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
What are the 3 phases of tubes?
Tube implementation:
- acute
- child requires feeding based on criteria
Tube maintenance:
- nutritional/medical status is being established
Tube weaning:
- nutritional/medical need for tube has resolved
- tube may be removed
What is the purpose of assessment in PFD?
To determine:
- Needs, strengths, family concerns and priorities
- Developmental and functional status
- Need for more comprehensive evaluation
- Need for intervention and guide treatment plan
- Progress over time
- The effectiveness of therapeutic intervention
Feeding assessment - five questions to ask
A thorough feeding assessment will involve finding answers to the following five questions:
- Is the current method of feeding safe?
- Is feeding adequate?
- Is feeding efficient?
- Is feeding developmentally appropriate?
- Is feeding a positive experience for child and parent?
What are the components of assessment?
- Case history
- General observations
- Oromotor / cranial nerve assessment
- Feeding assessment / meal time observation
Explain case history component of assessment
Always a first step in your assessment
- Some information may be provided in your referral
- Some organisations send questionnaires to collect information from families before they visit
Areas to cover:
- Pregnancy and birth history
- Other health/developmental issues
- Family situation
- Parent’s main concerns regarding feeding
- Early feeding history (breast/bottle feeding)
- Transitional feeding history (solids)
Explain general observations component for assessment in PFD?
Informal checklists
- Much of feeding assessment is done via observation
- Clinic
- Home
-School
- Consider importance of naturalistic environment
(video from home can be useful) - Very few formal assessments available
- Feeding assessment is an active and ongoing process
State
- In infants, we always consider the presentation of the infant before, during and after feeds
-For an infant, quiet alert is the optimal state for feeding Drowsy may be helpful for infants that are easily overstimulated or for infants with reflux → known as the “dream feed”
- Consider state regulation
- How quickly did they move through states?
- Were they responsive to intervention? What might you consider in an older child?
Physiological status
- Remember your ‘normal’ parameters (refer to lanyard or ax form)
- Again, we are examining this before, during and after feeds
- Difficult to measure heart rate and O2 sats outside of a medical environment
- Respiratory rate: count # breaths/ minute
- Heart rate: look for early fatigue, stress cues, sweatiness (particularly on the back of the head)
- O2 saturation: look for cyanosis (blue tinge) especially around the mouth and fingers
Respiratory status:
- Many of these are signs of respiratory distress
- Apnoea, cough and wet airway noise are clinical signs of aspiration
- Escalate to a clinical senior if you’re unsure!
Other General observations to consider:
- Parent-child interaction
- Motoric control (e.g., head control, sitting) and general tone
- Play and communication skills
- Developmental levels
Explain the oral motor/ cranial nerve component of assessment for PFD
- start with some general observations of oral structures
- oral reflex exam
- cranial nerve assessment
- non-nutritive sucking assessment
- oral motor assessment
Explain step 1 - general observations of oral structures
- tongue
- cheeks
- jaw
- lips
- palate
- face
- oral thrush
Explain step 2 - oral reflex exam
- use a gloved finger to stimulate oral reflexes, considering age and potential for diminishing reflex
- also important to consider state - a sleepy or satiated baby may not respond as promptly or strongly
Explain step 3 - cranial nerve assessment
- no specific assessment tasks, but should consider functioning in the context of oral structures/reflexes
Explain step 4 - non-nutritive sucking assessment
- best using gloved finger, nail bed down
- can use a dummy if the child is not stimulable with finger
Explain step 5 - oral motor assessment
- tongue
- jaw
- dentition
- saliva
- lips
- palate
- tonsils
- face
How to assess a tongue tie?
Key questions to ask if tongue tie suspected:
1. When did concerns start?
2. Any plan pre, during, or post feed?
3. What advice has been given, by whom and has it been useful?
4. Has it been possible to latch deeply and pain free at any time?
Explain the mealtime assessment component for assessing PFD?
Ensure that the parent/carer is aware of the need to bring:
- usual feeding equipment
- preferred and non-preferred foods
- food that the child finds easy/hard to eat
List the 3 holds that could be used in the bottle feeding assessment?
Cradle hold:
- common
Upright (elevated) cradle hold:
- slightly more upright position
- elbow propped
Side-lying:
- child lying on their side facing out
- typically swaddled for postural support
What are some probing questions around hydration?
- how many wet nappies per day?
- has there been a reduction in wet nappies?
- are they light (in weight) and strong smelling?
- do they have physical signs of dehydration (e.g. dry lips, absence of tears)?
- are they lethargic?
What are the clinical signs of suck swallow incoordination?
- occasional, infrequent coughing may be normal
- coughing/choking/spluttering
- prolonged sucking bursts without taking breaths appropriately (e.g. no breath for 5-20 sucks)
- short sucking bursts with frequent and/or long pauses
- disorganised/uneven sucking pattern - duration of sucking bursts and pauses varies considerably
- increased respiratory rate and/or work of breathing
- fluid pooling and/or spilling from mouth
What are some considerations to make when choosing a commercially available highchair?
- a high back with some padding
- tilt-in-space
- an accessible tray
- a foot palate with adjustable foot reset
- 5 point harness
What are some things to look for during and after feeding meal time?
- signs of fatigue and what impact this has on the child
- changes to postural control/positioning
- changes to oral motor skill/efficiency
- changes to child behaviour/engagement in the meal
- changes in state
- changes in cardiovascular and/or respiratory function
List some oral motor ‘red flags’
- difficulty transitioning to textured foods
- difficulty managing mixed textures
- frequent complaint of food ‘getting caught in roof of mouth’
- messy eating
- complaints of gagging or choking on foods
- extended chewing time
- difficulty/inability eating hard textures
- frequent use of fingers to help position food in mouth
What are some important considerations regarding the parent-child interaction?
- useful to observe the parent and child having a meal together
- usually ask the parent to bring in preferred/non-preferred foods for the child, or foods the child is having difficulty with
- examine the child’s environment, either through observation or interview
- routine: what do the family usually
do at mealtime - meal-time set up
- distractions
- routine: what do the family usually
- don’t forget to consider what positive mealtime interactions are observed
What is the assessment of Sensory Processing?
Not all feeding disorders have a sensory basis
Assessment occurs via:
Interview with parent/caregiver → child’s ability to accept a variety of sensory stimuli in the mouth, on face, hands, clothes
Observation of reaction to food/textures/smell
Further occupational therapy assessment if concerns identified
Sensory Profile 2
Oral Sensitivity – What does it look like?
May have a preference for starchy, white and bland foods
(often a typical presentation with children who have ASD)
Avoids or accepts some crunchy or dry textured foods
Avoids or accepts wet or ‘sticky’ foods
Limited variety or avoids food groups in particular vegetables,
fruits, meat
What is the assessment of self-feeding skills ?
Observation of child self-feeding
Consider child’s age – knowledge of developmental stages
Observe child with hand held foods + spoonable foods
- hand use – L or R; bilateral hand use
- grasp of utensils
- FM dexterity (e.g., palmar grasp, pincer grasp)
- eye-hand coordination
- endurance
- sensory issues
Observation of child self-feeding
Consider child’s age – knowledge of developmental stages
Observe child with hand held foods + spoonable foods
- hand use – L or R; bilateral hand use
- grasp of utensils
- FM dexterity (e.g., palmar grasp, pincer grasp)
- eye-hand coordination
- endurance
- sensory issues
List some formal assessments
Schedule for Oral Motor Assessment (SOMA)
Reilly, Skuse and Wolke (2000)
- Published assessment
- Valid and reliable
- Used in several published studies
- Skills judged from observation and video taping using a standardised rating system
Dysphagia Disorders Survey (DDS)
Sheppard et al
- Designed for identifying swallowing disorders in children (and adults) with a developmental disability
- Require formal training in order to perform
Sensory Profile 2
- Dunn (2014)
- Published assessment
- Standardised, valid and reliable
- Used in several published studies
- Parent completed
- OT usually assists with interpretation
How would you assess dietary intake?
3 day/24 hour dietary record
- Amount of intake
- Type of intake
- Texture of intake
- Frequency of feeds
- Duration of feeds
- Refer to dietitian for advice regarding nutrient and calorie needs
How would you formally assess mealtime behaviour?
Behaviour Paediatrics Feeding Assessment Scale (BPFAS)
- 35-item questionnaire (25 child/10 parent)
- Each statement rated on 5-point Likert scale
- Parents also indicate whether each statement is a problem for them
- Results create a Total Frequency Score (TFS) and a Total
- Problem Score (TPS) for both child and parent behaviours
- Normative data and cut-scores available from the UK (Dovey et al., 2013) and Canada (Crist et al., 2001
How would you formally assess PFD quality of life?
Feeding/ Swallowing Impact Survey (Lefton-Greif et al., 2014)
- 18-item parent-reported questionnaire
- Provides scores across 3 domains
- Impact on daily activities
- General worry
- Feeding difficulties
- Good psychometric properties (well validated)
Physiological measures assessment
Cervical Auscultation (CA):
Stethoscope
◼ Paediatric/neonatal bell
Lapel microphone
◼ Washer
◼ Adhesive
◼ Amplifier
Observe before, during and after oral feeds:
◼ Respiratory rate/distress
◼ SSB coordination
◼ Possible aspiration
◼ Biofeedback for parents to learn to pace feeding
Pulse Oximetry:
Transcutaneous, toe/finger clip
Observe before, during and after oral feeds
◼ Recommend SaO2 > 90% before commencing feeds
◼ Biofeedback for parents learning to pace feeding
◼ Consider other causes for desaturation
Instrumental assessment measures
Video Fluoroscopic Swallowing Study (VFSS)
Paediatric specific issues
◼ Barium mixed with age-appropriate foods/fluids
◼ Alter feeding utensils, positioning, pacing and fatigue
◼ Some adult strategies and manoeuvres not possible
◼ Assessment of breastfeeding not possible
◼ Compliance issues
◼ Radiation exposure
◼ Facilities
Necessary equipment:
- Liquid barium
- Milk/drink (usual consistency/thickened)
- Appropriate solids (mix with/coat with barium)
- Several spoons
- Range of teats (usual, restricted flow, variable flow, greater flow, soft)
- Range of bottles (regular, squeeze)
- Syringe +/- teat
- Toys to distract
- Parent to feed
Fiberoptic Endoscopic Evaluation of Swallowing (FEES)
- Not common in paediatric management yet
- Disadvantages in paediatric population:
- Compliance issues
-Invasive
- Facilities
- Cannot see functioning of airway
during swallow
When are VFSS or FEES required
In the majority of cases, clinical assessment will be adequate for children with feeding and swallowing difficulties
In some cases, questions you have about a child’s
presentation will not be able to be answered with clinical assessment alone
→ Instrumental assessment required
A clinical assessment should always preface and guide your instrumental assessment
