R M Katz, Johns Hopkins University School of
Medicine and Mount Washington Pediatric Hospital,
Baltimore, MD, USA
L Schuberth, Kennedy Krieger Institute, Baltimore,
C S Gulotta, Johns Hopkins University and Kennedy
Krieger Institute, Baltimore, MD, USA
© 2005 Elsevier Ltd. All rights reserved.
Feeding is the process by which growing children accept and digest food in amounts adequate to meet their nutritional needs. What seems at first glance to be a simple intuitive act is actually a complex process requiring successful caregiver interaction, adequate oral motor skills, and intact gastrointestinal motility and absorption. The term 'feeding disorder' is applied to situations in which young children are unable or unwilling to eat enough to maintain their nutritional needs. The Diagnostic and Statistical Manual of Mental Disorders, a compendium of diagnoses and the related criteria, more specifically defines pediatric feeding disorders as ''persistent failure to eat adequately as reflected in significant failure to gain weight or significant weight loss over at least one month.'' Feeding disorders are surprisingly common in children, and it has been reported that 25-35% of normal children will have mild feeding disorders and up to 70% of premature infants will have more severe feeding problems. Clinical manifestations include food refusal/selectivity, gagging, vomiting, swallowing difficulty, poor weight gain, or failure to thrive. These can be grouped into medical, oral motor, and behavioral categories, although many children have overlapping problems.
Certain groups may be at a higher risk for feeding difficulties. For example, children with food allergy may have accompanying gastroesophageal reflux and motility disorders, which then result in food refusal. A variety of medical conditions, such as cardiopulmonary, genetic, and metabolic disorders, can lead to poor appetite and slow weight gain. Oral motor and/or swallowing problems are commonly seen in children with congenital and acquired neurologic conditions such as cerebral palsy, structural abnormalities, or traumatic brain injury. Premature and medically fragile infants may miss sensitive periods of oral motor development resulting in delayed acquisition of feeding skills. This early interruption of feeding skills can lead to serious feeding disorders and food refusal due to lack of experience and impaired oral sensitivity.
Lastly, behavioral difficulties such as food refusal or selectivity are not always isolated problems. More often, they develop when medical illness adversely affects feeding patterns and caregiver interactions. If a child is failing to thrive, the most immediate solution to address the lack of weight gain and growth is to start nasogastric or gastro-stomy tube feeding. However, this supplemental feeding often results in a decrease in oral intake, which ultimately impacts on hunger, experience, and endurance. Medical issues (i.e., reflux, cleft palate, etc.) that occur very early in infancy can be the initial cause for food refusal. Consequently, for the majority of children with a feeding disorder, an early avoidance pattern is established. The parent-child interaction usually exacerbates this pattern. For example, because of severe reflux the child learns to associate eating with pain. Consequently, when the parent tries to feed the child, he or she will often encounter severe refusal behavior, which leads most parents to terminate the meal prematurely. At this point, the child not only has associated food with pain but also has learned that by having severe food refusal the meal will be terminated. Even when the reflux is medically managed, the child will still have the learned history of pain associated with eating, and the child will also have the new history of having refusal behaviors to escape the meal.
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