Palmer S Feeding Problems in Children

• Journal List
• Paediatr Child Health
• v.3(1); Jan-Feb 1998
• PMC2851259

Paediatr Child Health. 1998 Jan-Feb; 3(1): 21–27.

Language: English | French

Feeding problems in infancy and early childhood: Identification and management

Abstract

The purpose of this paper is to present a structured method to assess and manage feeding problems in children under three years of age and a newly developed instrument to assist in the assessment and monitoring of these feeding problems. Simple management strategies and practical suggestions are described, derived from clinical experience and a pertinent review of the literature. Because feeding problems are so prevalent (affecting up to 35% of infants), the use of structured parent questionnaires, interviews and observation scales is important when assessing and managing these problems.

Keywords: Feeding assessment, Feeding problems, Food aversion, Food refusal, Infancy

RÉSUMÉ :

Le présent article vise à présenter une méthode structurée d'évaluation et de prise en charge des problèmes d'alimentation chez les enfants de moins de trois ans ainsi qu'un nouvel instrument permettant de contribuer au bilan et à la surveillance de ces problèmes d'alimentation. On y décrit des stratégies de prise en charge simples et des suggestions pratiques tirées de l'expérience clinique et d'un examen pertinent de la documentation scientifique. Puisque les problèmes d'alimentation sont très prévalents (ils touchent jusqu'à 35 % des nourrissons), le recours à des questionnaires structurés aux parents, à des entrevues et à des échelles d'observation s'impose.

Feeding problems are estimated to occur in up to 25% of normally developing children (1) and in up to 35% of children with neurodevelopmental disabilities (2). One common definition of feeding problems is the inability or refusal to eat certain foods (2,3). Problems with feeding may lead to significant negative nutritional, developmental and psychological sequelae (4–7). Because the severity of these sequelae is related to the age at onset, degree and duration of the feeding problem (8), early recognition and management are important. The purpose of this paper is to provide guidelines to identify feeding problems in the first three years of life; to present a newly developed instrument to assess the presence of feeding problems and monitor the effects of management; and to describe basic management strategies that may eliminate or improve feeding dysfunction.

IDENTIFYING FEEDING PROBLEMS

Issues of definition and classification

The identification of feeding problems in infancy and early childhood is no simple task because there is no universally accepted definition or classification system (6,9). Furthermore, feeding problems are heterogeneous in nature as illustrated by the following list of symptoms of young children with feeding problems: multiple food dislikes (food selectivity, 'pickiness') (2); partial to total food refusal (10); difficulty sucking, swallowing or chewing (2); vomiting (10); colic (10); prolonged subsistence on inappropriate textures (inability to graduate to textured foods) (2); delay in self-feeding (2); tantrums and other problem mealtime behaviours (2); rumination (9); and pica (9). In addition, etiological factors contributing to feeding problems are often multifactorial and may interact to lead to the final clinical picture of a child with feeding and/or swallowing problems (Figure 1).

Decision tree for assessment and management of feeding and/or swallowing problems. GI Gastrointestinal; OT Occupational therapist; SLP Speech and language pathologist

Clinical assessment

Given that feeding problems in childhood are complex, multifactorial and lack universally accepted definitions and classification systems, health professionals need to rely on clinical assessments to determine the presence of such problems. A comprehensive clinical assessment, including parental report (parents' perceptions of mealtime behaviours and nutrient intake), review of the child's health and developmental, feeding and growth history, and observation of a meal, may help to identify the presence and severity of a feeding problem.

Parental report:

An established part of child health supervision includes asking caregivers about their child's feeding (11). Simple questions such as "How often do you find your child is difficult to feed?" can help 'quantify' the caregiver's experience with the feeding problem. More open-ended questions, such as "How do you find your child is doing with feeding?", may provide additional information. Despite its usefulness in identifying the presence of some feeding problems, parental report may not be the most reliable method to detect feeding problems. Parents may not be aware that their child has a feeding problem (12). For instance, Linscheid (12) presented the case of a mother who reported that her child was feeding well, only to discover on further questioning that the child only ate in the bathtub. On the other hand, some parents may be so anxious about feeding their child that they perceive minor problems as major (6).

However, the monitoring of parents' subjective experience of their child's feeding may indicate problems with feeding. This monitoring can be facilitated by using instruments such as the newly developed Infant Feeding Behaviours – Parent checklist (Appendix 1). Using this checklist, the parent is asked to rate 30 behaviours that might be exhibited by their child at mealtimes on a five-point Likert-type scale. A high rating suggests that the behaviour occurs almost always or that it is perceived as a significant problem. A total score is derived by adding parents' ratings of each of the 30 items. The higher the total score, the more severe the feeding problem is perceived to be by the parent. A decrease or increase in the total score over time may signal an improvement or deterioration in the feeding problem (13). Nutrient intake records or 'food diaries' may reveal information about current feeding practices. The parent is asked to document prospectively all foods consumed by the child over a three-day period. Alternatively, for the child who eats or drinks only one or two items daily, 24 h recall may be sufficient. Analysis of three-day food diaries or 24 h recall can provide information about the types, textures and volumes of foods ingested, duration of the meal and mealtime schedules. A detailed food diary may help to identify children who are fed textures that are developmentally inappropriate, for excessively long or short periods and 'on demand' versus a structured schedule.

Review of health, and developmental, feeding and growth history:

A review of the child's health history provides information about medical conditions that may contribute to feeding and/or swallowing problems (Figure 1). For instance, feeding and/or swallowing problems may be associated with any combination of the following: neurological deficits (eg, cerebral palsy); anatomical/mechanical problems of the upper airway (eg, choanal atresia); acquired/congenital defects of the oral cavity, larynx, trachea and esophagus (eg, cleft palate, tracheoesophageal fistula); drug side effect (eg, chemotherapy); chronic illness (eg, gastroesophageal reflux, cardiac and lung problems); multiple food allergies; and genetic or metabolic disorders (eg, Down syndrome, phenylketonuria) (14). In addition, traumatically acquired conditioned dysphagia (15) and post-traumatic feeding disorder (16) have been described as possible causes of persistent feeding problems. Traumatically acquired conditioned dysphagia and post-traumatic feeding disorder may result from repeated exposure to noxious substances, experiences or procedures (eg, choking, vomiting, forced feeding, repeated suctioning or insertion of tubes for feeding) in and around the mouth. The prevalence of these types of feeding problems may be on the rise because advances in medical technology enable more children with severe illnesses to survive. A comprehensive review of all health problems that may contribute to feeding and/or swallowing difficulties is beyond the scope of this paper. Extensive lists of medical diagnoses associated with feeding problems may be found elsewhere (14).

Furthermore, it is important to identify infants and young children with swallowing dysfunction. These young children may have an inability to protect their airway during feeding, thus rendering oral feeding unsafe. Symptoms of swallowing dysfunction may include history of recurrent pneumonias, respiratory illnesses, slow feeding, oral or nasal regurgitation, gagging, choking, or coughing before and/or during the swallow. When swallowing dysfunction is suspected, further clinical and laboratory evaluation (4,14) is necessary to ensure a safe swallowing mechanism.

However, feeding problems are not encountered exclusively in children with health problems (Figure 1). For instance, problems with regulation of internal states (17), sensory integration, quality of caregiving and behavioural mismanagement (eg, excessive parental anxiety at mealtimes, forced feeding) may play an important role in the development of feeding problems in early childhood (2,3,18). Quality of caregiving should be suspected as a possible contributing factor to the feeding problem when the parent is angry with the child, is overwhelmed by the feeding problems, has become indifferent towards the child (eg, has given up) or complains that the child's feeding problems are affecting other family members and/or other areas of family life.

An in-depth feeding history not only provides information about present feeding habits but also investigates feeding patterns from birth. Benoit (19) developed a Feeding History Questionnaire that is completed by the caregiver and may be useful clinically. The questionnaire inquires about progression to various textures, choking and other traumatic incidents, pica, duration of meals, feeding schedule, food intolerance, preferred foods and textures, previous treatment of feeding problems, and family history of eating/feeding disorders.

A review of growth parameters – height and weight – is an essential part of any comprehensive assessment of feeding problems because it can help to identify children with growth failure. A discussion of growth failure or failure to thrive is beyond the scope of this paper. However, it is important to emphasize that there is no empirical evidence documenting the frequency of association between feeding problems and growth failure (9,20).

Mealtime observation:

Observation should focus on child-feeder interactions, the child's oral motor skills and behaviours, the caregiver's responses to adaptive and maladaptive feeding behaviours, and the feeding's surroundings. To guide and organize observations, structured instruments such as feeding interaction scales (21) and child maladaptive feeding behaviour scales (Appendix 1) can be used. Table 1 provides some guidelines for mealtime observations.

TABLE 1:

Mealtime observation guidelines

1. A. General observations

   1. Positioning of the child. Is the child positioned in a developmentally appropriate manner?

   2. Surroundings. Are toys/distractions used to coax the child to feed? Are the surroundings noisy (eg, loud music, television, etc)?

   3. Types and amounts of food offered and consumed. Are they developmentally appropriate?

   4. How typical is the observed meal compared with meals at home?

2. Interactions between feeder and child

   1. How does the feeder offer the food? Is the child coaxed, distracted, entertained to eat? Is the feeder angry, intrusive, anxious, unavailable for interaction, too laid back? Is the child given the opportunity to self-feed if age appropriate? Is the food offered too quickly or too slowly? Is the child force fed? How does the feeder react to oppositional behaviours and/or adaptive eating behaviours?

   2. Is the child defiant, provocative, compliant or passive in response to the feeder's requests? Are oppositional behaviours (tantrums, pushing/throwing the food, etc) present?

3. Child's behaviours at mealtime

   1. The child's willingness to accept food. Does the child try to self-feed if age appropriate? How competent is the child at self-feeding? Does the child accept food willingly? Is the child eating too fast/too slowly? Does the child eat enough?

   2. How is the food handled once inside the mouth? Is the food swallowed? Is there obvious nasopharyngeal reflux, poor suck, coughing, gagging, vomiting, spitting, loss of food from the sides of the mouth? Does the child hold food in the mouth for extended periods of time?

   3. How does the meal end? Is the feeder or child frustrated or calm and relaxed?

MANAGEMENT OF FEEDING PROBLEMS

Many parents and health professionals fail to identify or underestimate the severity of feeding problems (12) and often use a wait-and-see approach (3,22). Unfortunately, the wait-and-see approach may make treating feeding problems more difficult for four major reasons. First, mealtimes with young children who have feeding problems are often very frustrating and anxiety-provoking for the child, the feeder and the entire family (6). The longer these mealtime conflicts persist, the more resistant they become to change (3,19). Second, the delayed introduction of developmentally appropriate foods at critical or sensitive periods may interfere with the expected progression of oral motor skills (5). Third, persistent feeding problems may lead to nutritional deficiencies that may be severe enough to warrant supplemental tube feeding (7). Fourth, children with unidentified swallowing dysfunction may develop chronic lung disease or die as a result of aspiration pneumonia (14). Early identification and management may prevent these problems (11,22).

A comprehensive clinical assessment should provide the information needed to develop the most appropriate management plan. When underlying health problems are identified as the major contributors to the child's feeding problems, they should be managed accordingly. A detailed discussion of the medical and/or surgical management of all health problems associated with feeding problems is beyond the scope of this paper.

In addition to treating the underlying health problems, three main questions should be addressed simultaneously when developing a management plan: Does the child have growth failure? Is the child safe to feed (and if so is the child able to eat? and is the child willing to eat?)? Is there a feeder-child relationship problem? (Figure 1). The answers to these questions should direct intervention strategies. For instance, infants and children who demonstrate significant growth failure and/or inability to protect their airway during feeding may require supplemental tube feeding to achieve nutritional rehabilitation and/or prevent pulmonary aspiration. In addition to tube feeding, infants who are unable to swallow safely may require an oral stimulation program (if considered safe) in an attempt to prevent oral hypersensitivity (4,7,14).

Infants who are able to swallow safely but are unable to eat, such as a child with cerebral palsy, may be willing to accept food placed in the mouth but may not have the motor ability to place the food in the mouth him- or herself, chew and move the bolus efficiently. Children with these types of feeding problems may benefit from occupational therapy or speech-language pathology interventions. These interventions focus on oral motor skills (eg, increasing strength and range of motion of oral motor structures, preventing hypersensitivity, promoting proper positioning, bolus modification) while encouraging positive parent-child interactions (2,4,7,14).

Infants and young children who are able to swallow but are unwilling to eat may turn the head away and refuse to open the mouth when the food is offered, may spit the food out or hold it in the mouth for extended periods. Children who are unwilling to eat may benefit from behaviour modification programs. Behaviour modification techniques have been reviewed elsewhere (3,12,14). These interventions focus on increasing the frequency of adaptive behaviours (ie, appropriate feeding behaviours) and decreasing the frequency of maladaptive behaviours (Appendix 1). The basic management strategies described in Table 2 are examples of simple and generic behaviour modification techniques that may be used individually or in conjunction with other more specific and refined techniques.

TABLE 2:

Basic management strategies

1. A. Physiological and environmental changes (for all ages)

   1. A structured mealtime schedule (eg, every 4 h) should be provided. No food or drinks are permitted between scheduled meals. However, if the child is thirsty, water may be offered for up to 2 h before the next scheduled meal.

   2. Meals should be time limited, eg, 30 mins.

   3. The child should be fed in a quiet place with few distractions (eg, no loud radio or television, no toys).

   4. The feeder should have a calm, positive attitude at mealtimes.

   5. The child should be positioned comfortably and in a developmentally appropriate 'seat', ie, high chair, if the child is able to sit independently.

   6. A limited number of feeders (ideally one person) should feed the child.

2. 'Food rules' (for children with self-feeding skills) (25)

   1. The child should be encouraged to self-feed as much as possible.

   2. Food should not be given as a present or reward (8).

   3. Mealtime is not playtime. Games should not be used to coax the child to feed (8).

   4. Food should be removed after 10 to 15 mins if child seems to play with the food without eating.

   5. The meal should be terminated if the child throws food in anger.

3. 'Mealtime rules' (for children with self-feeding skills) (11,22)

   1. Limits for the circumstances surrounding the ingestion of food should be set. A set of mealtime rules should be set (eg, remain seated, use silverware not fingers, no throwing of food). The rules should be reasonable and based on the age of the child, starting with two to three rules and gradually adding a few more rules until the child has learned appropriate mealtime behaviour.

   2. Mealtime rules should be explained without nagging before each meal until the child is complying consistently.

   3. Mealtimes should be pleasant; children should be included in conversations. Mealtimes should be an opportunity to praise appropriate behaviours. Children cannot be praised too often. Nagging the child to hurry should be avoided.

   4. If mealtime rules are broken, the child should practise correct behaviours. The third time that the rules are broken, the child should be disciplined with a time-out.

   5. Small portions of foods should be offered. The child should be praised for eating the amount provided. The amount of food required to receive praise should be gradually increased.

   6. When mealtime is up, plates should be removed from the table regardless of whether the child is finished. If the child has not finished the meal, the food should be removed without lectures or condemnation for not eating. If the child has not finished the meal, no dessert or snacks should be offered until the next meal. If the child continues to whine and ask for snacks, a time-out is required. Parents should not 'give in' and allow the child to eat snacks, this will only make the teaching process much longer.

When problems between the parent and child are suspected, referral to a mental health professional should be made for further assessment and treatment. If it is determined that no parent-child relationship problem exists, support for parents should be provided.

Because feeding problems are complex and multifactorial in nature it is often necessary to have several disciplines providing intervention to one child at any given time. The decision tree illustrated in Figure 1 provides some guidance in choosing appropriate interventions for the management of infants and young children with feeding problems.

Finally, it is important to recognize that an integral part of management includes appropriate follow-up. Follow-up should include weight monitoring, a review of the child's nutrient intake (feeding diaries) and monitoring of management strategies (by observing a meal and inquiring about ease of implementation, and the child and caregiver's progress).

CONCLUSION

Although feeding problems are estimated to affect one in three to four infants and young children, there are no universally accepted methods of management. This may reflect, in part, the heterogeneity of feeding problems and the lack of a unifying classification system. Yet the early recognition of feeding problems is important because it may prevent simple feeding problems from becoming pervasive or resistant to treatment (11,22). In this paper, a systematic approach to the assessment and management of feeding problems is proposed based on clinical experience and findings from the literature.

The use of parent questionnaires and observational rating scales, in addition to a structured clinical interview, is important when assessing infants and young children with feeding problems. Indeed, such instruments provide clinicians and researchers alike with structured ways to collect information, to compare individual children and larger groups, to identify the presence of feeding problems, to 'quantify' the severity of the feeding problems, and to measure the effectiveness of treatment. The failure to use structured assessment protocols and tools that permit comparison of subjects across studies has greatly impeded research in the field (9). An important focus of future research is the validation of instruments such as the Infant Feeding Behaviours – Parent and Rater checklists, the Feeding History Questionnaire, and other parent questionnaires and observational measures that help to structure assessment and treatment protocols of young children with feeding problems.

Poor outcomes associated with feeding problems early in life have been documented, including detrimental effects on family life (6) and behavioural problems (3,23) and eating disorders such as anorexia nervosa and bulimia (24). These serious short term and long term sequelae emphasize the importance to treat feeding problems early. The question of when interventions such as behaviour therapy, multidisciplinary approach nutrition counselling and occupational therapy should be used to treat young children's feeding problems needs to be examined formally. More research is clearly needed to understand which single or combined treatment methods are the best to treat which feeding problems.

Appendix 1) Parental report of problem feeding behaviours

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