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Feeding Issues in Special Needs Kids

Solomon Behar, MD, Michael Cosimini, MD, and Cheryl Garden, OT
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Sol, Michael and Cheryl discuss children with special needs and their unique feeding issues and strategies to improve feeding.

 

Pearls:

  • A three day feeding diary including what time a child ate and what they ate can be a good tool to get a better sense of how meals are going at home.

  • Families should always attempt to eat at least one meal as a family as an opportunity to role model normal feeding behavior.

  • In children with feeding issues typically three, and no more than four, different foods should be presented at once with at least one prefered food available.

  • New foods should be introduced in a gradual fashion starting with non-threatening interaction with food during which eating the food is not expected.

 

  • This segment addresses feeding issues in children with special needs including autism and cerebral palsy. Feeding issues in children with autism are common with between 25-89% of children with autism having some degree of feeding problems. Boys between four and 16 years of age with autism have been found to have higher rates of both overweight and underweight than matched controls and may have micronutrient deficiencies in their diets.

  • Castro K et al. Feeding behavior and dietary intake of male children and adolescents with autism spectrum disorder: A case-control study. Int J Dev Neurosci. 2016 Oct;53:68-74. PMID 27432261.

  • When a family is concerned about behavior issues around feeding or food refusal what questions can we ask to get a better sense of how feeding is going at home?

    • Try to get a sense of what mealtime looks like. Does the family eat together or does the child eat alone first? What types of foods are being offered?

    • What is the emotional setting for the meal. Does the child simply not want the specific foods that are being offered or is the mealtime something that is dreaded by the whole family and seen as a chore.

    • What strategies does the family use to get a child to eat? Are they placing the child in front of the IPad and feeding them or using other distraction techniques that should not be needed for typical feeding? Are the parents chasing the child around the house trying to get food in?

    • A three day diary of what a child eats and when can help get a good sense of the situation as well.

  • When we identify a problem, like a family chasing the child around the house to get them to eat a bite, what can we as pediatricians advise the family to do?

    • Number one as the medical provider  is to makes sure the nutritional status is OK. If this is the case the first recommendation is that parents need to back off. If a child is refusing foods they are trying to communicate that something does not feel right. The more you try to force a child to eat this reinforces negative behaviors and food refusal.

    • The other important piece of general guidance is to encourage family mealtime if only for one meal. Family should role model normal food behavior. Put a plate in front of the child and do not force them to eat. If  touch or eat the food  give lots of praise and make a big deal about it to further encourage the desired behavior.

  • Aside from chasing a child around the house to get them to feed or parents dreading mealtime how else can we identify a behavioral feeding problem? The term behavioral feeding problem is not really a diagnosis. This is a term that means there are behaviors that are maladaptive to eating.

    • Often there is some underlying source of the behavior like pain or a medical problem. For example an infant who has severe untreated reflux may learn that eating causes pain and then refuse to eat even after the reflux is managed.

  • Specifically with autism what feeding problems should we expect to address? With a child with autism or developmental delay, you're not looking at motor control or a mechanical feeding problem. They can use their mouth normally, they can chew, they can swallow.

    • There is often something from a sensory standpoint that they do not like. There is an aversive response because the food does not feel good in their mouth, does not smell good, feels weird, or looks weird.

    • Children with autism can be very ritualistic and routine is important and everything has to be predictable and the same all the time. Food is not typically like this. This leads to issues where a child will only want macaroni and cheese from a specific brand. This type of food is very predictable with a consistent color, texture and taste.

  • How can we ensure proper nutrition in a child who really will refuse all but a few foods?

    • In a child who has severe issues like this there can be significant issues. Families cannot got to a party or a restaurant as the child will not be able to eat. Children like this should be referred to occupational therapy for feeding therapy. Therapy can work in a gentle and slow way to introduce new foods.

  • How can new foods be introduced? It needs to be a gradual process. You cannot just go from macaroni to broccoli.

    • You may want to start with foods with similar textures, colors or tastes. For example going from macaroni to a cheese stick to a carrot dipped in sauce.

    • The first step with a new food is not eating the food. It may be simply accepting it on a plate. You can then work stepwise getting close to eating the food. For example smelling than licking,

    • Another good general rule is not to offer more than four foods on the plate at a time. Parents may be trying many different things all at once to try to find a food the child will accept. This can be overwhelming for the child and is not an effective strategy. The plate should typically have only three different things on it and at least one should be a prefered food that they know the child will eat.  

    • Introduction to new foods does not need to occur during mealtime. The initial exposure should be in a non-threatening fashion where they are not expected to put the food in their mouth,  Having the child use a new food in the context of an art project can be a way to introduce a new food.

    • *Editor’s note: specific steps for  introduction of new foods as well as other guidance for feeding issues in children with autism specifically can be found here: Mealtime Challenges and the Autism Spectrum

  • Outside of autism where else do you commonly see feeding issues? Children born prematurely are a group where feeding issues are common, children who have gotten chemotherapy and mucositis in the past can develop aversions, or children with other gastrointestinal problems like reflux or short gut syndrome.

  • What about cerebral palsy? In cerebral palsy there can be sensory issues but there is usually a motor problem.

    • Children need to chew food and manage it in their mouth then move it back to swallow the food the control of these functions can be affected in CP. There can be problems with the swallowing mechanism as well.

  • How do we figure out if there is a problem here? Do we just ask history in regards to coughing, choking or do we need a barium swallow? You do not need a barium swallow.

    • Good things to evaluate on history are.

      • What do mealtimes look like and what does the child eat. What are the textures and consistencies they will take.

      • How long does a meal take? Meals longer than 20 minutes can suggest a problem

      • Do they have signs of swallowing dysfunction like coughing, choking, watery eyes, congestion after eating. Is there a pattern in what type of fo

      • Do they get frequent sinus infections or pneumonia.

    • While the child is in the office you can look at:

      • Assess the child's control of the trunk, head and neck.

      • Is the child’s mouth open constantly.

      • Observe a feed in the office

      • How are they growing.

    • When is a barium swallow study needed? The barium swallow study would only be needed if there are concerns for the swallowing mechanism and an occupational therapist may be needed to help decide if this is the issue.

      • When you have this concern children should  be sent to a occupational therapist to get a good history and figure out what part of feeding is the issue. A barium swallow study only assesses if  the pharyngeal phase of swallow is intact. It will not help with other common issues like problems with the tongue or lips. In a modified barium swallow study the occupational therapist will try different textures and positions to see what is the safest and most effective way to feed.

      • Some doctors will also order this study when there is pulmonary disease and silent aspiration is suspected.

  • Are there any groups of patients that should always have an occupational therapy assessment?

    • Premature infants will often need help, especially if they have been fed with a feeding tube.

    • Anyone that has needed tube feedings.

    • Patients who have been on total parenteral nutrition.

    • Any child with food refusal.

What leads to feeding problems  in premature infants? They can show signs of gagging and retching as food is moved near their face. There are having a noxious sensation from the food. They are accustomed to being in the dependant position with things coming at them like oxygen, breathing treatments and other negative stimuli. When food is offered it feels foreign and nauseating to them.

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How to Rid the Kid of the Id (reaction) Full episode audio for MD edition 195:18 min - 92 MB - M4AHippo Peds RAP February 2017 Summary 329 KB - PDF

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