Current Problems in Pediatric and Adolescent Health Care Volume 37, Issue 10, November-December 2007, Pages 374-399

doi:10.1016/j.cppeds.2007.09.001 | How to Cite or Link Using DOI Copyright © 2007 Mosby, Inc. All rights reserved.

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Infant Feeding: Initiation, Problems, Approaches

John Nicholas Udall Jr MD, PhDa

aDepartment of Pediatrics; WVUHSC-Charleston, Women and Children’s Hospital, Charleston, WV.

Available online 28 November 2007.

Article Outline

Section I: Developmental Aspects of Swallowing and Feeding in Infants and Young Children (

http://www.nature.com/gimo/contents/pt1/full/gimo17.html) Incidence and Prevalence of Feeding and Swallowing Disorders in Pediatrics

Development of Feeding and Swallowing Skills Prenatal Swallowing and Sucking

Infant Feeding and Swallowing

Transition Feeding

Critical and Sensitive Periods with Implications for Behavioral and Sensory-based Feeding

Problems

Effects When Oral Feeding Is Not Possible in the Newborn Period

Taste and Smell in Oral Feeding of Infants and Young Children

Clinical Assessment of Pediatric Swallowing and Feeding Disorders for Primary Care Physicians Principles of Clinical Feeding Evaluation

Categories of Causes of Swallowing and Feeding Disorders

Caregiver Perceptions of Feeding Problems

Interdisciplinary Team Approach

Instrumental Examination of Swallowing

Management of Feeding and Swallowing Problems in Pediatrics

Section II: Gut Motility and Enteral Feeding Tolerance with an Emphasis on Premature Infants

Gastrointestinal Motility Esophagus

Stomach and Small Intestine

Postprandial Small Intestinal Motility

Interdigestive Small Intestinal Motility

Colon

Developmental Aspects Mouth and Esophagus

Stomach

Small Intestine

Feeding Recommendations for Premature Infants

Section III: Behavioral Treatment of Feeding Disorders Classification

Evaluating Feeding Problems

Treatment Appetite Manipulation

Behavioral Contingency Techniques

Section IV: Feeding Issues in the Disabled Child Magnitude of the Problem

Nutritional Needs Inadequate Intake

Increased Losses

Energy Requirements

Assessment Medical History

Nutritional History

Physical Examination

Anthropometrics

Laboratory Evaluation

Recommendations

Other Considerations

References The impetus for this issue comes from a Topic Symposium entitled, ―Infant Feeding: Initiation, Problems,

Approaches‖ held at the Pediatric Academic Societies meeting in Toronto May 6, 2007. The symposium

focused on four aspects of feeding infants and young children. Each aspect was discussed by an authority in

the field.

One presentation concerned the developmental aspects of swallowing and feeding infants and young

children. Another addressed the development of gut motility in the premature infant and its relationship to

enteral feeding. The third topic concerned the behavioral treatment of feeding disorders in toddlers and

finally, feeding issues related to neurologically impaired children were reviewed.

Feeding premature and full-term infants through the first few years of life has become an area of interest and

study over the past two decades. The realization that some infants and children are not fed easily or may

develop feeding problems resistant to traditional approaches has led to the institution of feeding teams at

larger pediatric centers. Hopefully, information presented at the Topic Symposium and contained within this

issue will be shared with others as we follow emerging research concerning the optimal feeding of normal

infants and children, and those with feeding disorders.

Section I: Developmental Aspects of Swallowing and Feeding in Infants and

Young Children (http://www.nature.com/gimo/contents/pt1/full/gimo17.html)

Adequate respiration and nutrition are essential throughout a lifetime. Breathing usually does not require

active effort by infants except for those with complicating factors, for example, bronchopulmonary dysplasia,

upper airway obstruction as in Pierre Robin sequence, other craniofacial anomalies, and severe

laryngotracheomalacia. Eating, on the other hand, requires active effort by infants who must have exquisite

timing and coordination of simultaneous breathing, sucking, and swallowing. Adequate growth, defined by

weight gain in early infancy and for the first few years of life, is the primary measure of successful feeding.

Breathing, sucking, and swallowing are activities that occur in the upper aerodigestive tract and are

orchestrated by cranial nerves and specific areas in the brain. Successful oral feeding requires that children

have functional oral sensorimotor and swallowing skills, adequate pulmonary and gastrointestinal function,

central nervous system integration, and normal musculoskeletal tone. A breakdown in coordination of

swallowing and breathing can result in aspiration. Aspiration may present with coughing and choking,

usually during feeding, and is indicative of compromised airway protective reflexes. If laryngotracheal

sensation is also affected, aspiration may be silent without overt manifestations.

Normal feeding patterns reflect the early developmental pathways that are the basis for later communication

skills. The interrelationships between feeding (in all living beings) and complex verbal communication

(unique to humans) are multifactorial and in need of continued research. The study of comparative anatomy

and its implications for human communication are well described.1

Professionals who examine and treat infants and children who have feeding and swallowing problems must

have a thorough understanding of embryologic and developmental anatomy of the upper aerodigestive tract

and the physiology of deglutition. Research in the past 30 years has added to the understanding of the

orderly development of feeding and swallowing in utero through infancy.

Incidence and Prevalence of Feeding and Swallowing Disorders in Pediatrics

Feeding and swallowing disorders are relatively common in early infancy and in some instances may be

markers for significant health implications that do not become obvious until later. As many as 35% of infants

exhibit food selectivity and refusal, as revealed by parent interviews in general population surveys. Feeding

problems are relatively common in various infant populations, including, but not limited to, preterm ―at-risk‖

infants, infants with congenital heart disease following open-heart surgery, infants diagnosed with

nonorganic failure to thrive, and children with cerebral palsy (CP). Prevalence rates of dysphagia range from

57 to 92% varying by type of CP.2 Children with CP and dysphagia are found to have a higher incidence of

undernutrition, growth failure, and poor health than those children without swallowing problems. Children

with more severe forms of CP and dysphagia have higher mortality rates than other groups.

This review provides an overview of (1) the development of feeding and swallowing skills, including

critical/sensitive periods with implications for behavioral and sensory based feeding problems; (2) taste and

smell, and their impact on oral feeding; (3) clinical assessment; (4) instrumental examination of pediatric

swallowing disorders; and (5) management of pediatric feeding and swallowing disorders.

Development of Feeding and Swallowing Skills

Prenatal Swallowing and Sucking

In utero studies of fetuses have documented the early development of swallowing and oral-motor function3

(Table 1). In utero swallowing is important for the regulation of amniotic fluid volume and composition,

recirculation of solutes from the fetal environment, and the maturation of the fetal gastrointestinal tract.4 The

pharyngeal swallow, one of the first motor responses in the pharynx, has been observed between 10 and 14

weeks’ gestation.5 Recent studies have demonstrated swallowing in most fetuses by 15 weeks’ gestation

and consistent swallowing by 22 to 24 weeks’ gestation.3

TABLE 1.

Gestational ages for swallowing and sucking

Swallowing function Gestational age (wk)

Pharyngeal swallow 10-14

True suckling 18-24

Tongue cupping 28

Sustained total oral nutrition 34-37 View Within Article

True suckling begins around the 18th to 24th week and is characterized by a distinct backward and forward

movement of the tongue. The frequency of suckling motions can be altered by taste. Taste buds are evident

at 7 weeks’ gestation. By 12 weeks’ gestation, distinctively mature receptors are noted. Self oral-facial

stimulation usually precedes suckling and swallowing. Tongue cupping is seen by 28 weeks’ gestation.

This backward and forward movement of the tongue in suckling is all that can be expected because the

tongue fills the oral cavity at this stage of development. Backward movement appears more pronounced

than forward movement. Tongue protrusion does not extend beyond the border of the lips. Serial ultrasound

images have shown that suckling motions increase in frequency in the later months of fetal life.3 By 34

weeks’ gestation, a healthy preterm infant likely suckles and swallows well enough to sustain nutrition strictly

through oral feedings. Some healthy preterm infants may be ready to begin oral feeding by 32 to 33 weeks’

gestation.

It has been estimated that the near-term human fetus swallows 500 to 1000 mL/d of amniotic fluid.4 Earlier

reports had indicated that the fetus swallows about 450 to 500 mL of amniotic fluid per day (of the total 850

mL) and excretes about the same amount in urine.6 Decreased rates of fetal suckling are associated with

digestive tract obstruction or neurologic damage. Intrauterine growth retardation may be a manifestation of

neurologic damage. Lack of regular swallowing by the fetus should lead one to suspect problems that may

be related primarily to the preterm infant or primarily to the mother. Maternal polyhydramnios characterized

by excessive amniotic fluid in the uterus may result from multiple fetal and maternal etiologies. Severe

polyhydramnios is more strongly associated with congenital malformations than mild or moderate

polyhydramnios.7

Infant Feeding and Swallowing

Oral feeding that requires suckling, swallowing, and breathing coordination is the most complex

sensorimotor process the newborn infant undertakes. Premature infant patterns differ from those of full-term

infants. Lau and coworkers describe five primary developmental stages of sucking that characterize the

maturational process (Table 2).8 Sucking patterns in infants born at less than 30 weeks’ gestation were

monitored from the time they were introduced to oral feeding until they reached full oral feeding. The five-

stage scale demonstrates the relationship between the development of sucking and oral feeding

performance of preterm infants. A high interobserver reliability was observed on 50 bottle-feeding

assessments. The authors suggest that there is no significant in utero maturation of sucking occurring

between 26 and 29 weeks’ gestation, or they had insufficient statistical power to detect a difference over this

developmental period. A significant correlation between the level of maturity of an infant’s sucking and

gestational age was found. Feeding performance correlated with progression of oral feeding. These authors

suggest that developmental scales can be used clinically for the identification and characterization of the

oral sensorimotor skills of preterm infants at any point in their development as they progress in their

individual oral feeding schedule. Objective and quantitative evaluations of infants’ nonnutritive and nutritive

sucking would be helpful in evaluating strength and coordination. One proposal includes a finger pressure

device to allow for quantification of specific measures of nonnutritive sucking in combination with a

nipple/bottle system developed for monitoring nutritive sucking.9 However, there is no standardized

quantifiable procedure available currently.

TABLE 2.

Five primary stages of sucking in preterm infants

Stage

Description

1a No suction; arrhythmic expression

1b Arrhythmic alternation of suction and expression

2a No suction; rhythmic expression

2b Arrhythmic alternation of suction and expression; sucking bursts noted

3a No suction; rhythmic expression

3b Rhythmic suction and expression; suction amplitude increases, wide amplitude range, prolonged sucking bursts

4 Rhythmic suction and expression; well-defined suction, amplitude range decreased

5 Rhythmic, well-defined suction and expression; increasing suction amplitude; sucking pattern similar to term infant

Adapted from Lau et al.8

View Within Article

Term infants typically show food-seeking behavior through rooting for a breast or bottle. Preterm infants

gradually achieve skills for rooting, suckling, and swallowing for functional oral feeding as they mature.

Important early developmental milestones and feeding skills from birth to 36 months are shown in Table 3.

Children older than 36 months typically are eating regular table food and drinking from an open cup. They

continue to refine their skills but do not attain new skills.

TABLE 3.

Developmental milestones and feeding skills birth to 36 months

Age (mo)

Development/posture Feeding/oral sensorimotor

Birth to 4-6

Neck and trunk with balanced flexor and extensor tone

Visual fixation and tracking

Learning to control body against gravity

Sitting with support near 6 months

Rolling over

Brings hands to mouth

Nipple feeding, breast, or bottle

Hand on bottle during feeding (2-4 months)

Maintains semiflexed posture during feeding

Promotion of infant–parent interaction

6-9 (transition feeding)

Sitting independently for a short time

Self-oral stimulation (mouthing hands and toys)

Extended reach with pincer grasp

Visual interest in small objects

Object permanence

Stranger anxiety

Crawling on belly, creeping on all fours

Feeding more in upright position

Spoon feeding thin, pureed foods

Suckle pattern initially suckle →suck

Both hands to hold bottle

Finger feeding introduced

Vertical munching of easily dissolvable solids

Preference for parents to feed

9-12 Pulling to stand Cup drinking

Age (mo)

Development/posture Feeding/oral sensorimotor

Cruising along furniture

First steps by 12 months

Assisting with spoon; some become independent

Refining pincer grasp

Eats lumpy, mashed food

Finger feeding for easily dissolvable solids

Chewing includes rotary jaw action

12-18

Refining all gross and fine motor skills

Walking independently

Climbing stairs

Running

Grasping and releasing with precision

Self-feeding: grasps spoon with whole hand

Holding cup with two hands

Drinking with 4-5 consecutive swallows

Holding and tipping bottle

>18-24

Improving equilibrium with refinement of upper extremity coordination

Increasing attention and persistence in play activities

Parallel or imitative play

Independence from parents

Using tools

Swallowing with lip closure

Self-feeding predominates

Chewing broad range of food

Up–down tongue movements precise

24-36

Refining skills

Jumping in place

Pedaling tricycle

Using scissors

Circulatory jaw rotations

Chewing with lips closed

One-handed cup holding and open cup

Age (mo)

Development/posture Feeding/oral sensorimotor

drinking with no spilling

Using fingers to fill spoon

Eating wide range of solid food

Total self-feeding, using fork

Adapted from Arvedson and Brodsky10

(pp. 62-7).

View Within Article

The development of independent, socially acceptable, feeding processes begins at birth and progresses

throughout the first few years of childhood. Oral sensorimotor skills improve within general

neurodevelopment, acquisition of muscle control that includes posture and tone, cognition, and language,

and psychosocial skills (Table 3).10

Feeding and swallowing skill development parallels psychosocial milestones of homeostasis, attachment,

and separation/individuation (Table 4).11

Infants during the first 2 to 3 months of life strive toward

homeostasis with the environment. Goals include sleep regulation, regular feeding schedules, and awake

states that are developmentally advantageous in the development of emotional attachment to primary

caregivers. Successful pleasurable feeding experiences foster efficient nipple control, reaching, smiling, and

social play. Thus, feeding gradually becomes a social event. Caregivers should not interpret pauses

between sucking bursts as a need for burping or early satiety. Once caregivers interrupt feeding, some

infants do not resume sucking readily. Caregivers then may perceive that an infant is full or too tired to

continue, so they stop the feeding. If this pattern becomes habitual, the infant is likely to gain weight slowly

or not at all, which results in undernutrition or failure to thrive. If the interactions between infant and

caregiver fail to develop appropriately, the infant may indicate lack of pleasure, loss of appetite, and, in

severe forms, vomiting and rumination. Significant feeding problems can evolve out of a mismatch between

infants’ cues and caregivers’ interpretations of the cues.

TABLE 4.

Feeding-related psychosocial milestone: birth to 36 months

Stage Psychosocial milestones

Birth to 3 months (homeostasis)

Cues for feeding: arousal, cry, rooting, sucking

Caregiver responds to cues (leads to

Stage Psychosocial milestones

self-regulation)

Infant quiets to voice

Hunger–satiety pattern develops

Infant smile promotes interaction with primary caregiver

Pleasurable feeding experiences → greater environmental interaction

3-6 months (attachment)

Primary interactions—―falling in love‖

↑Reciprocity of positive infant and caregiver interactions

Consistent cues

Anticipation of feeding

Pauses likely socialization, not necessarily for burping or to indicate satiety

Smiling, laughing, social, alert

Preferred feeders are parents

Calls for attention by 6 months

6-36 months (separation/individuation)

Responds to ―no‖

Imitates movements, and gradually imitation of speech

Play activity to explore environment (7-9 months)

Facial expression used to indicate likes and dislikes

Follows simple directions

Self-feeding emerges

Stage Psychosocial milestones

Mealtimes become more predictable

Speech becomes important

Direction following—gradually 2- to 3-step commands

Mealtimes become part of whole family schedule

Rapid increase in language 24-36 months

Independent feeding by end of period

Adapted from Chatoor et al.11

View Within Article

Transition Feeding

Infants show readiness for the transitional feeding period that usually begins around 4 to 6 months in

typically developing infants, which also is the period of attachment for psychosocial milestones (Table 4).11

Transition feeding describes the readiness for and initiation of spoon feeding, usually with thin cereal mixed

into breast milk or formula for most infants. Infant developmental skills that indicate readiness for spoon

feeding include, but are not limited to, upright sitting with minimal support, midline head position maintained

for several minutes without support, hand-to-mouth motor skills, dissociation of lip and tongue motions, and

anatomic changes resulting in more space for the tongue within the oral cavity that allow for vertical motion

of the tongue in addition to the previously restricted movements of ―in and out‖ suckling. Over the next

several months, infants gain oral sensorimotor skills for accepting thicker and lumpier food by spoon. Then,

they move into a period of greater independence noted by finger feeding of easily dissolvable solid food.

They gradually become more precise in picking up small pieces of food (or other objects), as they attain a

pincer grasp with thumb and forefinger, which is expected by 10 to 12 months.

Critical and Sensitive Periods with Implications for Behavioral and Sensory-based Feeding Problems

The concept of critical and sensitive time periods in overall human development is well documented in some

areas of development and in animal research. Lorenz12

interpreted findings from animal embryologic studies

to imply that there is a period during early development when the organism is primed to receive and perhaps

permanently encode important environmental information. These interpretations do not mean that later

learning cannot occur or that it is not important, but they do emphasize the possible significance of these

early experiences.

Critical and sensitive periods are believed to exist in the development of normal feeding behavior.

Descriptions of these critical periods typically focus on the introduction of chewable textures (Table 3).

Children develop oral side preferences for chewing that relate to hand preferences in many instances.

Chewing skills vary with textures. Children develop mature chewing skills for solid foods earlier than for

viscous and pureed foods. However, it is common for children who have not mastered the timing and

coordination for swallowing purees and other smooth food to be kept on those textures because caregivers

may believe that these children are not ready for introduction of chewable food, which is not necessarily

true. Children need to be introduced to solid foods at the most appropriate times. Children may reject solids

on initial presentation if they are introduced after the critical periods. The longer the delay in the introduction

of solids, the more difficult it is for many children to accept chewable food. Withholding solids at a time when

a child should be able to chew (6 to 7 months developmental level) can result in food refusal and even

vomiting,13

which in turn may have a significant negative effect on nutrition and hydration status.

Studies in mice reveal that those fed a soft-feed (powdered) diet after weaning reduced synaptic formation in

the cerebral cortex and impaired the ability of spatial learning (radial maze) in adulthood when compared

with mice fed a hard-feed (pelleted) diet.14

Similar deficits may result from lack of experience and exposure

to age-appropriate foods in humans, providing a conceptual framework to explain clinical observations of the

challenges encountered in the learning of oral sensorimotor and other skills in children not fed during

critical/sensitive periods for oral skill development. Perhaps when children have not been introduced to solid

foods within the critical sensitive periods, broad aspects of development may be affected negatively. One

may assume that these children missed not only this critical period for chewing, but also the underlying

skills, which include trunk stability, head control, mobility of limbs, and mouthing experiences involving

hands, fingers, and toys. Physiologic processes that are underpinnings for oral sensorimotor and swallowing

skills, such as respiratory control, also have critical periods that can impact the feeding process.

Psychosocial development, personality, and environment are additional factors that must be considered for

children with feeding issues. Some children may respond in aversive ways when presented with certain

textures, tastes, or temperatures of food and liquid. These same children may be hypersensitive to tight

clothes or tags on their clothes. They may not like to wear shoes. They may get upset when their hands get

dirty, so they refuse to do finger painting and will not put their fingers into pudding or other pureed food.

Critical and sensitive periods may apply to the mother, with effects related to the potential for efficient

feeding and global development of an infant.15

Maternal early contact with both preterm and term infants has

been found to have a positive effect on the mother’s attachment behavior and ultimately enhanced

development of the infant.

Effects When Oral Feeding Is Not Possible in the Newborn Period

When infants with major physical and physiologic problems are prevented from initiating oral feeding in the

same timeframes as their more typically developing peers, many demonstrate prolonged delays and

significant difficulty with oral feeding. In addition, significant variations are found in the form and function of

the ingestive systems of age-matched healthy infants and at-risk infants. Ultrasounds revealed that fetal

swallowing occurred most commonly in the presence of oral-facial stimulation. Hands were touching face

and mouth. In some instances, fingers or thumbs were seen in the mouth. Perhaps some infants miss critical

periods while still in the womb. Miller and colleagues3 postulate that prenatal development indices of

emerging aerodigestive skills may guide postnatal decisions for feeding readiness and, ultimately, advance

the care of medically fragile neonates. Clinicians must have knowledge regarding normal development to

appreciate and understand the implications of differences in infants and young children with feeding and

swallowing problems, which are likely to be just one or two pieces of a much larger and more complex

puzzle. All aspects must be delineated to plan management strategies that will permit adequate nutrition

without pulmonary issues and without stress to the child as well as to the caregiver.

Taste and Smell in Oral Feeding of Infants and Young Children

Understanding an infant’s awareness of taste and smell, along with responses to textures and temperature,

is fundamental for clinicians of any discipline to determine the potential for acceptance of new foods.

Physicians, dietitians, nurses, and therapists who guide parents when children are failing to thrive, or have

limited range of foods in the diet, must examine the broad parameters that can impact on a child’s feeding

status. These experiences occur much earlier than many professionals would expect. Initial experiences

with flavors occur before birth, because the flavor of amniotic fluid changes as a function of the dietary

choices of the mother. Flavors from the mother’s diet during pregnancy are transmitted to amniotic fluid,

which are not only perceived by the fetus but also enhance the acceptance and enjoyment of that flavor in a

food during weaning from the breast. The ability to detect additional tastes and flavors develops after birth.

Thus, it is clear the early sensory experiences have an impact on the acceptance of flavors and foods during

infancy and childhood.16

It has long been shown that human infants are born with a preference for sweet. Their sensory apparatus

can detect sweet tastes. Tatzer and colleagues17

found that preterm infants fed exclusively via gastric tubes

exhibited more nonnutritive sucking in response to minute amounts of glucose than to water solutions

presented intraorally. Infants produced more frequent and stronger sucking responses when offered a

sucrose-sweetened nipple compared with a latex nipple.18

Exposure to flavors in breast milk may serve to heighten preferences for these flavors and facilitate the

weaning process. Some breastfed infants are more willing to accept a novel vegetable on first presentation

than are formula-fed infants.19

Children who have been breastfed for at least 6 months are also less likely to

become picky eaters.20

The ability to detect and prefer a salt taste does not appear until infants are about 4 months of age. Animal

model studies demonstrate that this developmental change may reflect postnatal maturation of central and

peripheral mechanisms underlying salt taste perception.21

The preference that emerges at this age appears

to be largely unlearned.

An example of the importance of early exposure to flavors is found in the acceptance of protein hydrolysate

formulas by 7-month-old infants who had readily accepted this kind of formula when compared with their

regular milk- or soy-based formula in the first couple months of life. These formulas are known by a variety

of names depending on the company that produces and distributes them in the United States and in other

countries throughout the world. A sensitive period in early infancy is suggested as at least one important

factor, as shown by the finding that those infants 7 months and older avidly accept these formulas if they

have experienced them during the first months of life. However, in marked contrast, 7- to 8-month-old infants

who had no previous experience with hydrolysate formulas strongly rejected them and displayed extreme

and immediate facial grimaces, similar to those observed in newborns in response to bitter and sour

tastes.22

Professionals who make decisions regarding feeding of infants and young children have to consider multiple

variables. Differences in flavor acceptance that occur from breastfed to bottle-fed infants and that likely

change over time reflect complex interactions of sensory and motor factors.

Clinical Assessment of Pediatric Swallowing and Feeding Disorders for Primary Care

Physicians

There are four key questions that physicians and nurses in primary care can ask parents when an infant or

young child presents at the office or clinic with parental concerns related to feeding. The answers help

determine if a comprehensive clinical feeding and swallowing assessment is needed, even though the

answers do not necessarily define the problem:

• How long do mealtimes typically take? If more than about 30 minutes on any regular basis, there is a problem. Prolonged feeding times are major red flags pointing to the need for further investigation. • Are mealtimes stressful? Regardless of descriptions of factors that underlie the stress, further investigation is needed. It is very common for parents to state that they ―just dread mealtimes.‖ • Does the child show any signs of respiratory stress? Signs may include rapid breathing, gurgly voice quality, nasal congestion that increases as the meal progresses, and panting by an infant with nipple feeding. Recent upper respiratory illness may be a sign of aspiration with oral feeds, although there may be other causes. • Has the child not gained weight in the past 2 to 3 months? Steady appropriate weight gain is particularly important in the first 2 years of life for brain development as well as overall growth. A lack of weight gain in a young child is like weight loss in an older child or adult.

Principles of Clinical Feeding Evaluation

The clinical evaluation of an infant or child with complex issues related to feeding and swallowing includes a

thorough history, physical examination, and feeding observation. Instrumental assessments of swallowing

may be needed following the clinical evaluation when concerns are noted regarding pharyngeal phase

physiology and risks for aspiration with oral feeding. Most children are best served in the context of an

interdisciplinary team. Unfortunately, such teams are available only in a limited number of medical centers in

the United States and in other countries throughout the world. Information is provided that should be useful

for physicians, dietitians/nutritionists, and other professionals who do not have an interdisciplinary team

available. All professionals who work with these infants and children are urged to collaborate with

appropriate colleagues and to develop an interdisciplinary team to whatever extent is possible. Particular

attention is paid to factors that are likely to interfere with adequate nutrition and hydration, because the most

fundamental goals for all children relate to optimal status of nutrition and hydration.

Categories of Causes of Swallowing and Feeding Disorders

A careful reading of the medical, developmental, and feeding history is the first step that is critical to

decision-making. Swallowing and feeding disorders in infants and children are complex and can have

multiple causes in various categories of disorders including, but are not limited to the following:

• Disorders that affect hunger/appetite, food-seeking behavior, and ingestion • Anatomic abnormalities of the oropharynx • Anatomic/congenital abnormalities of the larynx and trachea • Anatomic abnormalities of the esophagus • Disorders affecting suck-swallow-breathing coordination • Disorders affecting neuromuscular coordination of swallowing • Disorders affecting esophageal peristalsis • Mucosal infections and inflammatory disorders causing dysphagia • Other miscellaneous disorders associated with feeding and swallowing difficulties, for example, xerostomia, hypothyroidism, trisomy 18 and 21, Prader–Willi syndrome, allergies, lipid and lipoprotein metabolism disorders, and a variety of craniofacial syndromes. Link and Rudolph

23 have a detailed list of specific causes within each of the above categories.

Caregiver Perceptions of Feeding Problems

Each person involved with feeding and caring for a child is likely to have perceptions of the feeding status

and problems that differ from other caregivers and professionals. Information is needed from more than one

caregiver or professional involved with the child. Questions are formulated to delineate the feeding status as

clearly as possible. The following questions go beyond the screening questions suggested earlier. A

discussion of each of these questions can be found at

http://www.nature.com/gimo/contents/pt1/full/gimo17.html.

How long does it take to feed the child? Is the child independent for feeding or dependent on others to a greater degree than would be expected for age and overall developmental status? Is the child a total oral feeder? Do differences in food textures, temperatures, or tastes change the child’s response at mealtime? Does the feeding problem change throughout the course of the meal? Does the feeding problem vary by time of day or by feeder? Does the child maintain a midline neutral position of the trunk, neck, and head without requiring added support? Are there signs of breathing difficulties during feeding? Does the child have emesis regularly? Does the child refuse food? Does the child get irritable or sleepy and lethargic during mealtimes? How do the child and caregiver interact? Are there signs of forced feeding?

Interdisciplinary Team Approach

An interdisciplinary team approach offers the benefit of coordinated consultation and problem-solving for

multiple interrelated problems. Effective management of these medically complex children depends on the

expertise of many specialists, who may work independently and as a team (Table 5). Case coordination is

often a critical component that is intensive and needed to optimize the child’s health and development along

with the family’s ability to cope with multiple issues and sometimes disparate opinions and

recommendations. An interdisciplinary approach is recommended at institutions where professionals

evaluate and treat children with complex feeding and swallowing problems. Success factors include the

following:

• Collegial interaction among relevant specialists • Shared group philosophy related to diagnostic approaches and management protocols • Team leadership with organization for evaluation and sharing of information • Willingness to engage in creative problem-solving and research • Time commitment for the labor-intensive work that is required TABLE 5.

Feeding/swallowing team members and their functions

Team member Function

Parents Primary caregiver and decision-maker for child

Physician Medical leader

(gastroenterologist, developmental pediatrician, or pediatric physiatrist)

Team co-leader

Pediatric health and neurodevelopmental diagnosis

Medical and health monitoring

Team member Function

within specialty area

Speech-language pathologist

Team co-leader (active in feeding clinic and coordinates programmatic activities)

Clinic and inpatient feeding and swallowing evaluation

Videofluoroscopic swallow study (VFSS) with radiologist

Flexible endoscopic examination of swallowing (FEES) with otolaryngologist

Oral sensorimotor intervention program

Nurse

Leads preclinic planning

Reviews records and parent information

Coordinates patient follow-up

Changes gastrostomy tubes

Dietitian/nutritionist

Assesses past and current diets

Determines nutrition needs

Monitors nutrition status

Psychologist

Identifies and treats psychological and behavioral feeding problems

Guides parents for behavior modification strategies

Directs inpatient behavioral feeding program

Occupational therapist Evaluates and treats children with problems related to posture, tone, and sensory issues

Social worker

Assists families for community resources in a variety of ways

Acts as advocate for the child

Team member Function

Additional specialists

Otolaryngologist

Physical examination of upper aerodigestive tract

Detailed airway assessment

FEES with speech-language pathologist

Medical and surgical treatment of airway problems

Pulmonologist Lower airway disease—evaluation and management

Radiologist

VFSS with speech-language pathologist

Computed tomography (CT) scan of chest

Varied radiographic diagnostic studies

Pediatric surgeon Surgical management of gastrointestinal disease

Cardiovascular surgeon Surgical management of cardiac disease

Neurologist/neurosurgeon Medical and surgical management of neurologic problems

Physical therapist Seating evaluations and modifications to seating systems

Adapted from Arvedson and Brodsky10

(pp. 6-7).

View Within Article

Depending on the expertise and interest in different institutions, team members may be drawn from different

disciplines. The functions should cover those described (Table 5). Not all disciplines will be needed for all

children. It is important to determine which disciplines can best serve the child and family so that patient

care can be both efficient and efficacious. Specific discipline involvement may change over time as the

child’s needs change.

Instrumental Examination of Swallowing

Instrumental examinations may be needed for infants and children particularly when the pharyngeal and

esophageal physiology needs to be delineated objectively to answer specific questions related to the safety

and efficiency for oral feeding. However, a full discussion of this is beyond the scope of this article and the

reader is referred to http://www.nature.com/gimo/contents/pt1/full/gimo17.html.

Management of Feeding and Swallowing Problems in Pediatrics

Management decisions are made in light of the total child with consideration for medical/surgical, nutrition,

oral sensorimotor, behavioral, and psychosocial factors. Intervention strategies are focused on primary

problem areas of deficit. Evidence-based practice guidelines are needed. Airway stability and adequate

nutrition/hydration status are prerequisites for all oral sensorimotor and behavioral approaches to increase

the volume of oral feeding or to improve oral skills to expand food textures and to increase efficiency. Initial

efforts to improve caloric intake may include increasing caloric density of food, as per the dietitian and

physician, along with making adjustments of food textures to improve efficiency and safety or oral feeding.

Adequate fluid intake is critical to meet hydration needs and to minimize potential of constipation, which can

be a major complicating factor in facilitating hunger, appetite, and interest in feeding.

Oral sensorimotor intervention involves strategies related to the function of oral structures for bolus

formation and oral transit that are under voluntary neurologic control, that is, the jaw, lips, cheeks, tongue,

and palate. Techniques vary widely among therapists with little evidence of efficacy, efficiency, and

outcomes. Some children appear to improve oral function when foods vary on the basis of texture, tastes,

and temperature. Other children show significantly improved oral skills and timing of swallowing with posture

and position changes. Frequently used strategies include tapping or stroking the face and using a ―Nuk®‖

brush or other kinds of stimulation. Parents and therapists report that this kind of stimulation will ―wake up

the system‖ and then the child will swallow more quickly and more firmly. However, data are sorely lacking.

Goals of specific exercises usually relate to improved strength and coordination, but without defined

objective measures of outcomes.

Professionals and parents do not disagree about the importance of adequate nutrition/hydration. However,

there is more likely to be disagreement regarding the need for a gastrostomy tube (GT). It is not unusual for

parents to need some time, at least a few weeks or even months, before they agree to a GT. A nasogastric

tube may be used for a few weeks as a test to determine if the child tolerates needed volume of liquid per

feeding without discomfort or emesis. The nasogastric tube feeds also provide an opportunity to monitor

weight gain. If nonoral feeds are likely to be required for longer than several weeks, not necessarily for total

oral feeding but perhaps just to meet fluid requirements or for medications, a GT should be considered. A

feeding GT often relieves stress on the caregivers by allowing freedom from fear of malnutrition. More

efficient caloric delivery also frees time for other more pleasurable interactions with the child. Some oral

therapy should continue at appropriate levels to ensure the continued experience and maximal development

of oral skills over time. Speech-language pathologists can train parents, who can then take advantage of

offering tastes during several brief ―practice‖ sessions each day. Duration of each session should be only

about 5 to 10 minutes in these circumstances. When a child is on bolus feeds, optimal timing for

―pleasurable practice‖ is likely to be shortly before the start of the tube feeding, providing the child does not

show aversive reactions to the tube feedings.

Data on evidence-based research are needed. All therapeutic approaches have a primary goal for each

child to experience healthy, safe, and pleasurable oral feeding, whether the child is a total oral feeder or gets

just limited quantities and types of food for practice and pleasure. Pulmonary stability and nutritional well-

being are always the primary goals for all infants and children.

Section II: Gut Motility and Enteral Feeding Tolerance with an Emphasis on

Premature Infants

The gastrointestinal tract is a complex organ that starts at the mouth and ends at the anus. Its functions

include mastication of food, digestion and absorption of nutrients, elimination of waste, and protection of the

host from infectious organisms and toxins. Normal intestinal motility is important for each of these functions.

When normal motility is absent or impeded a variety of diseases and/or disorders may occur.

Much information now exists concerning gastrointestinal motility in adults. However, we are just beginning to

understand the developmental aspect and the importance of motility in premature and term infants.

Gastrointestinal Motility

When considering motility in adults and children, the intestine may be divided into segments that are

separated by sphincters. Food introduced into the mouth is masticated, mixed with fluid, electrolytes,

immunoglobulins, and enzymes. The mixture is delivered to the esophagus, propelled distally through the

gastroesophageal sphincter and into the stomach where it is churned with additional fluid, electrolytes, acid,

and enzymes. The mixture then transits the pylorus and empties into the small intestine. Long-chain fats and

triglycerides present in the mixture empty slowly from the stomach. Liquids low in fat have a more rapid

transit into the small intestine where digestion continues and where nutrients are absorbed as they move

fairly rapidly through the small intestine. Ingested material not digested and absorbed is delivered to the

colon through the ileocecal valve. Transit slows as the colon reabsorbs water, and the liquid chyme is

propelled by peristalsis into the transverse and descending colon. By the time waste reaches the sigmoid

colon and rectum, much of the water has been reabsorbed. The fecal mass is then compact and ready for

elimination.

Esophagus

Motility in each of the gastrointestinal segments is unique to that part of the intestine. The esophagus can be

divided into three functional regions: upper esophageal sphincter (UES), esophageal body, and lower

esophageal sphincter (LES). The coordinated motor pattern of the esophagus, or primary peristalsis, is

initiated by the act of swallowing. A rapidly progressing pharyngeal contraction transfers the bolus through a

relaxed UES into the esophagus (Fig 1). As a swallow is initiated, there is laryngeal elevation as the

swallow-bolus passes from the pharynx, across the UES, and into the proximal esophagus. As the UES

closes, a progressive circular contraction begins in the upper esophagus and proceeds distally along the

length of the esophageal body to propel the bolus through a relaxed LES. The LES is not an anatomically

discrete sphincter but a high-pressure zone (Fig 1). Secondary peristalsis is a progressive contraction in the

esophageal body that is not induced by a swallow, but rather by stimulation of sensory receptors in the

esophageal body. This type of peristalsis is usually induced in two ways: by luminal distention from refluxed

gastric contents or following incomplete clearing of esophageal contents by primary peristalsis.

Full-size image (345K)

FIG 1. Esophageal motor events in response to a swallow. The UES relaxes when the swallow-bolus moves

from the pharynx into the proximal esophagus. The contraction wave moves down the esophagus and as it

approaches the LES there is relaxation of that high pressure zone. *While every effort has been made to

locate the copyright owner of this work, Academy Professional Information Services, we have been unable

to do so and obtain permission for the reproduction of this figure. Given its scientific value, we have taken

the step of reproducing it here and invite anyone with a claim to the copyright of this work to contact us at

212-633-3957.

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Physiologically, the LES in children is a 2- to 3-cm-long segment of tonically contracted smooth muscle at

the distal end of the esophagus. Intraabdominal pressure, gastric distention, peptides, hormones, various

foods, and many drugs modify the LES pressure. When swallowing, LES relaxation is mediated via

preganglionic, cholinergic vagal fibers in addition to postganglionic, noncholinergic, nonadrenergic nerves.

However, the LES can also transiently relax independent of swallowing, and an increased proportion of this

type of inappropriate relaxation has been reported in children with gastroesophageal reflux.[24] and [25]

Stomach and Small Intestine

The stomach mixes the food-bolus with additional fluid, electrolytes, and enzymes and propels the chyme

toward the pylorus. The mixture is emptied into the proximal small intestine. Two distinctive patterns of

motility may occur in the small intestine: postprandial and interdigestive.

Postprandial Small Intestinal Motility

Following a meal, there can be segmentation contractions of the stomach and small intestine that chop, mix,

and roll chyme, and/or peristalsis, which propels the chyme toward the large intestine.

Interdigestive Small Intestinal Motility

This pattern of motility is seen between meals when the stomach and small intestine are devoid to a large

extent of food and chyme. During this period, so-called housekeeping contractions originate in the gastric

pacemaker or proximal small intestine and propagate down the small intestine, sweeping it clean of debris.

This pattern is called the migrating motor complex. The migrating motor complex consists of three distinctive

contraction patterns or phases (Fig 2). Phase 1 is a motor quiescent period, which follows phase 3 and

precedes phase 2. Phase 2 is a period of irregular contractions, varying in amplitude and periodicity. Phase

3 is a distinctive pattern of regular, high-amplitude contractions repeating at a maximal rate for several

minutes. Each phase migrates proximal to distal. The term migrating motor complex best describes the

entire cycle, although it has been occasionally used interchangeably with phase 3.

Full-size image (128K)

FIG 2. Gastrointestinal motility pattern in a healthy adult. Note the cyclic occurrence of each phase of the

migrating motor complex. The most recognizable motor pattern is phase 3 (asterisks), which is distinguished

by a band of repetitive contractions. It is followed by phase 1, motor quiescence, and then phase 2, which is

characterized by periodic irregular contractions. Phase 3 starts either in the stomach or in the proximal small

intestine. *While every effort has been made to locate the copyright owner of this work, Academy

Professional Information Services, we have been unable to do so and obtain permission for the reproduction

of this figure. Given its scientific value, we have taken the step of reproducing it here and invite anyone with

a claim to the copyright of this work to contact us at 212-633-3957.

View Within Article

Motility in the small intestine, as in all parts of the digestive tube, is controlled by excitatory and inhibitory

signals from the enteric nervous system with input from the central nervous system. In addition, a number of

gastrointestinal hormones affect gastrointestinal motility.26

Colon

Three prominent patterns of motility are observed in the colon: (1) segmentated contractions; (2)

antiperistalic contractions which tend to propel fecal debris toward the cecum; and (3) mass movements. In

periods between meals, the colon is generally quiescent. Following a meal, colonic motility increases

significantly due in part to gastrocolic and duodenocolic reflexes. Several times each day mass movements

push feces into the rectum. When rectal volume increases to the appropriate threshold, the internal anal

sphincter relaxes. When this is followed by voluntary relaxation of the external anal sphincter, defecation

occurs. Figure 3 shows the sequence of pressure changes in the normal colon.26

Full-size image (159K)

FIG 3. This colonic motility pattern is characterized by high-amplitude propagated contractions (HAPCs)

starting in the descending colon and migrating both proximally and distally. *While every effort has been

made to locate the copyright owner of this work, Academy Professional Information Services, we have been

unable to do so and obtain permission for the reproduction of this figure. Given its scientific value, we have

taken the step of reproducing it here and invite anyone with a claim to the copyright of this work to contact

us at 212-633-3957.

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This complex and coordinated mechanism which moves ingested nutrients and fluid through the

gastrointestinal tract is immature at birth. It is common to see this immaturity manifest as gastroesophageal

reflux, abdominal distention, or sometimes diarrhea and/or constipation. We have recently gained a better

understanding of the development of gastrointestinal motility. Hopefully, as we continue to explore this new

area of research, improved methods for feeding premature and full-term newborns will be developed.

Developmental Aspects

Mouth and Esophagus

The gastrointestinal tract is essentially fully formed by 11 weeks of gestation, when swallowing of amniotic

fluid begins. By 18 to 20 weeks sucking movements appear, and at 37 weeks’ gestation a normal fetus can

swallow and process nearly 500 mL. of amniotic fluid a day.26

As early as 1983, Bernbaum and colleagues

studied nonnutritive sucking during the gavage feedings of 30 premature infants with birth weights less than

1500 g.27

All feedings were performed using oral-gastric feeding tubes. The control group (n = 15) was fed a

standard formula using set amounts of formula. The experimental group of 15 premature infants was fed the

same formula and amount. However, in the experimental group the oral-gastric tube was inserted through a

central aperture in a nipple that the infant sucked while being fed via the oral-gastric tube. This was defined

as nonnutritive sucking (NNS). The investigators found that NNS decreased intestinal transit time (increased

motility) and caused a more rapid weight gain despite comparable caloric intake, resulting in a shortened

hospital stay. They concluded that, although the physiologic mechanisms resulting from the NNS were not

elucidated, NNS may be an important factor to consider when feeding premature infants.27

More recently Pinelli and Symington reviewed the literature and set out to determine whether NNS in

preterm infants influences: (a) weight gain; (b) energy intake; (c) heart rate; (d) oxygen saturation; (e) length

of hospital stay; (f) intestinal transit time; (g) age at full oral feeds; or (h) any other clinically relevant

outcomes.28

Several data bases were searched including The Cochrane Central Register of Controlled

Trials. After a comprehensive search, the authors found that there was a significant decrease in length of

stay of premature infants receiving a NNS intervention. Other positive clinical outcomes of NNS were a more

rapid transition from tube to bottle feeding and better bottle-feeding performance. No negative outcomes

were noted. However, the review did not reveal a consistent benefit of NNS with respect to other major

clinical variables (weight gain, energy intake, heart rate, oxygen saturation, intestinal transit time, age at full

oral feeds, and behavioral state). Based on available evidence, the authors concluded that NNS in preterm

infants appeared to have some clinical benefit and did not have short-term negative effects.28

Primary esophageal peristalsis, induced by swallowing, begins during early fetal life. One aspect of

esophageal motility that has been studied in infants is the laryngeal chemoreflex. This collective response to

stimulation of the pharynx or larynx includes startle, rapid swallowing, apnea, laryngeal constriction,

hypertension, and bradycardia—mechanisms that protect the fetus living in an aqueous environment from

amniotic fluid aspiration. The development of these mechanisms prepare the fetus for postnatal adaptation.

The chemoreflex can be studied in infants by stimulating the pharynx with saline or water.29

In some infants,

laryngeal chemoreflexes may be ineffective, leading to aspiration, or they may be overly effective, resulting

in apnea. However, in infants born extremely premature, or with congenital anomalies or hypoxic/ischemic

encephalopathy, feeding difficulties may precede the diagnosis of delayed neurologic development.

There is not much evidence of esophageal defense mechanisms against gastroesophageal reflux (GER) in

infants, although a wealth of information exists from adult studies. Using new techniques, Jadcherla and

colleagues have characterized esophageal protective phenomena in developing infants.29

Their study

apparatus consists of a water-perfusion manometry system with a specially designed manometric catheter.

The researchers infuse varying volumes of air, water, or apple juice into the mid-esophagus and note

responses of the upper gastrointestinal tract to these stimuli. They have identified three responses to the

stimuli: (a) occurrence of esophageal peristalsis unrelated to a swallow (secondary peristalsis); (b) increase

in UES pressure; and (c) occurrence of primary peristalsis. These protective reflexes were elicited reliably

and safely.29

With this new technology, we may be able to study feeding techniques and nutrient formulations that

minimize recruitment of these protective mechanisms. Perhaps this information will lead to infant formulas

that are better tolerated and associated with less GER.

Stomach

It is common practice to check gastric residuals (GR) before feeding very low birth weight infants. The

gastric residual volume (GRV) is regarded as an objective parameter for feeding intolerance in premature

and term infants. Increased pregavage residuals are regarded as one of the gastrointestinal manifestations

of stage I (suspected) necrotizing enterocolitis. The definition of increased GR, however, and its relation to

feeding intolerance has never been studied in a systematic manner during enteral feeding of extremely low

birth weight infants (ELBW: <1000g). Furthermore, the presence of gastric fluid, which is green, suggests

poor emptying or reflux of bile into the stomach and may prompt the suspension of feedings or the initiation

of diagnostic procedures. However, the significance of green GR and its impact on feeding intolerance has

not been studied in ELBW infants. Mihatsch and coworkers in Germany studied 99 ELBW premature infants

in regards to GR volume and green gastric aspirate.30

Using a standardized protocol, premature infants were

evaluated from day 3 to day 14 of life. At 48 hours of age, milk feedings were started at 12 mL/kg/d, divided

over 12 feeding periods each day. When GR were checked before each feeding, a GRV of 2 mL or less was

tolerated by infants who weighed <750 g at birth and a gastric residual volume up to 3 mL was tolerated by

infants weighing >750 g at birth. When GRV increased markedly, feedings were reduced or withheld. The

color of the GR was also assessed. The investigators found that the median volume of formula tolerated by

infants at 14 days of life was 103 mL/kg/d. The mean GRV for infants in the study did not correlate with the

amount that was taken on the 14th day. Furthermore, green GR did not correlate with the feeding volume,

which could be tolerated on day 14. The authors concluded that GRV below 2 and 3 mL, respectively, for the

two weight groups (<750 and >750 g) and a green color of the residual should not slow down the

advancement of feeding volumes.30

Gastric emptying has also been studied in older infants. Tolia and coworkers designed a prospective study

using gastric scintigraphy to assess gastric emptying and the frequency of GER when three different

formulas were fed infants.31

Twenty-eight infants under 1 year of age with GER were studied. They were

given three different formulas using the same volume per single feeding: a casein-predominant formula, a

soy formula, and a whey-hydrolysate formula were all given in randomized order. A significant difference (P

< 0.05) in GER episodes was noted when comparing the casein-predominant and whey hydrolysate

feedings. Gastric emptying was more rapid with the whey-hydrolysate formula compared with the casein-

based formula. The presumption is that casein-based formulas curdle in the stomach and slow gastric

emptying, whereas whey-based formulas do not curdle and clear the stomach more rapidly. The curdling

predisposes the infant to GER. The authors suggest ―that formula selection may be important in the

treatment of conditions associated with delayed gastric emptying.‖31

Others have noted similar findings when

comparing whey-based and casein-formula feedings in spastic quadriplegic children.32

Small Intestine

As survival of preterm infants has increased, so has morbidity related to immaturity of the gastrointestinal

tract. Although a variety of enteral feeding regimens are used for feeding preterm infants, few studies have

tested the efficacy of these regimens, because no direct measure of intestinal motility has been available.

However, experience suggests that preterm infants may tolerate enteral feedings well using special formulas

designed for premature infants if they are fed in a carefully prescribed regimen. Physical characteristics of

the nutrients, such as caloric content, osmotic load, pH, fat content, and fiber content, may all affect gastric

emptying and gastrointestinal motility in infants as they do in adults.

Jadcherla and others recently developed a technique to record small intestinal motility in preterm and term

infants.[33] and [34]

As in the adult, intestinal motor activity in the neonate changes in response to enteral

feeding. When slow-infusion feedings are given to preterm or term infants, duodenal motor activity

significantly increases postprandially compared with that seen during fasting. This ―fed response‖ may be

altered by the rate of infusion and the concentration of the formula. Using a low-compliance, continuous

perfusion manometry system, motor activity responses to different formulas can be assessed in preterm and

term infants.[33] and [34]

Jadcherla and his group studied two commercially available formulas of different nutrient densities: Similac

20 (20 cal/oz) and Similac Special Care (24 cal/oz).34

Infants in a very controlled fashion received both

formulas at different times. Motor responses during the feeding of the two formulas differed significantly.

When the preterm infants were fed for the first time, their motor activity increased when they were fed the

lower calorie-dense formula, Similac 20. Motor activity decreased when fed the higher calorie-dense

formula. However, these differences in motor responses to the two formulas were not present 10 days later

when the infants were restudied using both formulas. The inhibition of motor responses to the calorically

denser formula early on may underlie the feeding intolerance infants experience when they are first fed

formula. However, this inhibitory response diminishes with age, suggesting that denser formulas can be

introduced later to preterm infants.34

Feeding Recommendations for Premature Infants

Although we are just beginning to appreciate the complexity of gastrointestinal motility in premature and full-

term infants and understand how formulas and feeding may influence gastrointestinal motility,

recommendations based on current evidence is available.35

Optimal nutrition is critical in the management of small, preterm infants. However, no standard has been set

for the precise nutritional needs of infants born prematurely. Present recommendations are designed to

provide nutrients to approximate the rate of growth and composition of weight gain for a normal fetus of the

same postmenstrual age and to maintain normal concentrations of blood and tissue nutrients. Generally,

intrauterine growth rate can eventually be achieved, but it is not obtained until well after the time of birth.

Nearly all ELBW infants experience significant growth retardation during their stay in the neonatal intensive

care unit. This is largely a result of the management of acute neonatal illnesses and gradual advancement of

feeding to minimize the risk of feeding-related complications, such as necrotizing enterocolitis.35

The quality of postnatal growth depends on the type, quantity, and quality of the feedings consumed.

Preterm infants fed standard infant formulas gain a higher percentage of their weight as fat when compared

with a fetus of the same maturity. The use of specially formulated preterm infant formulas and preterm

human milk fortifiers results in a composition of weight gain and bone mineralization closer to that of the

reference fetus.35

Randomized prospective trials of ELBW infants fed specially formulated preterm formulas (Table 6) have

shown significant improvements in growth and cognitive development when compared with feeding of

standard formulas for full-term infants.36

TABLE 6.

Nutrient data/liter for formulas used to feed low-birth-weight and prematurely born infants

Similac Special Care 24

Enfamil Premature Lipil

24

Neosure Advance

22 cal

Enfacare 22 cal

Liquid (Ross

Laboratories

Columbus, OH)

Liquid (Mead

Johnson,

Evansville, IN)

Liquid (Ross

Laboratories,

Columbus, OH)

Liquid (Mead

Johnson,

Evansville, IN)

Energy, kcal 806 810 746 740

Protein, g 22 24 19.4 21

Fat, g 43.8 41 41 39

Polyunsaturated, g

8.3 10.3 — —

Monounsaturated, g

3.5 4.5 — —

Saturated, g 32 26.2 — —

Linoleic acid, g 5.7 8.5 5.6 7.1

Carbohydrate, g

86.1 90 76.9 79

Reproduced from reference35>

with permission.

View Within Article

Recent findings concerning gastrointestinal motility and formula composition underscore the need for the

clinician to carefully plan and monitor the nutritional care of preterm infants during hospitalization and after

discharge. A consensus recommendation of nutrition experts on specific nutrient requirements in preterm

infants summarizes available data and recommendations and should be referred to for more detailed

information.[37], [38] and [39]

Hopefully, with a better understanding of gastrointestinal function, intestinal motility, and formula

composition, we will be able to design more appropriate formulas for premature and term infants.

Section III: Behavioral Treatment of Feeding Disorders

Feeding is an important part of the everyday life of infants and young children, and much parent–child

interaction occurs during feeding. About 25 to 40% of infants and toddlers are reported by their caregivers to

have feeding problems, mainly colic, vomiting, slow feeding, and refusal to eat.40

Severe feeding problems

are prevalent in 40 to 70% of children with developmental disabilities and chronic medical conditions.[40] and

[41] It has been suggested that many feeding disorders develop as a result of an organic condition but are

maintained over time by behavioral factors.41

Because of the prevalence of feeding disorders, busy

pediatricians will have ample opportunity during their careers to come in contact with these challenging

problems. They must be prepared to handle them and have a strategy as to how to approach the simple

uncomplicated problems and know when to refer more complicated patients to a tertiary center that has a

feeding team in place.

Classification

A review of the literature reveals several attempts to classify pediatric feeding disorders. Earlier, physicians

and investigators focused on failure to thrive as a diagnostic label. This diagnosis was made when an

infant’s or child’s weight and height measurements fell below the 5th percentile on growth standards or a

patient’s established growth curve decelerated across two major percentiles over time.42

The most

frequently cited classification of failure to thrive was that of organic or nonorganic. Organic failure to thrive

included problems related to structural or anatomic abnormalities involved with feeding (eg, defects of the

palate, tongue, and esophagus), neuromuscular problems (eg, cerebral palsy, paralysis), or other known

physiological reasons (eg, esophagitis, gastroesophageal reflux). In contrast, nonorganic failure to thrive had

origins based in disruptive social and environmental influences, which adversely influenced or contributed to

the problem.41

It has been suggested that the vast majority of childhood undernutrition in the United States

in the past has been attributable to the so-called nonorganic causes.43

The organic–nonorganic classification

was rigid and failed to account for feeding problems, which may have a combination of physiological,

environmental, and/or behavioral components. In most instances there are several reasons or causes for a

feeding disorder.41

In 1998 Burklow and her colleagues at Cincinnati Children’s Hospital Medical Center suggested an

alternative classification.41

Their Interdisciplinary Feeding Team (IFT) reported a classification system that

allowed them to categorize 103 children (64 males and 39 females) with feeding disorders. The children

were referred to the IFT for concerns related to poor oral intake and problems with sustained growth.

Disciples represented on the team included Pediatric Gastroenterology, Nursing, Nutrition, Occupational

Therapy, Psychology, and Speech Pathology. Intake evaluations were reviewed on each consecutive child

seen from September 1992 to September 1995. The IFT identified five categories that reflected the nature of

the complex feeding disorders in these infants and children: (1) structural abnormalities; (2) neurological

conditions; (3) behavioral issues; (4) cardiorespiratory problems; and (5) metabolic dysfunction.

Developmental delay or mental retardation was reported in 74% (n = 76) of all subjects. Thirty-eight percent

(n = 39) of the subjects were born prematurely (range, 24-36 weeks). There were no significant gender

differences for prematurity, developmental delay, or categorization of feeding problems. The percentage

occurrence of categories and clusters of categories are shown in Figure 4. It is of note that 85% of subjects

were categorized as having a behavioral component to their feeding disorder. Neurological conditions were

identified in 73% of the sample: structural abnormalities in 57% of the sample; cardiorespiratory problems in

7%; and metabolic dysfunction in 5% of the sample.41

Full-size image (10K)

FIG 4. Percent of subjects assigned to each category (alone or in combination). Bar 1: behavioral issues, n =

88 (85%); Bar 2: neurological conditions, n = 75 (73%); Bar 3: structural abnormalities, n = 59 (57%); Bar 4:

cardiorespiratory problems, n = 7 (7%); Bar 5: metabolic dysfunction, n = 5 (5%). *Reproduced from

reference 41

with permission.

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The authors note that a majority of the feeding disorder patients had a combination of organic and

nonorganic problems. They therefore suggest that no attempt be made to force a choice between organic

and nonorganic characterization of feeding problems. They conclude that children referred to their team

represent those with the most complex types of feeding disorders, including structural anomalies, who have

been unresponsive to initial treatment efforts in the community by a single discipline such as Occupational

Therapy or Speech Pathology. Their report underscores the point that behavior plays an important role in

children with feeding problems.41

More recently, an alternative classification of feeding disorders has been suggested by Bernard-Bonnin.40

She suggests that early feeding disorders be classified according to the following: (1) structural

abnormalities; (2) neurodevelopmental disabilities; and (3) behavioral-feeding disorders (Table 7). Like

Burklow and her group, she suggests that there is often overlap. The first category, that of structural

abnormalities, includes three anatomic areas: the naso-oropharynx, the larynx and trachea, and the

esophagus. The second category, neurodevelopmental disabilities, is composed of conditions that disrupt

the process of learning to eat and result in oral-hypersensitivity and oral-motor dysfunction. The third

category, behavioral feeding disorders, includes six types of disorders (Table 7). It is not clear if pica should

be considered in this group since it is common for infants and children before 24 months of age to mouth

and occasionally eat nonnutritive substances. Pica should be considered only when the behavior persists for

longer than 1 month and is judged inappropriate for the developmental level of the child.42

TABLE 7.

Classification of feeding disorders

Structural abnormalities

• Abnormalities of the naso-oropharynx: choanal atresia, cleft lip or palate, Pierre Robin sequence, macroglossia, ankyloglossia

• Abnormalities of the larynx and trachea: laryngeal cleft, laryngeal cyst, subglottic stenosis, laryngo-tracheomalacia

• Abnormalities of the esophagus: tracheoesophageal

fistula, congenital esophageal atresia or stenosis, esophageal stricture, vascular ring

Neurodevelopmental disabilities

• Cerebral palsy

• Arnold–Chiari malformation

• Myelomeningocele

• Familial dysautonomia

• Muscular dystrophies and myopathies

• Möbius syndrome

• Congenital myotonic dystrophy

• Myasthenia gravis

• Oculopharyngeal dystrophy

Behavioral feeding disorders

• Feeding disorder of state regulation (0-2 months)

• Feeding disorder of reciprocity (2-6 months)

• Infantile anorexia (6 months-3 years)

• Sensory food aversions

• Feeding disorder associated with concurrent medical condition

• Posttraumatic feeding disorder

Reproduced from reference40

with permission.

View Within Article

Evaluating Feeding Problems

Bernard-Bonnin suggests that there are five key questions to be answered when evaluating feeding

disorders:

1 How is the problem manifested? 2 Is the child suffering from any disease? 3 Has the child’s weight and development been affected? 4 What is the emotional climate during meals? 5 Are there great stress factors present in the family?

She also suggests a thorough history and physical examination be obtained and laboratory investigations be

held to a minimum when infants have normal physical examinations, normal growth curves, and normal

developmental assessments.40

Linscheid notes that assessment of a feeding disorder can be accomplished by a number of standardized

questionnaires, by parent and/or child interaction observation schemes, and by interview.44

Verbal or written

information supplied by the referral source is important and reports from dieticians or language therapists

may help determine adequacy of the child’s current nutritional intake and possible oral-motor problems.

Questionnaires, designed to be completed by parents, yield information in terms of the nature and degree of

the feeding problem. The Childhood Eating Behavior Inventory and the Behavioral Pediatrics Feeding

Assessment Scale are good examples. Although these instruments are very important in research,

Linscheid has not found them to be useful in clinical practice.44

Although it is important to obtain information from the referring health care professional, an interview with the

parent or caregiver should serve as the main assessment strategy. During this interview, an attempt is made

to collect information in several areas. First, information should be gathered concerning the types, textures,

and variety of foods the child is eating. A 3- or 7-day food diary taken by the parents can be helpful.

However, in the absence of this, parents can fairly accurately recall the child’s intake over the past few days.

These data often constitute an adequate sample of overall nutrient intake.44

If the child is currently receiving tube feedings, it is important to get a thorough history of whether the patient

has ever eaten by mouth, when tube feedings were initiated, and the type of formula and the calories,

protein, and nutrient content of the tube feedings. Some children are on infusion pumps that administer

calories slowly into the stomach during the night or over much of the day. Others are fed by bolus feedings

or the deliverance of larger quantities (eg, 4 oz) over a shorter period of time using gravity, syringes, or

pumps. Parents should be asked whether the child shows any indication of hunger at any time throughout

the day. Children who have been on bolus feedings often indicate that they are hungry, either by their

behavior (becoming cranky) or by actually pointing to their feeding tube to indicate to the parent that they are

feeling hunger. Children on slow enteral infusion schedules are less likely to show signs of hunger.

If the child is not receiving tube feedings, it is important to document a typical eating day. Questions about

actual mealtime behaviors should reveal behavior problems. In some cases, the health care worker can

observe directly or by videotape a ―typical‖ feeding. Generally, misperceptions or inaccurate descriptions of

the problem by parents are usually not so great as to alter dramatically treatment decisions or cause a major

revamping of the treatment plan.44

The busy clinician in evaluating the infant or child should not ―rush to judgment.‖ This has been pointed out

in a publication almost 20 years ago.45

Two infants were described whose weight and/or height gradually

came to rank below the fifth percentile during the first 18 months of life. Numerous tests were performed,

and the diagnosis of gastroesophageal reflux led to fundoplication in each infant. The concept that higher

energy intakes result in greater increases in length led eventually to placement of a gastrostomy feeding

tube in each of the infants. Increases in weight during gastrostomy feedings had no effect on growth in

length. The vague concept of failure to thrive proved to be misleading in these two infants and obscured the

fact that constitutionally short children can fall below the 5th percentile in length at any time before the age

of 2 or 3 years.45

The difficulty in classifying and treating children with feeding disorders is underscored from a report by

Tolia.46

She reported seven infants and children who were between the ages of 13 and 30 months at the

time of presentation. They all failed to consume adequate calories and suffered delayed growth. No specific

etiology for the decreased intake was discovered. None had any developmental delay nor were there any

psychiatric conditions present in mothers. Changes in formula and psychologic intervention were

unsuccessful in modifying feeding habits except in two infants. All of the patients were supplemented with

enteral formulas. Three did not consume enough orally and needed nasogastric tube infusions, with

eventual placement of gastrostomy tubes in two. The third infant required continued nasogastric tube

feedings. A significant increase in caloric intake was associated with improvement in growth percentiles.

Weight and height percentiles improved in all and crept into the normal range in five and four patients,

respectively. Attempts at weaning off the supplements resulted in weight loss in all.46

This report

underscores the challenges the clinician faces in assessing and effectively treating infants and children with

feeding disorders.

Treatment

Appetite Manipulation

Motivation to eat can be related to deprivation of calories. Generally, calorie deprivation results in increased

appetite. How to make a child hungry and yet keep him or her safe is a major consideration in treatment

planning. Inducing hunger or stimulating appetite in a child is almost always as important, or in some cases

more important, for success than the specific behavioral contingencies which may be tried. This is especially

true for feeding problems related to an unusual variety of foods or to problems of food texture. The degree to

which hunger can be induced predicts the speed and degree of success.

Linscheid notes that the importance of motivation to eat can be demonstrated by a case with which he was

involved.44

A child was referred because he was taking 1 to 2 hours to eat each meal. The mother was

spending 3 to 6 hours a day attempting to feed the child. On interview, when asked what the child drinks, the

mother and grandmother, who were both at the interview, stated that the child consumed about ¾ of a gallon

of milk each day. Rough calculations suggested that this child was getting about 1800 calories a day from

milk. It was very easy to understand why the patient would have very little motivation to consume baby food

and why meals were taking so long to complete. The successful treatment of the child involved, first,

increasing oral intake of soft textured foods and then moving to normal textures and variety. This goal could

not be accomplished without a dramatic decrease in the calories obtained from the milk. There is no

behavioral contingency program strong enough to induce a child like this to dramatically increase his intake

of food as long as he is getting his daily caloric needs met with milk.44

The most basic form of appetite manipulation for children feeding by mouth is to simply restrict all calories

between meals, while continuing to offer water or other zero-calorie fluids during these periods. However,

some would suggest that an appetite stimulant such as cyproheptadine may be tried.[47] and [48]

This agent is

not without side effects.49

For children who are treated on an outpatient basis, it is very important to arrange daily weight checks and

hydration assessments and to teach parents the clinical signs of low blood sugar or dehydration. Parents

cannot be asked to take chances with their child’s health, and if they are not able to follow through with

appetite manipulation at home, the treatment most likely will be unsuccessful.44

Behavioral Contingency Techniques

Behavioral therapy is more efficacious in feeding disorders associated with tube feeding than nutrition

counseling alone.[50] and [51]

There are a number of straightforward behavioral procedures that have been

shown to be effective in the treatment of childhood feeding problems including those associated with tube

feedings (Table 8). These meal-time rules generally involve positive and negative reinforcement and mild

punishment. Rigid adherence to a specific technique may be counterproductive, and the appropriateness of

various techniques depends on behavioral changes that may occur during treatment. Feeding treatments

should initially be conducted by trained therapists or by parents serving as therapists. These strategies can

be based in the home or in the inpatient setting.52

A supportive therapist/parent should:

• Be engaging but not overwhelming. • Talk in a quiet and encouraging manner. • Be careful not to overwhelm with talking or behavior. • Seat the infant so that he/she is straight up and facing forward. • Sit directly in front of the infant. • Wait for the infant to pay attention and open up before feeding. • Feed when the infant wants to eat, but evolve structure. • Let the infant touch his/her food and feed himself/herself with their fingers. • Let the infant decide how fast he/she wants to eat. • Respect the infant’s food preferences. • Respect the infant’s caution: all children learn to eat eventually. • Let the infant eat as much as desired. • Stop when the infant indicates that he/she is full. TABLE 8.

Food rules applicable to children beyond infancy

Scheduling

• Regular mealtimes; only planned snacks added

• Mealtimes no longer than 30 minutes

• Nothing offered between meals except water

Environment

• Neutral atmosphere (no forcing of food)

• A sheet should be placed under the chair to catch any mess

• No game playing during feeding

• Food never given as reward or present

Procedures

• Small portions are offered

• Solids are given first and fluids last

• Self-feeding encouraged as much as possible

• Food is removed after 10-15 minutes if the child plays

without eating

• Meals are terminated if the child throws food in anger

• Wiping a child’s mouth and cleaning up occurs only after the meal is completed

Reproduced from reference40

with permission.

View Within Article

In the inpatient treatment model, meals are usually time restricted to a maximum of 25 minutes. This time

limitation is used for two reasons: First, it is felt that longer meal times, particularly in the early stages when

meals are distressing, may serve to reinforce the child’s perception that feeding is an unpleasant or stressful

activity. Second, children without feeding problems usually eat within this time period, and the cessation of

the meal after 20 or 25 minutes helps ensure that the child will be hungry for the next meal. Treatment meals

are usually done three times a day, 7 days a week. There are three treatment meals per day with 3½ to 4

hours in between feedings.44

The final step in inpatient treatment is to have the parent feed the child with the therapist nearby (either

observing through a one-way mirror or standing in the hallway) in case there are questions or problems.

Discharge from the hospital can be considered when three criteria are met. The first is that the child is taking

sufficient calories to at least maintain his or her weight. The second is that treatment goals for variety are

achieved. The third requirement is that the parent and the therapist agree that the parent has acquired the

necessary feeding techniques and is capable of implementing them at home.44

In summary, Chatoor suggests that, because feeding disorders are diverse in etiology and frequently involve

unusual or abnormal behavior of the infant and/or the mother in addition to medical issues that may relate to

choking, severe vomiting, reflux, or the intermittent insertion of a nasogastric tube, the behavioral therapy

should be tailored to the etiology of the feeding disorder.42

This requires a multimember team of health care

workers with experience in diagnosing and treating feeding disorders. However, it is up to the primary health

care provider to know when to refer these patients and how to search out resources that are best matched

for each infant and child.

Section IV: Feeding Issues in the Disabled Child

The subject of feeding disabled children has gained the attention of health professionals over the past 15

years. The Nutrition Committee of the Canadian Pediatric Society first addressed this issue in 1994 in the

publication, ―Undernutrition in children with a neurodevelopmental disability‖; a revision of the original

recommendations is currently in progress.53

The American Dietetic Association adopted a position statement

on ―Providing nutrition services for infants, children and adults with developmental disabilities and special

health care needs‖ in 2003.54

Then in 2004, the American Academy of Pediatrics devoted a chapter in their

Pediatric Nutrition Handbook entitled, ―Nutritional support for children who are neurologically impaired.‖55

Finally, a consensus paper published in 2006 addressed this same subject, ―Nutrition support for

neurologically impaired children: a clinical report of the North American Society for Pediatric

Gastroenterology, Hepatology, and Nutrition.‖56

This fourth section draws in part from information presented in these four documents.

Magnitude of the Problem

Infants and children with developmental disabilities have diagnoses and conditions that place them at

nutritional risk. A developmental disability may be the result of identified etiologies (eg, chromosomal

abnormalities, congenital anomalies, inherited metabolic disorders, specific syndromes, neuromuscular

dysfunction) or it may not be associated with any diagnosed condition. Occasionally, persons may have two

or more conditions (eg, cerebral palsy and epilepsy; Down syndrome and congenital heart disease).

Children with special health care needs are those who have or are at an increased risk for impaired physical

developmental, behavioral, and emotional problems which require health and related services of a type or

amount beyond that required by healthy children.57

A survey of children from birth to 3 years of age with

developmental delays in early intervention programs found 79 to 90% had one or more nutrition risk

indicators.54

The Centers for Disease Control and Prevention reported that 17% of children under 18 years

of age have some type of developmental disability.58

Undernutrition, growth failure, overweight, micronutrient deficiencies, and osteopenia are nutritional

comorbidities that affect the neurologically impaired.56

Monitoring neurologically impaired children for

nutritional comorbidities should be an integral part of their care. Early involvement by a multidisciplinary

team of physicians, nurses, dieticians, occupational and speech therapists, psychologists, and social

workers is essential to prevent the adverse outcomes associated with feeding difficulties and poor nutritional

status. Undernutrition and overweight lead to increased health care use, hospitalization, and physician visits,

as well as diminished participation in home and school activities. Careful evaluation and monitoring of

severely disabled children for nutritional problems are warranted because of the increased risk of nutrition-

related morbidity and mortality.59

Undernutrition is a frequent problem in children with severe CP who often have significant impairment of

their eating and swallowing mechanisms.53

CP occurs in 3 to 4 per 1000 live births, and one-third of these

children are severely affected.60

Even without intervention, some children with a severe disability live more

than 30 years; the average death rate in severe cerebral palsy is 5% or less per year. Pseudobulbar palsy,

which occurs in severe CP, affects eating and swallowing. As a result, food intake is decreased and eating

time is increased. Thus oral feeding may meet with little success, despite the efforts of caregivers. GER and

aspiration of food and severe constipation often compound the problem.53

The early alternative to oral feeding has been nasogastric tube feedings; however, the use of such tubes is

associated with unacceptable long-term complications—mainly reflux and vomiting. A new approach to

feeding disabled children is through a percutaneous gastrostomy tube, which bypasses most problems with

nasogastric tube feeding. In the past most children with severe CP lived in institutions. Today they return to

the community to live in group homes or with their families. This makes a systematic approach to the

nutrition support even more important.53

Many of these children have clinically important GER regardless of whether they have been fed through a

nasogastric tube. The cause of reflux in such patients is unclear; it is probably related to intestinal

dysmotility, delayed gastric emptying, and the fact that many of them spend many hours in a recumbent

position.[32] and [53]

If reflux is significant and frequent, it may increase the risk of food aspiration and aspiration

pneumonia. In addition to reflux, aspiration of food or liquids while being fed orally is a risk in children with a

severe disability.53

Body mass index and other anthropometric parameters have been used to better determine if children with

developmental delay were obtaining appropriate nutritional support. Sanchez-Lastres and coworkers

evaluated the nutritional status of 128 developmentally delayed children.61

Historical information and multiple

anthropometric data were obtained for each subject. Analysis of the data suggested that 33% of subjects

showed borderline or definite malnutrition. Children with definite malnutrition had significantly lower IQ

scores than those who were better nourished. The authors concluded that malnutrition as determined by

anthropometric variables occurs with a high prevalence in developmentally delayed children and that the

prevalence of malnutrition increases with age and increasing IQ deficit.61

It is clear that developmental disabilities are common and that children with developmental disabilities are at

risk for malnutrition and it comorbidities.

Nutritional Needs

Campanozzi and coworkers studied body mass index and anthropometric variables in 21 children with CP,

GER, and/or chronic constipation and correlated these parameters with motor function.62

One aim of the

investigators was to evaluate the role of nutrition on gross motor ability using Gross Motor Function Measure

before and after 6 months of nutritional rehabilitation. The authors found that malnutrition and

gastrointestinal disorders were common in children with CP. However, improved nutrition status, particularly

a gain in fat-free mass, appeared to have a positive impact on motor function in children with CP.62

Nutritional factors such as inadequate intake, increased losses, and altered energy requirements clearly

contribute to the poor nutritional status of patients with neurological disabilities.

Inadequate Intake

Inadequate intake seems to be a major factor contributing to malnutrition since aggressive nutritional

supplementation improves growth.55

An increase in weight for length Z-score from −2.71 to −1.18 was seen

23 months after gastrostomy and tube feedings were initiated in a group of disabled children.55

Some note

an increase of 10 to 46% in body weight over 5 weeks with a 50% increase of intake by means of

nasogastric tube feedings.63

Children with CP spontaneously consume fewer calories than age-matched

control children.64

Reasons for inadequate intake are numerous. Oral-motor dysfunction is found in more

than 90% of children with cerebral palsy.65

Sucking and swallowing problems, inadequate lip closure,

drooling, and persistent extrusion reflex make oral feedings difficult. It is a major factor in the pathogenesis

of malnutrition in patients with CP since weight, height, and weight-for-height Z-scores are significantly lower

in patients with oral-motor dysfunction than in other patients.66

Because of their poor oral and fine-motor

skills, these children depend on a caretaker for feedings. Since they are often unable to communicate

hunger and satiety, the caretaker ends up regulating their intake. Often times, the task of feeding such a

child is difficult and time-consuming, and inadequate intake may ensue. It has been shown that the

caretaker often overestimates caloric intake and time spent feeding the child.55

In addition, GER may also

lead to food refusal, especially if reflux esophagitis is present.

Increased Losses

In addition to decreased intake, excessive losses may occur from spillage and frequent emesis.

Energy Requirements

Defining energy requirements is very important because of the patient’s inability to communicate hunger and

satiety and because of abnormal physical activity, body composition, and food intake. Unfortunately, energy

needs are poorly defined in this heterogeneous population. Energy intake in normally growing patients with

spastic quadriplegic CP fed exclusively by gastrostomy has been estimated in some studies at 60 ± 15% of

recommended daily allowance for gender and age, and 103 ± 32% of recommended daily allowance for

weight.55

Resting energy expenditure in well-nourished, nonambulatory, bedridden patients is significantly

less than that of healthy age-matched controls.67

In addition, resting energy expenditure per unit of body cell

mass is significantly reduced, suggesting a role of the central nervous system in energy regulation.

Therefore calculation of total energy needs based on healthy children overestimates the energy

requirements of children with spastic quadriplegic CP.67

Caloric needs of children with developmental disabilities should be individualized, taking into account basal

metabolic rate, muscle tone, activity level, and desired growth. A formula to calculate the energy needs of

children with severe CP has been developed by Krick and coworkers.68

It uses basal metabolic rate and

accounts for muscle tone, activity level, and growth factors (normal growth-for-height age and catch-up

growth). As can be seen from Table 9, increased motor-tone and increased activity result in a higher daily

caloric requirement. However, the best way to evaluate adequacy of nutritional therapy in a given patient is

to monitor response in terms of weight gain. Caloric intake can then be adjusted accordingly.69

TABLE 9.

Calories (kcal/d) = (BMR × muscle tone factor × activity factor) + growth factor. Where: BMR (kcal/d) = Body

surface area (m2) × standard metabolic rate (kcal/m

2/h) × 24 h

Muscle tone factor 0.9 decreased muscle tone

1.0 normal muscle tone

1.1 increased muscle tone

Activity factor 1.15 bedridden

1.2 dependent (wheel chair)

1.25 crawling

1.3 ambulatory

Growth factor 5 kcal/g of desired weight gain

Reproduced by permission from reference.55

View Within Article

Assessment

Medical History

Assessment of health status must include knowledge of the underlying disease to better understand its

natural history (ie, static versus degenerative versus temporary neurological impairment). The type of

intervention will differ depending on whether the underlying disease is a terminal condition, a short-term

reversible condition, or a chronic condition. In addition, the duration and the severity of the neurological

disability may correlate with a greater risk of malnutrition. The presence of other medical problems such as

chronic respiratory symptoms, recurrent pneumonia, GER, constipation, and the use of medication must be

evaluated and considered when planning nutritional intervention.55

Nutritional History

The nutritional history is of the utmost importance and must encompass all aspects of the feeding process. A

good evaluation of oral motor skills must be done since oromotor impairment is a major factor leading to

malnutrition. Swallowing function, including adequacy of lip closure, drooling, spilling, extrusion reflex,

incoordination, gagging, delayed swallowing, and symptoms suggestive of aspiration, such as choking and

coughing, should be evaluated. The amount of time spent feeding the child should be estimated. Feeding

efficiency in patients with severe CP is far below normal, as it may take them 12 to 15 times longer to chew

and swallow than normal children of the same weight. Even longer mealtime does not compensate for the

child’s feeding impairment and, as a consequence, caloric intake is often insufficient. Appetite and ability to

self-feed, as well as feeding schedule, must be taken into account. Sixty percent of patients with CP are

totally dependent on a caretaker for their intake.64

For the caretaker, often the parent, too much time spent

around meals may impair the parent–child relationship and take the caretaker away from other activities and

siblings. It is also important to assess parental perception of mealtime, as it is often perceived as a stressful

and not enjoyable experience.55

A review of a typical day’s food intake or a full 3-day food record will help assess caloric intake but also

adequacy of fiber, vitamin, and mineral intake. Food refusal or a recent change in feeding pattern may be

indicative of an underlying problem.

A careful review of the previous growth pattern is very important and growth charts for height and weight as

well as weight gain or weight loss must be recorded. Infants with CP who had low birth weight are at greater

nutritional risk.55

Physical Examination

Physical examination includes weight, height or length, and head circumference and signs of malnutrition or

specific nutrient deficiency. In addition, muscle tone, activity level, and skeletal deformities such as scoliosis

and contractures should be assessed.

Anthropometrics

Weight and length or height must be obtained at every visit and should be as accurate as possible, always

using the same technique and equipment. Weight should be measured on the same scale every time with

the child wearing little or no clothing. Length should be obtained supine in children under age 2 years or in

older children unable to stand. Linear growth assessment is important to detect chronic malnutrition but may

be difficult to obtain in children with severe contractures or scoliosis.

Laboratory Evaluation

Basic laboratory evaluation includes a complete blood count and iron studies, as iron-deficiency anemia

occurs frequently. Serum albumin and prealbumin will reflect nutritional adequacy in the previous month and

week, respectively. Serum electrolyte and blood urea nitrogen may help in assessing hydration status.55

Recommendations

The following recommendations are based on existing, mainly descriptive, studies and on expert opinion.53

Secondary undernutrition due to an eating problem in children with CP and other neurodevelopmental

disabilities should be treated or, ideally, prevented. The management of undernutrition in children with

neurodevelopmental disability is best performed by a multidisciplinary team. Restoring the nutrition of these

children and reducing the time spent feeding them each day should be regarded as an important part of their

general care. The nutritional status of these children is best determined by techniques that measure body fat

stores, for which there are normative data, such as triceps skinfold measurements.

Treatment should start with high-energy supplementation, given orally. However, in children with a severe

disability, therapy may necessitate tube feeding, either to supplement oral feeding or to replace it. The

advent of percutaneous enterostomy has introduced a welcome alternative for children who require tube

feeding for more than 6 to 8 weeks. Daily energy needs are lower in patients with a neurodevelopmental

disability than in other patients because they are inactive and have reduced muscle mass; energy needs

range from 2900 to 4600 kJ per day. Hence, formulas designed for infants or children less than 6 years of

age should be used because of their higher ratios of nutrients to energy (Table 10).

TABLE 10.

Formulas

Infant Pediatric Adult

Cow milk Cow milk Protein blend

Enfamil Lipil Kindercal Boost

Similac Advance Nutren Jr. Ensure

Pediasure Nutren

Osmolyte

Soy

Enfamil Prosobee Lipil — —

Good Start Supreme Soy — —

Similac Isomil Advance — —

Partially hydrolyzed (whey-based)

Good Start Supreme DHA & ARA

— —

Hydrolysate (casein) Hydrolysate (whey)

Hydrolysate (whey)

Nutramigen Lipil Peptamen Jr. Peptamen

Pregestimil

Alimentum

Amino acids Amino acids Amino acids

Elecare Elecare Vivonex TEN

Neocate Neocate 1+

Vivonex Pediatric

Reproduced by permission from reference56

.

View Within Article

In children with mild disabilities, oral motor skills should be maintained and improved. One effective strategy

is to feed the child through an enterostomy tube only when he or she is asleep, usually at night. The child is

then likely to get thirsty and hungry during the day and want to eat. This gives the caregiver or therapist an

opportunity to promote oral-motor skills.53

Other Considerations

There are issues concerning the feeding of disabled children which require additional study and continued

experience.53

These are noted below.

1 The management of children with a progressive neuromuscular disability must be considered individually, with the fully informed consent of parents and caregivers. For many of these children, enterostomy, gastrostomy, or jejunostomy feedings have helped improve their quality of life. 2 Many and perhaps all children with a neurodevelopmental disability have intestinal dysmotility, evidenced by gastroesophageal reflux, delayed gastric emptying, and constipation. A better understanding of intestinal function and motility and their management is needed. 3 Little is known about the nutrient needs of patients with CP and other neurodevelopmental disabilities. Existing pediatric enteral products have a limited calcium and phosphorus content. Bone mineralization in these children should be evaluated to determine whether present levels of calcium and phosphorus intake are too low. 4 Studies are needed to determine the best behavioral approaches to children whose oromotor skills have advanced to the point that they are capable of eating but who are unable to eat because of behavioral problems. Hopefully, continued research will improve our ability to assess these patients and increase our

understanding of how best to meet their specific nutrient requirements. This will allow us to optimize the

nutritional status, development, and health of each child.

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Current Problems in Pediatric and Adolescent Health Care Volume 37, Issue 10, November-December 2007, Pages 374-399