Feeding Difficulties A Case Perspective

Transcription

1 Welcome to Allied Health Telehealth Virtual Education Feeding Difficulties - A Case Perspective Rachel Lindeback - Dietitian Khadeejah (Kady) Moraby - Speech Pathologist Sydney Children s Hospital Please complete your online evaluation at Feeding Difficulties A Case Perspective Rachel Lindeback - Dietitian Khadeejah (Kady) Moraby Speech Pathologist June 2017 Please complete your online evaluation at 1

2 Feeding difficulties Estimated to occur in 25% - 40% of normally developing children (Bryant-Waugh et al, 2010) Up to 80% of children with developmental delays (Bryant-Waugh et al, 2010) or chronic disease (Manikam & Perman 2000) 25% incidence of feeding problems in the normally developing infant population (Aldridge 2010, Levy 2009) Many early feeding difficulties are transient Feeding difficulties Up to 50% if reported by parents (Coulthard 2003) Food refusal and aversion are common in paediatric practice (Levy 2009) Multifactorial in nature May lead to significant negative nutritional, developmental and psychological consequences Severity is related to the age at onset, degree and duration of feeding problem Early recognition and management are important 4 Please complete your online evaluation at 2

3 Feeding difficulties Stressful for parents mothers of children with feeding difficulties have less problem solving skills (Martin et al 2013) Go to extremes (lengthy mealtimes, force feeding, distractions) Abnormal patterns of feeding exacerbate feeding problems Flags for feeding difficulties Dietetic Speech Pathology Insufficient food/fluid intake Coughing, choking, gagging during Poor weight gain or weight loss feeds Food refusal Noisy breathing, inspirational stridor Constipation Drooling or pooling of secretions Dehydration Recurrent chest infections Joint focus Infant/maternal distress Maternal report Lengthy feed times (longer than 30min) Slow to feed, fatigue Stressful or difficult mealtimes Please complete your online evaluation at 3

4 Feeding difficulties as a continuum Typical fussy childhood behaviours slow eater, better with preferred foods, adequate volumes consumed repeatedly requests a particular food strong preference for how food is presented refuses particular food groups (vegetables, meat) cautious with trying new foods difficult at mealtimes too busy playing Adapted from The Royal Children s Hospital, Melbourne, Problematic feeding behaviours never hungry, very lengthy mealtimes, poor intake and growth unable to cope if food not presented in preferred way wide range of foods refused, range becomes more limited over time, choices made on sensory features of food distressed when presented with new foods disruptive behaviours at mealtimes Red flags for problem feeders Refuses new foods despite repeated presentation Acceptance of food may be rigid incorporating factors that do not relate to the food itself Diet becomes more restricted over time Additional sensory processing difficulties shown as dislike for complex tactile inputs 8 Please complete your online evaluation at 4

5 Food Neophobia The reluctance to eat, or the avoidance of, new foods (Dovey, TM et al, 2008) Infants and children are predisposed to be neophobic and reject new foods Survival instinct - emerges around months Peaks between 2-6 years of age (Addesi et al, 2005) Food Neophobia Associated with lower dietary quality and variety Experiences with food strongly influence children s preferences and intake - familiarity is the most important determinant of a child s liking for a particular food - put simply, children like what they know and they eat what they like (Birch & Fisher 1998, Cooke 2007) Please complete your online evaluation at 5

6 Food Neophobia Repeat exposure to unfamiliar tastes reduces neophobia: The later a new food is introduced, the more exposures may be needed (Birch & Fisher 1998, Cooke 2007) Despite a plethora of factors affecting the normal child s expression of food neophobia, one factor above all will predict how quickly the child overcomes it. This factor is experience. (Dovey,TM & Martin, C. 2010) Food Neophobia strategies Offer a variety of foods, without leaving the child stranded - 2/3 preferred foods, 1/3 non-preferred (10-15 times) - provide an out for the new food that is productive and acceptable E.g. Learning Plate (Toomey & Ross 2010) Repeat exposure to unfamiliar tastes reduces neophobia Steps to eating graded exposure Food exploration across different environments e.g. childcare, at a picnic, at home Discussion around new foods, to place focus on the properties rather than volumes consumed Modelling and the importance of family meals Removing distraction to increase engagement Please complete your online evaluation at 6

7 Faltering growth Also known as Failure to Thrive /FTT Otherwise known as symptom of under-nutrition, not a medical diagnosis. Used to describe a child who is not growing as expected i.e. not at the same rate as other children their age Diagnosis: At present, there is a lack of agreed consensus in current literature on the diagnosis of growth faltering. Generally defined as falling two or more percentiles for either weight or length/height Goulet, 2010 Women and Children s Hospital SA, 2011 Intervention around growth 1. High energy/high Protein Eating Adding calories into a healthy diet to result in desired weight gain e.g. additional oil on vegetables, having yoghurt with fruit, having eggs with toast etc. Use of high calorie drinks e.g. fruit smoothies, supplement drinks, concentrated formula 2. Enteral feeding Via NG/NJ tube, or gastrostomy/ jejunostomy A healthy diet foundation is key! Please complete your online evaluation at 7

8 Importance of plotting growth Can t you just tell from looking at the child? OBESE HEALTHY WEIGHT OVERWEIGHT Using a growth chart If < 2 years, use WHO- note that emr defaults to CDC 16 Please complete your online evaluation at 8

9 Milestones and Expectations Feeding milestones Age Textures Oro-motor development 0-4 months Breast milk or formula Reflexive feeding skills 0-4 months Around 6 months Start with smooth puree, after breast milk/formula 7-8 months Soft mashed food without lumps Finger foods Mashed/minced foods from 8 months 4-6 months: sucking action from spoon 6 months: opening mouth to spoon, more active lip involvement, vertical jaw movements 7-8 months: tongue lateralisation emerging Please complete your online evaluation at 9

10 Feeding milestones Age Textures Oro-motor development From 9-10 months More coarsely mashed, finely chopped foods from 9-10 months. Encourage finger foods and selffeeding Offer breast milk/formula after meals Introduce cup drinking 12 months plus Chopped family foods Regular use of a cup 9-10 months: active lip involvement, rotary jaw movements emerging, increasing tongue control 12 months: controlled bite developing, cup drinking developing 18 months: chewing and cup drinking skills continue to refine Adapted from Arvedson Please complete your online evaluation at 10

11 Texture progression How much should a child eat? 22 Please complete your online evaluation at 11

12 Factors affecting skill development Structural limits Neurological deficits Physiological limits Wellness limits Environmental limits Parent-child interactions Missed critical periods of development Eg. clefts, micrognathia, esophageal stricture /fistula, tracheo /laryngomalacia, pulmonary atresia/ stenosis, VSD Eg. cerebral palsy, HIE Eg. GOR, delayed gastric emptying, constipation, diarrhea, hypo/hypertonia, congestive heart failure Eg. immune response, response to medications, food allergies Eg. socioeconomic, parental limitations (cognitive, psychological) Eg. carer s difficulties reacting to infant s signals, negative feeding relationship, parenting beliefs and styles Eg. late weaning 23 Case Study Mr. HY Please complete your online evaluation at 12

13 Initial presentation (1 year 2 months) Presenting Problem Difficulty transitioning to solids Medical History 13mo boy born by NVD after unremarkable pregnancy, born term without complications PMHx eczema No parental concerns about development or unusual behaviours Social hx- Lives with parents and 13yo brother, who also had difficulties with transition to solids 25 Growth 26 Please complete your online evaluation at 13

14 Feeding history Breastfed for first month of life, then transitioned to a bottle due to maternal concerns about attachment to nipple Nil issues with early feeding reported No episodes of pneumonia Introduction of solids around 6mo of age, at which time he exhibited refusal and distress Noted pattern of excessive drooling with and without food Feeding environment described as restrictive- minimal opportunities to interact with food Mouthing and chewing on fingers Nil distractions in meals, distractions tried when feeding but did not help 27 Current feeding Solids offered once a day, 30 minutes to 1 hour duration Peaceful feeding environment with nil distractions, sits in a high chair Majority of foods provided: wheat/rice cereal and vegetable purees No force feeding Holds food in mouth before spiting it out. Some finger foods are offered (e.g. biscuits/crackers), however these are all fed to him by Mum Does not reach for food or express interest in eating; however, will watch parents when they are eating. Nutrition primarily provided by toddler milk Has 5 bottles of 200ml standard concentration formula daily. This alone meets/exceeds 100% of his macronutrient requirements 28 Please complete your online evaluation at 14

15 Feeding assessment Medical Cardiology, respiratory and abdominal examinations normal ENT exam normal Tone and cranial nerve exam normal Fine motor, gross motor, social and language skill are age appropriate 29 Feeding assessment Feeding On observation: smooth puree (nestle rice cereal) offered via a spoon by his Mother and a wheat biscuit, offered by his Mother. Minimal mouth opening on presentation of spoon Bolus holding, and?avoiding anterior-posterior movement of the puree bolus Facial grimacing noted with presentation of the puree Returned puree by spitting out, observed in conjunction with increased saliva loss Frontal chewing of biscuit Mother provided full assistance with biscuit i.e. placement in mouth, as well as assisting with the bite 30 Please complete your online evaluation at 15

16 Feeding impression Delayed oromotor skills and transition to solids related to lack of exposure to solids, as evidenced by food refusal, current reliance on toddler milk for nutrition and current meal time routines. 31 Recommendations 1. Nutritional bloods 2. Increase feeding occasions to reflect normal mealtime routine of 3 meals per day 3. Offer bite-dissolvable finger foods, to encourage independence and selffeeding 4. Offer milk AFTER trial of solids 5. Change to Sustagen Kids Essentials - at current volumes will provide 1000ml/day-101ml/kg/day, 1000kcal/day (101kcal/kg/day) and 30g protein/day-3g/kg/day. Intake to be determined by Mr HY 6. Review in General Paediatric Registrar Clinic to check progress 32 Please complete your online evaluation at 16

17 Patient journey Review 1 (1 year 3 months) 1 month post assessment to allow for implementation of routine Parents offering family foods across meal times and snack times Reported to rarely pick up food; however, on observation noted that parents were still feeding majority of meals Good at eating rice, dumplings, flour buns, bread, biscuits (hard). Not as interested in accepting porridge and soups Improved oromotor skills, likely due to exposure to age appropriate textures and opportunity with same. Sustained, controlled bite, with and without assistance, tongue lateralisation, chewing, nil bolus holding, prompt transfer and trigger of swallow Noted to be interested in feeding and more interactive, babbling and initiating communication attempts 33 Patient journey Review 2 (1 year 5 months of age) Parents report nil current concerns with feeding. Parents note difficulty with harder vegetables - avoiding offering as a result Now having family foods, and is reported to have a good appetite Weight tracking appropriately Having ~400ml of toddler milk per day On assessment, parents encouraging self feeding from the outset (change from previous sessions), adequate biting, mastication, and tongue lateralisation with a hard biscuit. Lips slightly open with chewing, but nil food loss Medical assessment normal. Mild drooling noted however cranial nerve and oral exam normal Recommended to change to cows milk, offer hard vegetables in small sized pieces to assist chewing, wean bottle to age appropriate drinking means Discharge 34 Please complete your online evaluation at 17

18 Feeding History Mealtime Behaviours (parent & child) Feeding Difficulties Environment Current intake Routine 35 Acknowledgements Jessica Menzies, Kylie Whitten, Dietitians, SCH Jennifer Hughes, Katelyn Vanos, Speech Pathologists, SCH Please complete your online evaluation at 18

19 References 1. Addessi E et al 2005, Specific social influences of the acceptance of novel foods in 2-5 year old children, Appetite. 45, Aldridge et al 2010, Identifying clinically relevant feeding problems and disorders, Journal of Child Health Care. 14, no.3, pp Arvedson,J.C & Brodsky, L. (2002) Paediatric Swallowing and Feeding: Assessment and Management (2 nd Ed) Delmar Cengage Learning 4. Birch, L.L. & Fisher, J.O 1998, Development of Eating Behaviors Among Children and Adolescents. Pediatrics. 101, Bryant-Waugh, R. et al. Feeding and Eating Disorders in Childhood. International Journal of Eating Disorders Cooke 2007, The importance of exposure for healthy eating in childhood: a review, Journal of Human Nutrition and Dietetics. 20, Dovey TM and Martin C 2010, Developmental, cognitive and regulatory aspects of feeding disorders, Feeding problems in children: A practical guide 8. Goulet O, 2010, Growth Faltering: Setting the Scene, European Journal of Clinical Nutrition, 64:S2-S4 9. Levy et al 2009, Diagnostic cues for identification of nonorganic vs organic causes of food refusal and poor feeding, Journal of Paediatric Gastroenterology and Nutrition. 48, Manikam R and Perman J 2000, Pediatric feeding disorders, Journal of Clinical Gastroenterology. 30 (1), Martin C et al 2013, Maternal stress and problem solving skills in a sample of children with nonorganic feeding disorders, Infant Mental Health Journal, 34 (3), Rommel, N., De Meyer, A., Feenstra, L. & Veereman-Wauters, G.. (2003). The complexity of Feeding Problems in 7001 Infants and Young Children Presenting to a Tertiary Care Institution. Journal of Pediatric Gastroenterology and Nutrition. 37, Toomey, K., & Ross, E. Picky Eaters and Problem Feeders: SOS Workshop, Brisbane Women and Children's Hospital SA, 2011, Clinical Nutrition Guidelines: Failure to Thrive for Infants and Children Less than 2 Years of Age 37 Resources Start them right guide, 2015, Public Health Services, Department of Health and Human Services, Tasmania. Shaw V & Lawson M 2007 Clinical Paediatric Dietetics 3 rd Edition Blackwell Publishing: Oxford SCH High Energy, High Protein fact sheet (available via the SCH homepage) 38 Please complete your online evaluation at 19