Feeding Issues

FEEDING ISSUES

Courtesy of The Special Parent Magazine

According to the Center for Pediatric Feeding and Swallowing at St. Joseph’s Children’s Hospital in Paterson, feeding issues affect between 25 to 40 percent of children, and are seen in children as young as newborn, but can also affect adolescents. These issues are often associated with a medical diagnosis, affecting about 80 percent of children with developmental disabilities. Because feeding and swallowing issues are complex, treatment is a collaborative effort.

Sometimes a child’s feeding problem is immediately recognizable, such as in the case of an infant with dysphagia, or difficulty swallowing. Parents may also seek assistance for their child because of a feeding issue due to nutritional factors, such as difficulty getting the child to eat a variety of foods to maintain a balanced diet, or because of a failure to thrive. A feeding issue can become apparent when it begins to affect the child’s social experiences, such as avoiding a friend’s birthday party, or passing up the chance to visit a friend because it includes eating a meal outside the home.

“Unfortunately some children with feeding concerns are labeled as picky eaters,” says William Roche, clinical director at the center, “and these children and their parents often struggle trying to navigate a journey towards more enjoyable mealtimes.”

There is a major distinction between the two. “Children who are considered picky eaters are going through a normal developmental phase,” he explains. “They are growing, all other phases of development are advancing, and they are gaining weight. Children with feeding issues are found to have feeding issues that persist, disrupt the daily activities of living, and become more complex with time.”

Roche says children may present with “partial or full food refusals, volume limitations, food aversions, vomiting and gagging, prolonged mealtimes, stooling issues, reflux, postural and respiratory compromises. Often these challenges overlap and you come to find that feeding disorders are multidimensional and therefore need the attention of a multidisciplinary team.”

Team Effort

“Hydration and nutrition are basic to human growth and development,” Roche says. “It’s a team skill to evaluate and provide the necessary interventions to insure success in those areas. The emotional, social, educational, parenting and financial aspects of a feeding disorder also need to be the focus of a multidisciplinary team approach.”

The first step in treating a feeding or swallowing disorder is to determine the cause. It could be the result of a medical issue, such as a gastrointestinal defect, an infection or inflammation or a birth defect.

“The fetus at 16 weeks of the pregnancy, partners with its mom by initiating the skill of swallowing,” explains Roche. “So the fetus practices suckling, develops respiratory support, all in preparation for the ability to carry on nutrition and hydration outside of the womb and sustain life by 34 weeks. So the consequences of not developing the appropriate structures, functions, respiratory and neurologic controls, even before birth, becomes obvious when a newborn presents with difficulty in the ability to coordinate sucking, swallowing and breathing. Prematurity, congenital anomalies such as cleft lip/palate, fistulas, neurological deficits, reflux and failure to thrive are just a few of the types of causes that may present with a feeding or swallowing issue at birth.”

Feeding issues can also appear later. “Throughout the first few years of development,” Roche says, “children are expected to progress through a variety of critical transitional feeding periods; nipple to cup, fingers to spoon, smooth pureed texture to chewable to solids. Any interruption in or delay in moving through these critical periods can result in a myriad of feeding challenges.”

While the reasons for feeding and swallowing problems can be medical, some problems are related to causes such as allergies, environmental issues, prolonged subsistence on one particular food, or sensory issues. The only way to discern the cause is through the collaborative efforts of doctors and therapists.

“In addition to their regular pediatrician, children may also see a developmental pediatrician,” says Cheryl Schmotolocha, speech/language Pathologist at ABC Therapy Services in Waldwick. “When a child is referred for an evaluation, there is collaboration between the doctor, the speech pathologist, an occupational therapist and possibly a dietician or nutritionist. When you evaluate the child, you see where their weakness is. Different factors that influence feeding include low tone and poor structure. These will result in a child’s inability to manage food properly. They may gag, choke or have food residue in their mouths. Metabolic disorders, prematurity, reflux, dysphagia and absent gag reflux will have a physiological effect on the child. Therefore, it is painful and uncomfortable to eat. Sensory issues make the child uncomfortable and scared to eat. Sensory is related to the physiological, the way they feel, the structure of their mouths, (and) affects the way they feel the foods and how they manage them.”

An evaluation may determine possible sensitivity in the mouth. Some children may have food aversions. “There is a sensory component to being a picky eater,” notes Schomotolocha. “A child with hyposensitivity may not have enough sensitivity in his mouth. He may hold something in his mouth and not have enough awareness of it. Without being aware of the texture of a food, the child won’t be able to manage it. In other words, you would manage a mouthful of Jell-O differently than hamburger. With hypersensitivity, a child may be too sensitive. These are the children who have food aversions. They may not eat certain foods because they don’t like the texture.”

Schomotolocha notes that many people have this dislike to some extent. That’s why some people don’t like the texture of tapioca pudding or applesauce. “Taste and texture preference is normal, but it doesn’t impact everything you eat. For these children, there is a greater impact. They won’t just avoid tapioca, they will avoid all pureed or soft foods. They’ll avoid the whole consistency. This sensitivity limits their whole diet.” This type of sensory issue can affect children of any age, explains Schomotolocha.

In addition to evaluating a cause, treating a feeding issue also requires collaboration. “I work directly with an OT in my practice,” says Schmotolocha. “It works best when we both treat a child.”

Because the act of eating is such an important part of family and social interactions, parents are included in the collaborative efforts of therapists. “The families of these children are as diverse as the feeding challenges,” says Roche. He notes that culture, religious beliefs, parenting strategies, finances and the emotionally-charged, heart-wrenching feelings of parents because they can’t get their child to eat all play a part. “The parents, grandparents, significant others, and sibs will need to contribute to the effort. Family education, inclusion in every facet of intervention and family counseling are all tools used at the center.”

A Closer Look

Differing opinions and viewpoints exist among experts regarding oral motor treatment. “Several therapists believe in traditional articulation therapy and don’t believe in an oral motor approach,” Schomotolocha points out. “Many therapists don’t take the sensory component into account.”

When feeding problems are due to a sensory issue, there are several approaches to therapy. “Some approaches have a child eating new foods,” Schomotolocha explains. “Some have foods slowly introduced based on texture or taste. Some have the foods they eat modified in some way (texture or taste).” Schomotolocha uses food chaining, an approach to have children expand their diet by using their favorite foods or drinks. It’s a low pressure approach where the child tries foods that they already enjoy, but they are modified in some way. Each child is looked at as an individual, and the plan is customized.

“Therapy varies from child to child. For one child, you may only need to change the consistency, with another it might be taste. If they like only sweet foods, you might modify the taste a little bit to expand what they’re eating.”

Family Affair

Feeding issues are not so uncommon, yet many families feel a strong sense of isolation and frustration. “Eating is supposed to be fun, pleasurable, satiable and socially interactive,” says Roche. “When we eat, we share, we communicate. A baby’s smile during nippling sends mom so many positive messages. When an infant offers a Cheerio from his tray to you, it provokes communication and socialization. When a 2-year-old shares his ice cream cone with the family dog, it too sets the scene for relationship building and communication. Kids with feeding disorders often miss out on so many of these social, emotional and communicative opportunities. Kids with feeding issues don’t often feel the fun, the pleasure of eating, and fail to satiate themselves. Eating is a chore, and for the other family members, mealtimes are just plain unpleasant.”

Feeding issues don’t just affect the child with the disorder. Roche notes, “Families of affected children feel the brunt of the disorder. The unaffected siblings often take a back seat. Mom and Dad’s relationship becomes uneven. They feel disempowered, often isolated, and without the appropriate strategies to fix all that is broken. A parent’s relationship with other family members and friends become odd because they cannot for the life of them understand why you can’t feed your child.”

This makes it vitally important for parents to empower themselves with knowledge. “Parents who can’t feed their newborn or child naturally feel a loss, a sense of uselessness. Any tool that will educate and empower that parent is worthy of inclusion in any approach to treatment of the feeding issues.” Just as important in dealing with a child in this situation is finding support. Having understanding relatives and friends is just one part of this support. Parents can benefit tremendously from the support of other parents who know firsthand, who have or are going through similar experiences, and who can provide a sense of normalcy.

“Surely other families who have made the journey to nutritionally sound and calm mealtimes can be great mentors or buddies,” says Roche. “Our family counselor at the center insures that each family has access to other parents’ experiences through our weekly parent meetings, our website, conferences and interactive two-way teleconferencing.”

Support groups are also available through agencies such as New Jersey’s Statewide Parent Advocacy Network and New York’s Parent to Parent. The first step in helping the child is discovering the cause. The first step in helping the family is in reaching out.