An Evidence Based Approach to the

Assessment and Treatment of

Pediatric Feeding Disorders
DR. RACHEL STANKEY, OTD, OTR/L
UNIVERSITY OF ST. AUGUSTINE FOR HEALTH SCIENCES
 An Evidence Based Approach to the Assessment
and Treatment of Pediatric Feeding Disorders
Disclaimer: There are multiple systems used to classify evidence, which differ across
professional and geographical boundaries. This, in conjunction with the multifactorial
and complex nature of pediatric feeding disorders, leads to research across disciplines.
I did not conduct formal literature reviews on topics included today, therefore I can not
claim that this summary is exhaustive. In addition, although I love working in teams, I
view the research through the lens of an occupational therapist. I know there must be
evidence that I have not included. I would welcome any additional references at
[email protected]

6/01/2013 DR. RACHEL STANKEY, OTD, OTR/L 2

 What is Evidence Based Practice
(EBP)?
ASSESSMENTS AND INTERVENTIONS ARE GUIDED BY A
COMBINATION OF:
The best available evidence
Clinical expertise and judgment
Patient values and preferences

6/01/2013 DR. RACHEL STANKEY, OTD, OTR/L 3

 The Evidence Hierarchy

http://www.acupuncturemoxibustion.com/research /

6/01/2013 DR. RACHEL STANKEY, OTD, OTR/L 4

 What Causes Feeding Disorders?
USUALLY, LOTS OF DIFFERENT FACTORS
Eating is learned, not instinctual
History of negative experiences
Gastrointestinal issues
Neurological problems
Congenital malformation
Allergies
Cardiac and/or respiratory problems
Abnormal muscle tone
Disordered child-caregiver relationships
KIDS DONT EAT IF THEY DONT FEEL WELL

6/01/2013 DR. RACHEL STANKEY, OTD, OTR/L 5

 What Causes Feeding Disorders?
It is extremely common for
the feeding disorder to persist
long after the underlying
issues have been resolved.

6/01/2013 DR. RACHEL STANKEY, OTD, OTR/L 6

 How Are Pediatric Feeding
Disorders Defined?
Persistent problem with eating, feeding, and/or swallowing*
Chronic food refusal
Feeding tube dependence
Food selectivity
Poor oral intake
Swallowing disorder

Lack of standardized definition impacts research and demographic data

collection
*Schwarz, 2010

6/01/2013 DR. RACHEL STANKEY, OTD, OTR/L 7

 How Are Pediatric Feeding
Disorders Defined?
ICD-9 codes
783.3 Feeding difficulties and mismanagement
779.31 Feeding problems in newborn
DSM-IV
Feeding Disorder of Infancy or Early Childhood
DSM-V
Feeding and Eating Disorders of Childhood
Failure to thrive/pediatric undernutrition
Dysphagia
Developmental delay

6/01/2013 DR. RACHEL STANKEY, OTD, OTR/L 8

 How Are Pediatric Feeding
Disorders Defined?
Early Intervention Programs
Federally mandated in all states by educational law - IDEA, Part C
Serves children from birth 3rd birthday
Every state has different standards of delay for eligibility
Self-help (adaptive) skills this includes feeding/eating
Social-emotional (personal-social) development relationships,
behavior, social communication
Feeding is the major work of infant and toddler
Often red flag for other medical or developmental
problems

6/01/2013 DR. RACHEL STANKEY, OTD, OTR/L 9

 How Are Pediatric Feeding
Disorders Defined?
School Systems (3-21)
Children may receive services or accommodations if:
Categorically eligible under IDEA AND feeding disorder is affecting
participation in educational environment
Some schools may provide accommodations under Section 504
Feeding disorder itself is not a category for special education services

6/01/2013 DR. RACHEL STANKEY, OTD, OTR/L 10

 Why Should We Care About
Pediatric Feeding Disorders?
HIGH PREVALENCE IN ALL OF WESTERN SOCIETY*
Between 25%-45% of typically developing children
Between 33%-80% of children with developmental delays/disabilities
40%-70% of premature infants born before 36 weeks require significant feeding
support

Miller, 2009; Lefton-Greif, 2008; Link, 2002, Manikam &

Perman, 2002

6/01/2013 DR. RACHEL STANKEY, OTD, OTR/L 11

 Why Should We Care About
Pediatric Feeding Disorders?
FEEDING DISORDERS IN CHILDREN AFFECT THE ENTIRE FAMILY*
Mothers demonstrate higher rates of:
Depression Obsessive-Compulsive Tendencies
Anxiety Stress
Social Isolation Feelings of Guilt and Failure
Decreased Role Satisfaction Lack of Leisure and Social Time
Decreased financial security
* Didenhbani, Kelly, Austing, & Wiechmann, 2011; Gree, Gulotta, Masler, & Laud, 2007; Coulthard & Harris, 2003

6/01/2013 DR. RACHEL STANKEY, OTD, OTR/L 12

 Why Should We Care About
Pediatric Feeding Disorders?
FEEDING DISORDERS IN CHILDREN AFFECT THE ENTIRE FAMILY
Siblings, dads, and other caregivers are also affected
Financial burden on families (and society?)
Food is an important part of our social relationships, especially with:
Family routines (e.g. weeknight dinners)
Family rituals (e.g. Thanksgiving)

6/01/2013 DR. RACHEL STANKEY, OTD, OTR/L 13

 ASSESSMENT AND
INTERVENTION: TEAMS
Children are best assessed and treated by
multidisciplinary/interdisciplinary teams*
Strength of evidence is low (expert opinion/consensus) however
is consistent across disciplines
Teams have family members/caregivers as key members
Teams can also include:
Occupational Therapists Speech-Language Pathologists Dietitians
Gastroenterologists Pediatricians Psychologists
Case Managers Social Workers Nurses
* Miller, 2009; Arvedson, 2008; Bell & Alper, 2007; Bernard-Bonnin, 2006; Manikam & Perman, 2000

6/01/2013 DR. RACHEL STANKEY, OTD, OTR/L 14

 ASSESSMENT AND
INTERVENTION: TEAMS
Feeding observations are best done in natural environments*
Assessments should include:
Manifestation of problem Thorough medical/developmental history
Data on growth and weight Emotional climate during meals
Family Stressors Motor skills, posture and tone
Antenatal and perinatal history Feeding routines and environments
Oral motor skills and swallowing Sensory processing
Feeding routines/environments Child behavior prior to and during meals
Self-regulation/level of alertness Strategies previously used
Context * Miller, 2009; Arvedson, 2008; Bell & Alper, 2007 Bernard-Bonnin, 2006; Manikam & Perman, 2000

6/01/2013 DR. RACHEL STANKEY, OTD, OTR/L 15

 PICKY EATER OR FEEDING
DISORDER?
https://www.feedingmatters.org/education/early-identification-
questionnaire
Gives you a printable summary to take to physician
Designed for concerns about chronic feeding issues

6/01/2013 DR. RACHEL STANKEY, OTD, OTR/L 16

 ASSESSMENT: ORAL MOTOR SKILLS
AND SWALLOWING
Expert opinion some signs of dysphagia may be detected through clinical
observation and assessment
Quality and timing of oral motor skills
Strength
Coordination
Sensory function
Tone
Asymmetry
Cranial nerve function
Motor planning
Gag, cough, quality of voice, watery eyes/nose may be indicators of
aspiration

6/01/2013 DR. RACHEL STANKEY, OTD, OTR/L 17

 ASSESSMENT: ORAL MOTOR SKILLS AND
SWALLOWING
Strong evidence suggests that the best diagnostic tool to detect
dysphagia is radiography, including:
Modified barium swallow studies
Dynamic and static studies of the pharynx
Biphasic esophograms
Other tools are considered acceptable:
Scintigraphy
Endoscopy
Esophageal manometry

6/01/2013 DR. RACHEL STANKEY, OTD, OTR/L 18

 ASSESSMENT: ORAL MOTOR SKILLS AND
SWALLOWING
Recurrent pneumonia or upper respiratory infections may be indicative of
aspiration (expert opinion, consistent across disciplines)
Should consider possibility of anatomic abnormalities when:
Children have difficulty swallowing
Stridor is present in relation to feeding*

Bernard-Bonnin, 2000

6/01/2013 DR. RACHEL STANKEY, OTD, OTR/L 19

 ASSESSMENT:OTHER EVIDENCE
There is no evidence to inform clinical practice on the use of a formal
feeding readiness tool to determine a preterm infants readiness to
commence oral feeding*
There is limited, but high quality, evidence to suggest that many children
with feeding difficulties present with sensory processing challenges**

*Crow, Chang, & Wallace, 2012

**Davis, Bruce, Khasawhneh, Schulz, Fox, & Dunn, 2013

6/01/2013 DR. RACHEL STANKEY, OTD, OTR/L 20

 After Assessment Is There
Evidence for Intervention?
Oral Motor Stimulation and Exercise
Positioning
Behavioral Strategies
Medications
Altered Diets
Sensory Strategies
Feeding Tubes
Vital Stim

6/01/2013 DR. RACHEL STANKEY, OTD, OTR/L 21

 INTERVENTIONS: NEONATES
Non-Nutritive Sucking (NNS):
Strong, high-quality evidence that NNS in preterm infants is correlated
with significantly shorter hospital stay
Weak evidence that NNS improves transition from tube to bottle feeds
Weak evidence that NNS improves bottle feeding performance
(although recommended by expert opinion)
No negative outcomes from NNS*

*Pinelli & Symington, 2005

6/01/2013 DR. RACHEL STANKEY, OTD, OTR/L 22

 INTERVENTIONS: NEONATES
In hospitalized, pre-term infants:
Insufficient, high-quality evidence to determine if scheduled or on-
demand feeds earlier full-oral feeding/hospital discharge*
Cup feeding should not be recommended over bottle feeding as
supplement to breast feeding; no benefits seen after discharge and
resulted in longer hospital stays. The evidence is high-quality albeit few
studies**

McCormick, Tosh, & McGuire, 2010

**Fint, New & Davies, 2007

6/01/2013 DR. RACHEL STANKEY, OTD, OTR/L 23

 INTERVENTIONS: ORAL-MOTOR
Parents report high degree of oral-motor and related feeding problems in
their children with cerebral palsy (CP); fair strength of evidence*
Low-level evidence (primarily expert opinion) that oral motor therapy
improves specific oral motor skills**
Despite expert recommendations to use oral sensorimotor interventions
with children with neurological impairment and dysphagia, there is
insufficient high-quality evidence to support effectiveness***
*Ghay & Sulman, 2013

**Wilcox, Potvin, & Prelock, 2009

***Morgan, Dodrill, & Ward, 2012

6/01/2013 DR. RACHEL STANKEY, OTD, OTR/L 24

 INTERVENTIONS:
FEEDING TUBES
Feeding tubes are common interventions for children with significant
feeding disorders, however there is a lack of research regarding the
efficacy of this intervention vs. oral feeding alone*
High level of evidence that decision-making re: feeding tube placement in
children is fraught with stress and conflict for
families**

Sleigh, Sullivan & Thomas, 2004

Mahant, Jovcevska, & Cohen, 2011

6/01/2013 DR. RACHEL STANKEY, OTD, OTR/L 25

 INTERVENTIONS:
FEEDING TUBES
Placement of feeding tube in children with significant feeding disorder
relieves some caregiver stress; low-level evidence*
Mixed evidence about risks and benefits of feeding tubes in children with
CP
Most children gained weight with feeding tubes
Many had increased complications that may/may not be result of tube,
including reflux and death **

*Peterson, Kadia, Davis, Newman & Temple, 2006

**Sleigh & Brocklehurst, 2004

6/01/2013 DR. RACHEL STANKEY, OTD, OTR/L 26

 INTERVENTIONS: POSITIONING
Fair evidence that proper positioning has many benefits for feeding*
Normalize or decrease abnormal neurological influences on body
Increase range of motion, maintain neutral skeletal alignment and
control, and prevent skeletal deformities and muscle contractures
Upgrade stability to increase function
Increase comfort and position tolerance
Enhance function of autonomic nervous system
Decrease fatigue
Facilitate components of normal movement
Facilitate maximum function with minimal pathology
Jones & Gray, 2005

6/01/2013 DR. RACHEL STANKEY, OTD, OTR/L 27

 INTERVENTIONS: POSITIONING
Limited, but positive evidence that positioning interventions improve oral
intake and skill in children with CP*(systematic review)
Videofluoroscopy may be helpful to determine optimal position for
feeding**(case series)
Key factors for positioning older children***(good evidence)
Goal Most function with the least support/restriction
Stable pelvis in neutral position
Supported feet!
Neutral or slightly flexed head
Arms forward and free to move
*Snider, Majnemer, & Darsaklis, 2011

**Morton, Bonas, Fourie, & Minford, 1993

***Joanna Briggs Institute, 2009 (BEST Evidence Statement); Snider, Majnemer, & Darsaklis, 2011 (systematic review); Stavness, 2006; (systematic review); Hulme, Gallacher, Walsh, Niesen, & Waldren, 1987

6/01/2013 DR. RACHEL STANKEY, OTD, OTR/L 28

 INTERVENTIONS: POSITIONING
Key factors for positioning infants*(fair evidence)
Positioning should be first intervention
Overall feeling of flexion
Head aligned with trunk, elevated
Most feed optimally semi-upright, with side-tilt positioning
May also position in front of you with head/neck supported to facilitate
eye contact
Swaddling provides additional support
*NGC, 2010; Fraker and Walbert, 2008; Swigert, 1998,

6/01/2013 DR. RACHEL STANKEY, OTD, OTR/L 29

 INTERVENTIONS: REFLUX
Lack of high-quality evidence to support or refute the efficacy of
thickening feeds in infants with reflux*
Despite significant costs and risks, there is no evidence to assist families
and practitioners in determining the most optimal treatment (surgery or
medication) for reflux for children with neurological impairment and
gastrostomy tubes**

*Huang, Forbes, & Davies, 2002

**Vernon-Robers & Sullivan, 2007

6/01/2013 DR. RACHEL STANKEY, OTD, OTR/L 30

 INTERVENTIONS: INTENSIVE
TREATMENT AND BEHAVIORAL
Fair evidence that intensive, multidisciplinary feeding programs are
effective at*:
Decreasing dependence on gastrostomy tubes
Decreasing some elements of caregiver stress
However, studies are limited by small sample sizes and lack of long-term
follow-up
There were no well-designed studies in this review that did not include
behavioral intervention as primary intervention
All participants demonstrated significant improvements in feeding behavior
while enrolled in intensive, multidisciplinary programs**
Cornwell, Kelly, & Austin, 2010; Clawson, Kuchinski & Bach, 2007; Greer, Gulotta, Masler, & Laud, 2007; Byars, Burklow, Ferguson, OFlaherty, Santory, & Kaul, 2003

**Sharp, Jaquess, Morton, & Herzinger, 2010

6/01/2013 DR. RACHEL STANKEY, OTD, OTR/L 31

INTERVENTIONS: SENSORY
There is expert opinion that sensory-based interventions are effective at
improving number and variety of accepted foods in children with sensory
processing issues
FEEDING AND MEALTIMES SHOULD BE FUN!!
Exploration and play with food
Find new ways to interact with food
Consider the sensory properties of food
Stretch sensory horizons
http://confessionsofthechromosomallyenhanced.blogspot.com/2011/03/feeding-therapy.html

6/01/2013 DR. RACHEL STANKEY, OTD, OTR/L 32

INTERVENTIONS: STRUCTURE
There is expert opinion (consistent across disciplines) that creating
structure around food and mealtimes is important when working with
children with feeding disorders
How?
Environment (positive place, sensory tools, conducive to self-
regulation)
Time (3 meals, 2-3 snacks, water between meals, food first, then
drinks)
Consistent preparatory activities (sensory, warn of transitions)
Visual and/or written schedules, counting

6/01/2013 DR. RACHEL STANKEY, OTD, OTR/L 33

 INTERVENTIONS: OTHER
STRATEGIES
Work on mealtime relationships; positive tilt
Parents choose the what and the when of meals; children choose the
whether and how much
Consider the size of the bolus; aim for success!
Try pretend play with real food
Engage children in meal prep and cooking
Food academics
Fun tools and toys

6/01/2013 DR. RACHEL STANKEY, OTD, OTR/L 34

 DECISION MAKING PROCESS
Review further
History Reassessment
evidence

Review Adjust
Intervention
Evidence Interventions

Assessment
Goal setting SUCCESS!
(safety first)

Assessment Review further

(all other areas) evidence

6/01/2013 DR. RACHEL STANKEY, OTD, OTR/L 35

 QUESTIONS?

6/01/2013 DR. RACHEL STANKEY, OTD, OTR/L 36

 REFERENCES
Arvedson, J.C. (2008). Assessment of pediatric dysphagia and feeding disorders: Clinical and
instrumental approaches. Developmental disabilities research reviews, 14, 118-127.
Bell, H.R., & Alper, B.S. (2007). Assessment and intervention for dysphagia in infants and children:
Beyond neonatal intensive care unit. Seminars in Speech and Language, 28(3), 213-222.
Bernard, Bonnin, A.C. (2006). Feeding problems of infants and toddlers. Canadian Family Physician,
52(10), p. 1247-51.
Coulthard, H. & Harris, G. (2003). Early food refusal: the role of maternal mood. Journal of
Reproduction and Infant Psychology, 21(4) 335-345.
Crowe, L., Chang, A., & Wallace, K. (2012). Instruments for assessing readiness to commence suck
feeds in preterm infants: Effects on time to establish full oral feeding and duration of hospitalization.
Cochrane Database of Systematic Reviews, 4. DOI: 10.1002/14651858.CD005586.pub2
Davis, A.M., Bruce, A., S., Khasawhneh, R., Schulz, T., Fox, C., & Dunn, W. (2013). Sensory processing
issues in young children presenting to an outpatient feeding clinic. Hepatology and Nutrition, 56, 156-60
Didehbani, N., Kelly, K., Austin, L., & Wiechmann, A. (2011) Role of parental stress on pediatric feeding
disorders. Childrens Health Care, 4(11), p.85-100. DOI: 10.1080/2739615.2011.564557

6/01/2013 DR. RACHEL STANKEY, OTD, OTR/L 37

 REFERENCES
Flint, A., New, K., Davies, M.W. (2007). Cup feeding versus other forms of supplemental enteral feeding for
newborn infants unable to fully breastfeed. Cochrane Database of Systematic Reviews, 2. DOI:
10.1002/14651858.CD005092.pub2
Ghay, N. & Sulman, N. (2013). Identification of oromotor impairments perceived by parents related to feeding
difficulties in children with cerebral palsy. Interdisciplinary Journal of Contemporary Research in Business,
4(9), 1372-1386.
Huang, R.C., Forbes, D., & Davies, M.W. (2002). Feed thickener for newborn infants with gastro-esophageal
reflux. Cochrane Database of Systematic Reviews, 3. DOI: 10.1002/14651858.CD003211
Joanna Briggs Institute (2009). Assessment and management of dysphagia in children with neurological
impairments [BESt Evidence Statement]. Best Practice, 13(1), 1-4.
Jones, M., & Gray, S. (2005). Assistive technology: Positioning and mobility. In S. Effgen (Ed.), Meeting the
physical therapy needs of children (pp. 455-473).
Lefton-Greif, M.A. (2008). Pediatric dysphagia. Physical Medicine and Rehabilitation Clinics of North America,
19(4), p.837-851. DOI: 10.1016/j.pmr.2008.05.007
Link, R. (2002). Feeding disorders in infants and children. Pediatric Clinics of North America, 49(1), p. 97-112.
DOI: 10.1016/S0031-3955(03)00110-X

6/01/2013 DR. RACHEL STANKEY, OTD, OTR/L 38

 REFERENCES
Mahant, S., Jovcevska, V., & Cohen, E. (2011). Decision-making around gastrostomy feeding in children with
neurological disabilities. Pediatrics. DOI: 10.1542/peds.2010-3007
Manikam, R. & Perman, J.A. (2000). Pediatric feeding disorders. Journal of Clinical Gastroenterology, 30(1),
34-46.
McCormick, F.M., Tosh, K., & McGuire, W. (2010). Ad libitum or demand/semi-demand feeding versus
scheduled interval feeding for preterm infants. Cochrane Database of Systematic Reviews, 2. DOI:
10.1002/14651858.CD005255.pub3
Miller, C. (2009). Updates of pediatric feeding and swallowing problems. Current Opinion in Otolaryngology
and Head and Neck Surgery, 17, p. 194-199.
Morton, R.E., Bonas, R., Fourie, B., & Minford, J. (1993). Videofluoroscopy in the assessment of feeding
disorders. Developmental Medicine and Child Neurology, 35(5), 388-395.
National Guideline Clearinghouse (2010). Dysphagia. American College of Radiology. Retrieved from
http://guideline.gov/content.aspx?id=23815&search=dysphagia
National Guideline Clearinghouse (2009). Pediatric gastroesophageal reflux clinical practice guidelines: Joint
recommendations of the North American society for pediatric gastroenterology, hepatology, and nutrition and
the European society for pediatric gastroenterology, Hepatology, and nutrition. Nutrition, 49(4), 498-547.

6/01/2013 DR. RACHEL STANKEY, OTD, OTR/L 39

 REFERENCES
Peterson, M.C., Kadia, S., Davis, P., Newman, L., & Temple, C. (2006). Eating and feeding are not
the same: Caregivers perceptions of gastrostomy feeding for children with cerebral palsy.
Developmental Medicine and Child Neurology, 48, 713-717.
Pinelli, J. & Symington, A.J. (2005). Non-nutritive sucking for promoting physiologic stability and
nutrition in preterm infants. Cochrane Database of Systematic Reviews, 4. DOI:
10.1002/14651858.CD001071.pub2
Royal College of Speech and Language Therapists (2005). Clinical guidelines: 5.5 Cleft palate and
velopharyngeal abnormalities. Taylor-Goh, S. ed., RCSLT Clinical Guidelines. Bicester, Speechmark
Publishing, Ltd.
Schwarz, S. (2010). Feeding disorders in children with developmental disabilities. Infants and Young
Children, 16(4), 317-330
Sharp, W.G., Jaquess, D.L., Morton, J.F., & Herzinger, C.V. (2010). Pediatric feeding disorders: A
quantitative synthesis of treatment outcomes. Clinical Child and Family Psychology Review, 13, 348-
365.
Sleigh, G., & Brocklehurst, P. (2004). Gastrostomy feeding in children with cerebral palsy: A systematic
review. Archive of Diseases in Childhood, 89(6). 5349

6/01/2013 DR. RACHEL STANKEY, OTD, OTR/L 40

 REFERENCES
Sleigh, G., Sullivan, P.B., & Thomas, A.G. (2004). Gastrostomy feeding versus oral feeding alone for children with cerebral
palsy. Cochrane Database of Systematic Reviews, 2. DOI:10.1002/14651858.CD003943.pub2
Snider, L., Majnemer, A., & Darsaklis, V. (2011). Feeding interventions for children with cerebral palsy: A review of the evidence.
Physical and Occupational Therapy in Pediatrics, 31(1), 58-77.
Stavness, C. (2006). The effect of positioning for children with cerebral palsy on upper extremity function: A review of the
evidence. Physical and Occupational Therapy in Pediatrics, 26(3), 39-53.
Swigert, N.B. (1998). The source for pediatric dysphagia. East Moline, IL: LinguiSystems. Vernon-Robers, A. & Sullivan, P.B.
(2007). Fundoplication versus post-operative medication for gastro-oesophageal reflux in children with neurological impairment
undergoing gastrostomy. Cochrane Database of Systematic Reviews, 1. DOI: 10.1002/14651858.CD006151.pub2
Weir, K., McMahon, S., & Chang, A.B. (2012). Restriction of oral intake of water for aspiration lung disease in children.
Cochrane Database of Systematic Reviews, 9. DOI: 10.1002/14651858.CD005303.pub3
Wilcox, D.D., Potvin, M., & Prelock, P.A. (2009). Oral motor interventions and cerebral palsy: Using evidence to inform
practice. Early Intervention and School Special Interest Section Quarterly, 16(4), 29-41.
Wolfenden, L., Wyse, R.J., Britton, B.I., Campbell, K.J., Hodder, R.K., Stacey, F.G., McElduff, P., & James, E.L. (2012).
Interventions for increasing fruit and vegetable consumption in children aged 5 years and under. Cochrane Database of
Systematic Reviews, 11. DOI: 10.1002/14651858.CD008552.pub

6/01/2013 DR. RACHEL STANKEY, OTD, OTR/L 41