Financial disclosures Dr Sanchez receives salary from: Protea - PDF document

2/12/20 Financial disclosures • Dr Sanchez receives salary from: – Protea Therapy (co-owner) – The Informed SLP PEDIATRIC FEEDING – Murdoch Children’s Research Institute – The University of Melbourne It’s Not Just Small Potatoes – La Trobe University Dr Katherine Sanchez • No relevant non-financial disclosures exist Learning objectives • Use correct current terminology to describe and diagnose issues in pediatric feeding • Discuss the bases of pediatric feeding problems in young children • Identify at least three different therapeutic DEFINITIONS approaches to address pediatric feeding disorders in young children • An eating or feeding disturbance (e.g., apparent lack of interest in eating or food; avoidance based on the sensory characteristics of food; concern about aversive consequences of eating) as manifested by persistent failure to meet appropriate Terminology nutritional and/or energy needs associated with one (or more) of the following: • Significant weight loss (or failure to achieve expected weight gain or faltering growth in children). • Significant nutritional deficiency. • Picky/fussy/selective eating • Dependence on enteral feeding or oral nutritional supplements. • Feeding disorder/problem/delay/difficulty/impairment • Marked interference with psychosocial functioning. • The disturbance is not better explained by lack of available food or by an associated • Pediatric dysphagia culturally sanctioned practice. • The eating disturbance does not occur exclusively during the course of anorexia • Avoidant/restrictive food intake disorder nervosa or bulimia nervosa, and there is no evidence of a disturbance in the way in which one’s body weight or shape is experienced. • Eating disorder not otherwise specified • The eating disturbance is not attributable to a concurrent medical condition or not • Infantile anorexia better explained by another mental disorder. When the eating disturbance occurs in the context of another condition or disorder, the severity of the eating disturbance • Oral/feeding aversion exceeds that routinely associated with the condition or disorder and warrants additional clinical attention. • Tube dependence 1

2/12/20 Eating disorders (e.g. anorexia or bulimia nervosa) Fussy/picky/selective eating Pediatric Feeding Disorder ARFID Tube dependence Oral and/or pharyngeal dysphagia Oral/feeding aversion Normal feeding development CAUSES AND CONTRIBUTORS Early experiences Inherent vulnerabilities • Preterm birth • Neurodevelopmental • Medically/surgically • Neurological complex • Craniofacial • Attachment issues • Other body systems • Trauma • Sensory processing • Temperament 2

2/12/20 External factors Where are the bumps? • Caregiver input • Neonatal period • Challenging • 3-4 months environment • Introduction to solids • Trauma • Texture transition • 12-18 months • 2-4 years Looks like … • Dysphagia • Refusal or avoidance • Food neophobia • Restrictions by taste, texture, or other sensory properties • Rigidities • Limited quantity APPROACHES TO FEEDING • Challenging mealtime behaviour THERAPY • Need for lots of compensatory strategies External motivation External motivation Internal motivation Internal motivation 3

2/12/20 Feeding behaviours: Feeding behaviours: • Avoidance • Avoidance • Refusal • Refusal • Neophobia • Neophobia • Restrictions • Restrictions • Rigidities • Rigidities • Tantrums • Tantrums Internal barriers: Internal barriers: • Oral sensorimotor issues • Oral sensorimotor issues • Sensory integration issues • Sensory integration issues • GI discomfort/dysfunction ( • GI discomfort/dysfunction ( constipation, allergies, into constipation, allergies, into poor motility) poor motility) • Other medical issues (e.g. r • Other medical issues (e.g. r cardiac) cardiac) • Tube dependence • Tube dependence • Anxiety • Anxiety Feeding behaviours: • Avoidance • Refusal • Neophobia • Restrictions • Rigidities • Tantrums Implicit training Explicit training Internal barriers: • Oral sensorimotor issues • Sensory integration issues • Tube dependence • Anxiety External motivation Implicit training Explicit training STRATEGIES IN FEEDING THERAPY Internal motivation 4

2/12/20 ‘Nudges’ Environmental therapies • Mostly shown to be effective • Division of Responsibility with typical ‘picky eaters.’ • Cue based feeding • Visual supports – Reading books about food • Mealtime modifications: – Playing with pretend food – Scheduling – Watching cooking shows – Family mealtimes – Eating off plates with food – Specific location pictures – Family style service – Removal of distractions Exposure therapies Operant conditioning therapies • Repeated exposure • Contingencies • Systematic desensitisation (rewards and punishments) • Food chaining • Taste fading/blending • Non contingent reinforcement • Bite/portion fading • Involvement in food • Escape extinction preparation • Physical guidance • Modeling Bolus modification therapies Motor therapies • Developmental texture • Posture and positioning grading • Physical guidance • Thickening fluids • Selecting foods to promote • Giving smaller or certain motor skills larger boluses • Using tools or implements • Varying the sensory to promote certain motor input from a bolus skills 5

2/12/20 Caregiver training Other therapies • In any of the above strategies • Appetite manipulation – Instruction (verbal, written) • Nutritional – Modeling • Sensory – Rehearsing • Family therapy/counseling – Role play • Pharmaceutical – Videofeedback • Surgical All therapy approaches and programs are combinations of strategies from this list EVIDENCE BASED PRACTICE 6

2/12/20 Limitations of the science Best supported • There’s not much treatment research • Operant conditioning • Some approaches have received much • Operant conditioning + more funding than others • A lot of treatments and strategies are extrapolated from population-level or obesity-focused research • What’s there tends to be low level, and/or low quality Low or no evidence • Exposure • Environmental • Motor • Bolus modification • Other Internal evidence • Form a hypothesis • Design and conduct an experiment • Collect and evaluate the results • Modify practice accordingly 7

2/12/20 Child considerations Family considerations • How old is the child? • What is the family’s capacity? • What is the cause of the PFD? • What is the family’s parenting approach? • What is the presentation of the PFD? • How much struggle is tolerable? • How does this child respond to pressure/ • Is there significant time pressure? demands? • Are there financial pressures? • Are there significant safety concerns? • What are the child’s care arrangements? • What has been effective or ineffective in the past? Also … • Consider restrictive practices and the experiences of Autistic adults WHERE TO NOW? 8

2/12/20 Free learning Books • ‘Helping Your Child with Extreme Picky Eating’ • PFASE • ‘Love Me, Feed Me’ • Holland Bloorview Feeding and • ‘How to Get your Child to Eat (but not too much)’ Swallowing Handbook • ‘Pre Feeding Skills’ • ‘Anxious Eaters, Anxious Mealtimes’ • Ellyn Satter Institute • ‘Child of Mine: Feeding with Love and Good Sense’ • ‘Broccoli Boot Camp’ • Podcasts (Tube to Table, First Bite, Down • ‘Raising Healthy, Happy Eaters’ the Hatch) • ‘Adventures in Veggieland’ Paid courses Evidence • Lots available! • SLP journals • Child development/GI/nursing/dietetic journals • Google Scholar and PubMed • Evidence translators 9