Feeding Disorders:Infants and Young ChildrenTessa Chesher, D.O.Assistant ProfessorOxley Chair of Child and Adolescent PsychiatryOU School of Community Medicine

Objectives Identify types of feeding disorders in

young children Recognize treatment strategies for these

feeding disorders

Epidemiology 25% of normally

developing infants 80% of infants with

developmental handicaps

1-2% of infants have poor weight gain due to feeding disorders

Disrupt infant’s early development

Sequelae Cognitive

developmental delays Behavioral problems Anxiety disorders Eating Disorders

Failure to Thrive History

FTT was used as a “catch all” for Feeding Disorders (FD) 2 types: organic and non organic Later a 3rd type: mixed

What about the infants with FD and no FTT? Should FTT be a symptom and not a

category?

DSM 5 Avoidant/Restrictive Food Intake Disorder

Was Feeding Disorders of Infancy and Early Childhood Feeding disturbance as manifested by persistent

failure to meet appropriate nutritional needs significant weight loss significant nutritional deficiency dependence on enteral feeding or oral nutritional

supplements marked interference with psychosocial functioning.

Not d/t GI or other medical condition Not d/t another mental d/o – i.e. rumination d/o Not d/t lack of food

DC:0-3R

2005 6 feeding disorders classified

Feeding Disorder of State Regulation

Feeding Disorder of Caregiver-Infant Reciprocity

Infantile Anorexia Sensory Food Aversions Posttraumatic Feeding Disorder Feeding Disorder Associated

with a Concurrent Medical Condition

Infantile Anorexia Small appetite Poor weight gain Malnourishment during the toddler years Difficulty turning off excitement, interfering

with sleep and eat In excited state, do not recognize hunger Prefer playing and talking over food

Infantile Anorexia Treatment Teach how to recognize hunger and fullness Establish a regular feeding schedule

Feed toddler at 3-4 hour intervals No in-between snacks If thirsty – only water

Offer very small portions of food and allow child to ask for 2nd, 3rd, and 4th helpings Keeps child engaged in eating process Prevents boredom Prevents them from being overwhelmed by large amount of

food Eat meals together as a family

Keep toddler in high chair until “mommy’s or daddy’s tummy is full.”

Infantile Anorexia Treatment Meals should last no longer than 20-30 min Do not praise or criticize the toddler for

how much or how little the toddler is eating

During feeding No toys or T.V.

Food is not to be used as a reward or expression of affection

Infantile Anorexia Treatment No throwing of food or utensils No playing with food instead of eating it Allow toddler to self-feed with own spoon Introduce finger foods Re-focus child if distracted

“We need to eat now, and talk later.” Enact time-out method if the child wants to

leave the table before everyone is finished with their meal

Time-Out Method It’s important to use the time-

out method for any distracted behavior at meal times running away to play throwing food and utensils

It teaches the child to self-soothe makes it easier to settle down in

all excited situations Child will learn to calm his or

herself to eat and sleep.

Time-Out Method The parents are to give only one

warning. The child should be put in time- out in a

safe place Child is alone and doesn’t see parents This is for calming and not punishment Crib or playpen

Time out begins after child is calm Parents set the timer for a few minutes Child is taken back to correct behavior Parents need to follow through once

time out starts

Sensory Food Aversions Children who either change their food

preferences often or consistently refuse the same foods.

Two types Children who change food preferences

frequently Children who develop sensory food

aversions, which can be a taste, texture, or even a whole food group.

Sensory Food Aversions Selective eating disorders are caused by

several genetic and environmental influences: Genetic influences

Taste bud sensitivity Fear of trying new foods is hereditary

Environmental influences Exposure to new food Role of rewards on food preferences Effect of modeling eating by parents and peers

on food preferences Effect of negative experiences associated with

eating certain foods

Sensory Food Aversions These types of eating disorders tend to

surface when new foods are introduced. Can begin the first few weeks of life

Different sucking patterns 100 fewer sucks per feeding session than non-

picky children 17% refused to suck at all

Usually begins around 6-10 months Introduction of baby foods

Often have other sensitivities as well i.e. don’t want to get hands messy

Sensory Food Aversion Treatment Determine underlying reason for selectivity

Is it food aversion or is the child changing food preference constantly?

Set limits with children who change food preferences frequently by only offering three different types of food at mealtimes and not giving into demands

Upon protest of new limits, enable time-out method Encourage eating meals together, as a family, to

increase modeling If your child gags or vomits upon first try at a new

food, keep mood neutral, but make a mental note not to serve that food again

Posttraumatic Feeding Disorders Behaviors exhibited when an infant relates a painful or

frightening experience with eating. Also known as:

choking phobia swallowing phobia functional dysphagia.

Most of the time, this fear is associated with bottle feedings, but can also be associated with solid food.

The fear can be triggered by more than one incident of vomiting, or gagging or choking as a result of forceful feeding by a caregiver.

Often, toddlers will remember their fear of drinking milk from a bottle and this will transition to a fear of drinking milk from a cup later.

Treatment of PFD in Infants Parents need to recognize signs of

infant distress Crying at sight of a bottle or bib Crying when positioned for feeding Crying when approached with bottle

Figure out the baby’s fear Help infant overcome the fear slowly

Provide positive associations with feeding position Example: While in feeding position,

rock and sing to the infant Let the infant play with the bottle Try new feeding devices, like a cup

and straw Avoid force-feeding

Posttraumatic Feeding Disorder Children can also experience a fear of

eating solid foods. They can become fearful of choking after

they have had an experience choking, watched someone else choke, or even heard a scary story about someone else choking.

Treatment of PFD in Children If your child refuses to drink any water, take them

to the emergency department If your child does drink water, encourage them to

try milk or a liquid supplement to increase nutrients in their diet Gradually try to add soft foods and purees

Eat at the table to help child overcome fear of choking as they watch their parents successfully finish a meal

If your child is unable to overcome their feeding fears, professional help may be necessary.

FD with Medical Condition GERD Cardiac conditions Pulmonary Conditions

Chief Complaint Associated Feeding Disorder

Has a poor appetite and does not eat enough to grow. Shows little hunger and interest in feeding and wants to play rather than eat.

If < 6 months old: Feeding Disorder of State RegulationIf > 6 months old: Infantile Anorexia

Has a limited diet of a few foods. Consistently refuses certain foods or whole food groups

1. Sensory Food Aversions2. Posttraumatic Feeding Disorder

Refuses to drink from a bottle or cup, but eats solids or vice versa.

Posttraumatic Feeding Disorder

Refuses all solid foods, but eats pureed foods.

1. Sensory Food Aversions2. Posttraumatic Feeding Disorder

Refuses most or all feedings and depends on nasogastric/gastrostomy tube feedings.

1. Posttraumatic Feeding Disorder2. Feeding Disorder Associated with a

Concurrent Medical Condition

Chatoor, 2009

Chief Complaint Associated Feeding DisorderRefuses to eat something one day, but may eat it the next day.

If no weight concerns: OppositionalFeeding Behavior which can be associated with food refusal of toddlers in general.If there are weight concerns: Infantile Anorexia

Cries a lot and arches during feedings. Tires quickly during feedings and eats too little.

If < 6 months old: 1. Feeding Disorder of State Regulation2. Feeding Disorder Associated with a Concurrent Medical Condition

Sleeps through feedings Feeding Disorder of State Regulation

Gags or vomits before, during, or after feedings

1. Posttraumatic Feeding Disorder2. Sensory Food Aversions3. Feeding Disorder Associated with a

Concurrent Medical ConditionCries when positioned for feeding or when presented with food

Posttraumatic Feeding Disorder

Chatoor, 2009

Chatoor, 2009

Video Examples https://www.youtube.com/watch?v=0m

GbOeuuuB8

References http://childrensnatio

nal.org/news-and-events/our-blogs/parenting-blog/2012/december/feeding-disorders-infantile-anorexia

Chatoor, Irene. Diagnosis and Treatment of Feeding Disorders(2009).

Questions?