8/19/2018 Understanding Feeding Challenges in Young Children - PDF document

8/19/2018 Understanding Feeding Challenges in Young Children Noreen Clarke, DNP , RN, CNS Olivia Hsin, PhD Karen Park, OTD, OTR/L, BCP , SWC, CLE Anet Piridzhanyan, MS, RD GROW Symposium 2018 | Children’s Hospital Los Angeles Objectives • Understand the early developmental signs of potential feeding challenges in young children. • Identify the multiple interrelated factors that impact feeding and eating in young children. • Describe some developmental, medical, environmental, sensory, and nutritional considerations when feeding difficulties are identified. 2 Case Study Jan… • 3 year 5 month old girl female • Hx of underweight; <5 th percentile • Diet: vanilla yogurt only; does not chew food • Hx of force feeding by caregiver What else do you need to know? Who would you want to consider collaborating with? 1

8/19/2018 Overview I. Feeding Challenges II. Early Identification: Factors that Impact Feeding III. Interventions I. FEEDING CHALLENGES Normative Picky Eating versus Feeding Difficulties Normative Picking Eating • Can tolerate touching or tasting food. • May have preferences but are able to tolerate different brands of same food. • Eat a variety of textures. • Can accept new foods after a few exposures (~15). • After burning out on a food, food is regained quickly after a break. • 40% of children continue to have picky eating after 2 years. 6 2

8/19/2018 More than Picky Eating When does it become a problem? • Nutritional deficit • Impairment on functioning – Individual • Anxiety, crying, or other distress around new food • Behavior problems – tantrumming, throwing food – Parent • Stress, time spent – Parent-Child Relationship • Battles at most meals – Spousal Relationship 7 Prevalence • 8-50% of children have feeding concerns: – picky eating – selective eating – challenging feeding problems • Feeding difficulties are found more often in children with special health care needs (CSHCN). 8 Feeding in Children with Special Health Care Needs Feeding Difficulties in.. • Children with chronic medical concerns: – 40-70% have feeding difficulties • Children with developmental disabilities: – Up to 80% have element of a feeding disorder – 3-10 % have severe feeding disorders • Children with Autism Spectrum Disorder: – Up to 87% have feeding difficulties 9 3

8/19/2018 Normative Picky Eating versus Feeding Difficulties Feeding Difficulties - Difficulties related to feeding that impact physical or emotional health may consist of.. • Food and/or liquid refusals • Food selectivity o by type (pasta versus tortillas) o by texture ( mushy foods, wet foods, pasta with sauce, pizza) o by brand (only McDonald’s fries or only Tyson brand nuggets) o by shape (rotini but not spaghetti) Oral motor problems/not advancing textures • Dysphagia (swallowing disorder) • 10 Normative Picky Eating versus Feeding Difficulties Feeding Difficulties continued.. • Frequent vomiting • Reduced or absent self-feeding for developmental level • Inappropriate meal time behaviors • Stressful mealtimes • Long mealtimes • Feeding dependent on child being distracted (screen time) or sleepy 11 EARLY IDENTIFICATION: FACTORS THAT IMPACT FEEDING 4

8/19/2018 Factors Impacting Feeding Development • Medical • Structural, Physiological, and Sensory • Nutritional • Developmental • Experiential / Cultural / Psychological 13 Early Identification: Factors that Impact Feeding MEDICAL CONSIDERATIONS Medical Considerations History • Prenatal • Birth • Feeding • Developmental milestones • Parent’s understanding of feeding challenges 5

8/19/2018 Medical Considerations • NICU (birth trauma, prematurity, congenital malformations) • Dentition (caries, pain, trauma) Medical Considerations • GERD • Food allergies and Eosinophilic Esophagitis (EoE) • Delayed gastric emptying • Constipation Early Identification: Factors that Impact Feeding STRUCTURAL, PHYSIOLOGICAL, AND SENSORY CONSIDERATIONS 6

8/19/2018 Structural, Physiological, and Sensory Considerations • Developmental o Oral structures o Development of head/neck and postural control o Oral motor and swallowing coordination o Self feeding skills o Developmental expectations and readiness Structural, Physiological, and Sensory Considerations • Sensory Consideration o Sensory systems (olfactory, visual, auditory, tactile, gustatory, proprioceptive, vestibular) o Sensory experiences • Response to taste, texture, temperature • Hyperresponsiveness vs. hyporesponsiveness • Exploration o Sensory regulation and modulation o Praxis/motor planning Structural, Physiological, and Sensory Considerations • Sensory Consideration o Sensory systems (olfactory, visual, auditory, tactile, gustatory, proprioceptive, vestibular) o Sensory experiences • Response to taste, texture, temperature • Hyperresponsiveness vs. hyporesponsiveness • Exploration o Sensory regulation and modulation o Praxis/motor planning 7

8/19/2018 Structural, Physiological, and Sensory Considerations • Structure of mealtime routines o Distracted eating o iPad/TV as distractor • Physical space • Social environment o Isolated eating • Temporal environment Early Identification: Factors that Impact Feeding NUTRITIONAL CONSIDERATIONS Nutritional Considerations • Growth: more than any other assessment tool, reliably indicates the nutritional status of a pediatric patient. Growth o most rapid during infancy o decelerates during childhood o increase in velocity during puberty Protein and Energy Needs o Increased during infancy o decelerates during childhood o Increases during puberty 8

8/19/2018 Nutritional Considerations • Growth: indicates the nutritional status of a pediatric patient. • Medical conditions/diagnosis: can impact growth and assessment of energy and nutrient needs. • Medications: can impact appetite as well as vitamin/mineral absorption/reactions. • Overweight | underweight | healthy weight o Can still be malnourished in all three. o Ex. only eats chicken nuggets and tortillas with butter all day. Nutritional Considerations • Nutritional Support: can this child thrive on current diet alone? o Nutritional supplements/enteral feeding: separates delivery of nutrients/calories from the act of eating. • Opportunities for child to feel hungry: o Frequency of meals/snacks o Quality of foods in diet Ex. high intake of sugary sweet beverages –reduce appetite Ex. lack of fiber in diet –increase constipation / reduce appetite o Mealtime routine –what does it look like Nutritional Considerations • Overall goal of medical nutrition therapy is to improve the child’s health and nutritional status while promoting a family’s enjoyment of their child at mealtime.  Meeting nutritional needs to support growth / development.  Correcting energy imbalances.  Encouraging success with self feeding. • Family centered approach. 9

8/19/2018 Nutritional Considerations Nutrition Assessment answers 3 important questions: 1) Is the child being fed a diet that meets his/her nutritional requirements? 2) Is the child growing as expected for his or her age, gender, condition? 3) Is there a feeding or eating problem interfering with growth/ meeting nutritional requirements? Early Identification: Factors that Impact Feeding EXPERIENTIAL, CULTURAL, PSYCHOLOGICAL CONSIDERATIONS Experiential, Cultural, Psychological Considerations Community / Culture Parent / Caregiver Fam & Com. Child-comm. Child Parent-child 10

8/19/2018 Experiential, Cultural, Psychological Considerations Experience • Eating is not instinctive Community / Culture • Children can learn to Parent / Caregiver eat Fam & Com. Child-comm. Child Parent-child • Children can also learn NOT to eat 31 Experiential, Cultural, Psychological Considerations Children Learning to Eat • Parent smiles • Parent praises or pays attention to eating Children Learning to Eat • Child enjoys the taste • Child plays with the food • Child watches others eat and enjoy food • Child is successful with manageable foods EATING CAN BE FUN & I CAN DO IT! 32 Experiential, Cultural, Psychological Considerations Children Learning Not to Eat • Negative experiences in hospital with things being done near the face • GERD • Motor problems • Breathing problems • Ear infections or dental problems • Developmental delays • Parent-child arguments EATING IS HARD, PAINFUL, EATING IS HARD, PAINFUL, FRUSTRATING, OR ANXIETY-PROVOKING FRUSTRATING, OR ANXIETY-PROVOKING 33 11