social participation and quality of life?
- Restrictions or modifications in childcare, school, or other environments that involve mealtimes
- Families report impacts on daily life and social participation e.g., having to be stationary during tube feeds; not being invited to birthday parties)
- Similar (and sometimes significantly lower) scores on PEDS-QL than children with other medical conditions (e.g., acute liver failure; kidney transplant; brain arteriovenous malformations)
- Impairment of social relationships and even the attainment of employment
How does PFD impact financial burden?
- 85% of families report that attending their feeding therapy appointments takes at least half a day
- Despite being offered a ‘free’ service, feeding therapy appointments cost families between $58 and $508 in direct costs (e.g., parking, accommodation, food and drink) – this direct cost was generally greater for families from non-metropolitan areas
- Most families (76%) report at least moderate financial burden e.g., one parent had to quit work, not take a promotion or cut back on work hours to care for child with PFD
- Many other direct costs e.g., equipment, special seating, special food, cleaning fees
- Lifetime average income loss of $125,645 for a family
What are the indications for tube feeding?
- Inability to suck or swallow (e.g. unsafe swallow, premature)
- Increased nutrition requirements/ inadequate oral intake
- Primary disease management
- Weight loss/ poor weight gain
What is Bolus feeding and pros/cons?
2 to 12 times per day
* “Gravity feed” – using a syringe for smaller intermittent feed/volumes
* Can use a pump
Advantages
- Mimics normal oral feeding
- Do not need a feeding pump but can use a pump if larger volumes
- Allows freedom of movement/breaks
Disadvantages
- Increased risk of reflux aspiration
- Child may have poor tolerance of volumes
- Gut upset
What is Continuous Feeding and pros/cons ?
Feeds run continuously with a feeding pump
Advantages:
- Maximum nutrient absorption
- Improved tolerance
- Allows increased amount of formula
- Can be given at night
Disadvantages:
- Equipment
- Tied to feeding equipment
- Less likely to have hunger cycle
What is important to consider about tube placement?
Can be traumatic for the patient & family
Preparation is important; OT can help
There are many benefits to tube feeding for the children that require it, including:
- Improved nutrition
- Improved development
- Improved parent-child interactions
- Improved sleep
Adverse effects of tube placement:
- Elevated parental stress and impacts on maternal identity
- The child experiences reduced motivation to consume food
- Tube feeding may disrupt early feeding development, through delayed exposure to eating and drinking as well as aversive experiences
- Cost of tube feeding to family and medical system
- Children who are non-oral feeders may have difficulties with:
- Hypersensitivity (traumatic
experiences, lack of experience)
- Hyposensitivity (so habituated to
medical interventions around their
face)
- Delayed oral motor skills (due to
lack of experience)
- Impaired parent-child relationship
(due to lack of bonding
opportunity around feeding)
What is tube dependency?
Common characteristics of tube dependent children:
- High levels of food avoidance and refusal
- Limited natural motivation for food intake
- Oral sensory disorders and oral aversion is common
- Oral skills development is typically delayed
