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EVIDENCE-BASED FEEDING STRATEGIES FOR CHILDREN WITH

SPECIAL NEEDSSandee Dunbar DPA, OTR/L, FAOTA

Professor – Occupational Therapy

Assistant Dean of Professional Development

Nova Southeastern University – Ft. Lauderdale, Florida

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Objectives

■ Identify key evidence that supports therapeutic feeding intervention

■ Apply evidence-based literature to case examples

■ Examine various strategies for improved feeding among children

■ Recognize the significance of family-centered care

approaches for feeding intervention

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Is Feeding an Issue?

■ At least 5% of infants and young children have feeding issues

■ Children with developmental disabilities have an increased risk (40-70%)

■ Feeding, eating and swallowing difficulties are caused by multiple underlying factors.

■ Represents one of the most frequent concerns in pediatric settings

Sharp et al (2017)

Definitions

■ Feeding – process of setting up, arranging, and bringing food from a plate or mouth

■ Eating – ability to keep and manipulate food in mouth, then swallow

■ Swallow – food or fluid moving through mouth, then pharynx, then esophagus, then stomach

OT Practice Framework, 2014

Oral Motor Structures

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Stages of the Swallow

1. Oral Preparatory Phase2. Oral Transit Phase3. Pharyngeal Phase4. Esophageal Phase

Oral Motor Structures

Anatomy and Swallowing Process

Swallowing Phases

Swallowing Phases

Reference: https://www.youtube.com/watch?v=YQm5RCz9Pxc

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Oral Motor Development Overview

■ Birth – 3 months – predominance or oral reflexes (suck, rooting, gag), suck/swallow/breathe coordination

■ 4-6 months – bringing hands to midline to help with bottle, starting spoon feeding

■ 6-9 months – increasing textures, cleans spoon, holding bottle, increased tongue mobility

■ 10-12 months – sippy cup, finger feeding, some solids, attempts at utensil use

Video - 10-12 month feeding skills

Reference: https://www.youtube.com/watch?v=hkN-PUXCHw0

Are you evidence-based?

■ Process of questioning

■ Reading the available literature in the

related areas

■ Evaluating available information

from the literature (evidence)

■ Applying the information to practice

■ Evaluating your own clinical outcomes

(Law, 2008; Brown, 2017)

Levels of Evidence

1. Randomized studies

2. Comparison Group

3. Single Subject

4. Case Study

5. Clinical Data (Your treatment notes are evidence!)

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The Cycle of Evidence Based Practice

Brown, 2017

1. Formulate a question

2. Identify relevant evidence

3. Evaluate the evidence

4. Implement and apply

5. Evaluate the outcomes

The Cycle of Evidence-Based Practice

Feeding Project Example■ My own question – How can we move children from tube to

oral feeding successfully? What are the outcomes of a multidisciplinary feeding program?

■ Relevant evidence – Articles related to tube to oral feeding programs (Blackmon and Nelson) – Specific steps (introduce/prepare, compliance, cooperation, parent ed)

■ Evaluation – compare/contrast to others, what fit with OT philosophy

■ Implement – intense inpatient program for 2-3 weeks with MD, Dietician, OTs

■ Evaluate – 3/4 children had significant improvements in oral intake

Dunbar, Jarvis and Breyer, ‘91

Treatment Notes into Graphs -

Single Subject Research

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Outline

■ Autism

■ Developmental Delays

■ Prematurity

■ Sensory Processing Issues

■ Models for Eval and Treatment

Family Centered Care

Person Environment Occupation

■ Advancing the Evidence Approach

Autism

■ Complex disorder with varying levels of severity of symptoms

■ Characterized by impairments in social interaction, communication and activity participation (APA, 2013)

■ Diagnosis typically in the preschool years (CDC, 2014), but behaviors may indicate differences much earlier

■ Children with autism often display issues related to feeding (Smith, 2016)

Autism and Feeding

Challenges■ Up to 89% with feeding difficulties

■ Restricted variety in diets

■ Strong food preferences

■ Aversion to certain textures

■ Excessive mouthing of objects

■ Extreme attachment to routines with resistance to change in routines

■ Repetitive movements

■ Food neophobia

■ Restrictive interests

■ Difficulty with sensory processing

(Smith, 2016; Marshall, 2014)

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Feeding Video – Child with Autism and Oral Aversion

■ Feeding Issues - 18 month old

Reference: https://www.youtube.com/watch?v=iVUbVcKrmGI

How many identifiable issues or questions?

1.

2.

3.

Other

Developmental Delays

■ Cognitive delays – Difficult to understand mealtime concepts, instructions etc.

■ Motor delays and differences – CP, exaggerated reflexes, limited use of UEs to assist with feeding, poor postural control, poor lip closure, low or high tone

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Intervention for Various Developmental Needs – Jaw

Control

Jaw Control with Tongue Pressure

Positioning

■ Midline

■ Body symmetry as much as possible

■ Hips at 90 degrees as able for older child

■ Neurodevelopmental treatment to prepare for feeding

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NDT as Preparation for Feeding

■ NDT for poor trunk control

Reference: https://www.youtube.com/watch?v=fLm9MaTELZA&list=PLuzKn45IjydlccuJ21wVuuH-M1rSrzQJM

The Necessary Nuk

Nuk Use

■ Increase oral tone

■ Facilitate tongue lateralization

■ Tactile input

■ Decrease tongue thrusting

■ Work on decreasing gag response

■ Facilitate lateral and rotary chew

■ Oral desensitization

■ Systematic desensitization (term - Marshall et al, 2014)

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Transitioning to Cup

■ Prolonged bottle use past 18 months (keep in mind cultural differences) tooth decay, higher risk for obesity

■ Sippy cup by 7-9 months typically

■ Try different kinds of sippy cups

■ Put milk on tip for tasting

■ Encourage fine motor engagement

■ With transition to cup, initial jaw control

Grading the Transition to Cup-Pre-requisite Skill Development

Pre-requisite skill development and management PRIOR to cup drinking.

Examples -

■ Fine motor

grasp refinement

■ Sensory

tactile acceptance

■ Oral motor

tongue mobility

THE EVIDENCE

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Interventions to Improve Feeding Difficulties for Children

with Autism

THE EVIDENCE

Marshall et al (2014)

23 studies –low samples

Behavioral approaches

Increased volume, but not variety

Managing Behaviors in Feeding with Developmental

Delays

Howe & Wang (2013) Systematic Review

■ Behavioral Intervention – 7 studies

■ Attention, positive reinforcement, physical guidance, and shaping

■ Evidence supports that behavioral interventions can improve acceptance of a variety of foods.

Feeding Video – Child with Autism and Oral Aversion

What strategies can you now incorporate?■ Feeding Issues - 18 month old

Reference: https://www.youtube.com/watch?v=iVUbVcKrmGI

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Feeding and Prematurity

Common Concerns

■ Synactive Theory – Autonomic, Motor, State, Attention, Self-Regulation differences

■ Suck/swallow/breathe coordination – 34 weeks plus

■ Low tone

■ Sensory issues

■ Prolonged intubation and other negative experiences

■ Need for adaptive devices

■ Need for parental collaboration and understanding

Synactive Theory of Neurobehavioral Development

H. Als■ Autonomic - respiration, heart rate, skin color

■ Motor - tone, posture, movement

■ State - level of arousal

■ Attention-interaction – efforts at engaging

■ Self regulation - ability to achieve, maintain, or regain balance in each subsystem.

Feeding the Premature Infant

■ Take breaks for babies who do not have an established suck-swallow-breathe pattern yet. You can help to develop with strategic breaks.

■ Be intentional about integrating the family

■ Listen/collaborate with the nurses, dieticians

■ Posture is essential

■ Monitor the influence of the environment

■ Jaw control, cheek stroking

■ Tongue stroking

■ Massage for high tone, tap lightly for low tone

■ Supplemental oxygen as needed for those how have respiratory issues

■ Caution – Aspiration – Swallow studies will assist for ensuring safest feeding

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Feeding the Premature Infant

Intervention continued■ Non-nutritive sucking

■ Tactile input around face

■ Nuk brush for older, more regulated babies, to stimulate tongue mobility

■ Try various nipples, based on suck strength and mouth size

■ Watch for signs of previous subsystems to assess readiness for feeding. If still in autonomic, then not ready.

So many choices

The Feeding Evidence -Prematurity

Chorna et al Pediatrics, 2014

■ Vanderbilt Children’s Hospital in Tennessee

■ 94 premature infants at 34-36 weeks, randomly selected in experimental and control group

■ Experimental group – 5 days for 15 minutes

■ Sucking on pacifier (non-nutritive sucking)- resulted in hearing recorded mothers voice

■ Tubes out one week earlier, increased intake and faster feeding rate

■ Way to engage families for family centered developmental care

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Oral Readiness in Premature Babies

Harding et al (2016)

Assessed 15 nurses on their ability to assess oral readiness in their study. None of the nurses indicated parental teaching regarding states or use of formal assessments.

Signs of readiness

■ Stability in motor sub-system

■ Stability of suck-swallow-breathe pattern

■ Ability to demonstrate hunger cues

■ Evidence or oral reflexes

■ Practitioner competence

■ Quiet alert state

■ State control and variability

LESS PREPARED TO

■ Understand impact on parent-interaction

■ Use formal checklists

Feeding the Premature Infant

Sidelying FeedingReference: https://www.youtube.com/watch?v=Bl_hNk3NoC4&list=PLDLTp_qK_bIX6BsLcWFXmJ8nN5SJOPIQh&index=2

Feeding Resource

http://nomasinternational.org/

Sidelying Feeding

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Key LiteratureEVIDENCE-BASED PRACTITIONER QUESTIONS

DOES ORAL MOTOR THERAPY WORK?

DOES PARENTAL TRAINING WORK?

Howe & Wang (2013) – Systematic Review with positive results – 1. Behavioral, 2. Parental training, 3. Physiological interventions.

Sigan et al; (2013) – Parental training- 81 children randomized into training and non-training groups. Training group significantly improved on feeding scores.

Other studies have moderate to strong support. No consensus on best form of parental training. Combined with tx seems more effective.

Key Literature

Howe & Wang (2013) Systematic Review – 21 studies

■ Physiological interventions

■ Breathing, sucking, swallowing

■ Physical and sensory aspects

Results – Prep Activities (non nutritive sucking) decreases hospital stays, improves breastfeeding, but not weight gain.

Feeding Skill Training – shortens tube feeding time, improves quality of oral feeding, increases oral intake

Sensory Aspects of Feeding

■ Tactile Defensiveness – observable aversive or negative behavioral responses to certain types of touch stimuli that most people find to be non-painful. Inability to interpret/process touch in a meaningful way

■ Think of skin as a receptive organ with multiple receptors

(Murray, Fisher and Bundy, 1991 – based on Jean Ayres original work in Sensory Integration)

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Case Example - Sensory

■ Sensory Feeding Issues

Reference: https://www.youtube.com/watch?v=4AF0fpvqRko

Family Centered Care

Core Principles of Family Centered Care

1. Listening

2. Flexibility

3. Sharing of information

4. Formal and informal support systems

5. Collaboration at all levels

6. Building on strengths of families

Heffernan et al, 2014

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Why Family Centered Care?

■ Decreased hospital length of stay

■ More efficient utilization of resources

■ Reduced litigation risk

Clay and Parsh, 2016

Family Centered Care in Feeding

■ Ask parents about typical mealtimes

■ Recognize and respect differences in culture based food selections

■ Create goals collaboratively that reflect parental preferences

■ Be aware of your own implicit biases

■ Discuss appropriate options with the family during intervention

■ Include the family in decision-making for mealtimes, food etc.

Family Centered Care (Con’t)

Definitions

■ https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4201206/

■ https://medicalhomes.aap.org/Pages/Providing-Family-Centered-Care.aspx

Survey

■ http://www.fv-ncfpp.org/files/4113/0626/9064/fcca_ProviderTool.pdf

Institute for Patient and Family Centered Care

■ http://www.ipfcc.org/

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Case Example – Family Centered Care

Marsha Dunn Klein - OT

■ Transition to Oral and Jaw Control

Reference: https://www.youtube.com/watch?v=oF2ZE5YTq4o

Triad of Feeding for Assessment and Intervention

■ Person

Physical

Sensory

Cognitive

■ Environment

Family

Physical space

Culture

■ Occupation

Self-feeding with a spoon

Social participation at mealtime

Cup-drinking

Feeding Assessment Tool Samples

■ Feeding Assessment – Centra

■ Feeding Assessment – CHOC

■ Huntington Speech - Feeding Form

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Be aware of your own “EVIDENCE”

■ Excellent documentation

■ Parent report

■ Video

■ Pre-post data from standardized assessments

■ Observations

■ Experience

Designing your own

How effective are preschool feeding groups for increasing oral intake? Or mealtime socialization? Or utensil use?

1. P-E-O considerations

2. Review of the literature (evidence)

3. Baseline data – Formal feeding evaluations

4. Case study or single subject

5. Collect data

6. Analyze data

7. Adjust approaches based on the evidence

AOTA Evidence-Based Resources

■ http://www.aota.org/Practice/Children-Youth/Evidence-based.aspx

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What can you commit to for evidence-based feeding

intervention?■ Read, read, read

■ Critically appraise

■ Journal clubs

■ Use of strategies for simple

research projects

■ Question

■ Professional involvement (membership, conferences etc.)

■ Dialogue with peers

■ Learn something new every day!

Case

Matthew is a 5 year old with a diagnosis of developmental delay, functioning around a 2-3 year old level for many skills. You receive a feeding referral, due to his very limited food diet. During your general assessment, you observe that he is tactilely defensive when you present different toys for him to play with. He withdraws when objects aren’t smooth. You also observe with his snacks that he barely wants to touch them on the tray. When you observe his general play, while talking to his parents, Matthew has poor postural control and doesn’t maintain anti-gravity postures for more than a couple seconds on the gym swing. What are three areas of intervention that you would prioritize for Matthew?

1.

2.

3.

Case continued

Describe 3 specific treatment strategies that you would use with Matthew during the first month of therapy. Be specific for your area (PT, OT, ST etc.)

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Summary

Creating intentionality for being an evidence-based practitioner is essential. As therapists, we are obligated to engage in best practices for optimal therapeutic gains. Stay updated, have conversations, record your success and read, read, read. Feeding is a very critical area of need among so many children with and without specific disabilities. Use the very available opportunities to get involved and make a difference for increased participation in what can be one of life’s most enjoyable occupations!

Questions

sdunbar@nova.edu

ReferencesBrown, C. (2017). The evidence based practitioner. Philadelphia, PA: F.A. Davis

Bundy, A.C., Lane, S J., & Murray. (2002). Sensory Integration: Theory and Practice (2nd

ed). Philadelphia, PA: F.A. Davis

Chorna, O. D., Slaughter, J. C. & Wang, L. et al. (2014). A pacifier-activated music player with

mother’s voice improves oral feeding in preterm infants. Pediatrics. 133:462-68.

Clay, A.M. & Parsh, B. (2016). Patient and family centered care: It’s not just for pediatric

anymore. American Medical Association Journal of Ethics, 18, 40-44. doi: 10.1001/journalofethics.2016.18.01.medu3-1601.

Dunbar, S.B., Jarvis, A.H., Breyer, M. (1991). The transition from nonoral to oral feeding

in children, American Journal of Occupational Therapy, 45, 402-408.

Harding, C., Frank, L., Botting, N., & Hilari, K. (2015). Assessment and management of infant feeding.

Infant, 11, 85-89.

Heffernan, J., Gustafson, K., Packard, S. & Toole, C. (2014). What works: All in the family –

How a family advisory council promotes family-centered care in the NICU. American

Nurse Today, 9.

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References Cont.Howe, T., & Wang, T. (2013). Children with feeding difficulties ages birth- 5 years.

American Journal Occupational Therapy, 67, 405-412.

Law, M. & MacDermid, J. (2002). Evidence-based rehabilitation. Thorofare, New Jersey: Slack Inc.

Marshall, J., Ware, R., Ziviani, J., Hill, R.J., & Dodrill, P. (2014). Efficacy of interventions to improve feeding difficulties in children with autism spectrum disorders: A systematic review and meta-analysis. Child: Care, Health and Development, 41, 278-302 doi:10.1111/cch.12157.

Sharp, W.G., Volkert, V.M., Scahil, L., McCracken, C.E., McElhanon, B. (2017). A systematic review and meta-analysis of intensive multidisciplinary intervention for pediatric feeding disorder: How standard is the standard of care? Journal of Pediatrics, 181, 116-124.

Smith, J.A. (2016). Sensory processing as a predictor of feeding: Eating behaviors in children with autism spectrum disorder. The Open Journal of Occupational Therapy, 4 dx.doi.org/10.15453/2168-6408.1197.