Children with feeding disorders are among the most complex pediatric patients that speech-language pathologists treat. For many, the problem has been ongoing for several years and will require intensive effort to meet long-term goals.
The most important issue for SLPs treating children with feeding disorders is to first be sure that any associated medical problems have been addressed. Peggy Eicher, medical director of the Pediatric Feeding and Swallowing Center at St. Joseph's Children's Hospital in Paterson, NJ, notes that common medical etiologies of feeding difficulties include gastrointestinal (e.g., reflux, slow stomach emptying, constipation), respiratory, and cardiac issues. Coordinating the suck-swallow-breathe pattern is a complex task and is often a problem for premature or sick infants. Other associated problems may include motor and sensory integration problems. Feeding difficulties often are seen in children on the autism spectrum and with developmental disabilities.
A team approach—including the physician, SLP, occupational therapist, physical therapist, and behavioral analyst—has been found to be effective in working with children with complex feeding problems. The parent or caregiver also should be included as part of the team. Oral motor, pharyngeal, and esophageal phase problems may be present and will need to be addressed. Proper positioning is essential in order to advance feedings. Family and cultural issues also must be considered in the assessment and treatment of children with feeding and swallowing problems.
Justine Joan Sheppard, an SLP from Nutritional Management Associates and Columbia University, notes that behavioral problems associated with feeding may be called conditioned dysphagia. Conditioned dysphagia is a learned disorder or maladaptive habit that maintains a behavior beyond the physiological need. Feeding aversion, failure to advance to age-appropriate foods, food selectivity, negative mealtime behaviors, and gagging are examples of conditioned dysphagia and may lead to problems such as failure to thrive. Parents of children with feeding problems often will report excessive vomiting in infancy and the best feedings occurring when a child was sleepy and her defenses were down. In some cases, children with feeding disorders require partial or full tube feedings to meet their nutritional and caloric needs.
When instituting a behavioral feeding program, it is essential that the clinician remember that nutrition is the primary issue. At mealtime, children should be offered the foods that they are already successful with and are readily consuming. Additional calories may have to be added to the foods or a supplement may be needed. New foods should be introduced during feeding therapy, which may coincide with snack time. This should be done in a setting that contains no or minimal distractions. It is suggested that the feeder begin with a previously accepted food and then modify the taste or the texture or the quantity, always working on one change at a time. The developmental hierarchy should guide decisions when advancing to the next level. Ideally, the session should end on a positive note, when the child has completed a task. If a positive response cannot be obtained, then the session should be terminated after a preset time. Once a new food is readily accepted, it can be added to mealtime and a new food introduced during feeding therapy. If a child will not advance beyond jarred purees, for instance, we often recommend moving to home-prepared purees, so that the child begins to get used to the change in consistency. Once that is accepted, the texture of the purees can be increased and mashed foods introduced. For some children who do not tolerate any food by mouth, treatment may require developing sensory tolerance for feeding, including sitting in a high chair, acceptance of utensils, and acceptance of the smells of various foods.
The instructional hierarchy can be broken down into three parts:
- acquisition, during which the child learns the new behavior (orienting to food, chewing)
- fluency, during which the child practices the behavior so that he can complete it accurately and quickly
- generalization, during which the child can complete the learned behavior with different items or in various settings
During the acquisition period, the complexity of the task and environmental stresses are reduced. Procedures to teach a child a new skill include modeling, hand-over-hand prompting, shaping, and feedback. Providing additional practice and reinforcement will increase the speed and accuracy for completing the task. It is important to develop consistent baseline behaviors before advancing the program. It is essential that the clinician change only one dimension of the skill at a time. For example, if moving from an outpatient therapeutic setting to a home setting, the parent should have the opportunity to feed in the therapeutic setting, under observation, before trying the skill at home.
Other interventions can be grouped into antecedent-based procedures, which include changes made to the dimensions of the food and changes made to how the food is presented, and consequence-based procedures, where the appropriate mealtime behaviors are reinforced and negative mealtime behaviors are extinguished. Positive reinforcement includes access to a preferred toy paired with verbal praise each time the child completes the required task (i.e., takes a bite). Selecting the appropriate reward is critical. It should be something that the child enjoys and does not have access to at other times of the day. The reward may be changed during the session as needed. Initially, any positive behavior should be reinforced. For some children, this may be sitting quietly in a high chair, accepting an empty spoon, or accepting a spoon dipped in food. Gradually the difficulty of the task should be increased. If the child does not accept in a set time (i.e., five seconds), no toy should be provided and the feeder should not provide any attention. Initially, ignoring behaviors may result in an increase in the negative behaviors, but with persistence these behaviors will reduce significantly.
If difficulties occur, as expectations become more demanding for the child, the clinician should return to the previous level to determine if the change caused the difficulty or if it was some other issue. Other procedures for overcoming difficulties during treatment include keeping the spoon in direct contact with the child's lips and ignoring all disruptive behaviors. Replacing expelled bites also may be required. With all procedures, pacing is critical. This means the bites should be presented on a fixed schedule, regardless of the child's behaviors. Goals may include acceptance within five seconds of presentation, swallowing within 30 seconds of acceptance, and the absence of expelling, gagging, coughing, vomiting, or disruptive behaviors.
Managing children with feeding disorders is a challenge for even the most experienced SLP. A team approach is vital to address all aspects of the child's care, including medical status, nutrition, sensory issues, and positioning, as well as feeding and swallowing. Patience and creativity on the part of the intervention team are essential to ensure the child's success and well-being.
Visit http://www.feedingcenter.org/ and http://www.nutritionalmanagement.org/ for additional information.