Pediatric feeding problems come in all shapes and sizes. They tend to be complicated and often result from a combination of factors. This can make effective treatment challenging for the feeding therapist. A feeding problem is defined as “The failure to progress with feeding skills. Developmentally, a feeding problem exists when a child is ‘stuck’ in their feeding pattern and cannot progress.”
So where should the speech-language pathologist start? We should always begin by trying to figure out why the child is stuck and not progressing with eating and oral motor skills. Whether the child is dependent on tube feedings, not moving to textured foods, grazing on snack foods throughout the day, failing to thrive, pocketing foods, or spitting foods out, using medical management strategies can greatly improve a child’s success in feeding therapy.
A significant number of children with feeding difficulty also have a history of gastrointestinal problems such as gastroesophageal reflux, constipation, poor appetite, poor weight gain, and sometimes food intolerance. These issues can cause eating to be painful for the child which can lead to food refusal and avoidance and subsequent oral motor delay due to decreased practice eating the needed volumes for growth and poor acceptance of age appropriate foods. Research has shown the relationship between feeding difficulty and gastroesophageal reflux.
Most of the children we work with can’t tell us what is wrong. Their eating behavior tells us a lot about their digestive tract. These children often graze, volume limit, or avoid food because filling up their stomachs hurts. Some children complain that they have stomach pain while others vomit, spit up or cry with eating. We know that if these problems persist for any length of time, they become learned patterns of behavior.
Medical strategies that promote “gut” comfort and encourage appetite will help the child be receptive to eating and can improve response to feeding therapy. These strategies typically involve the following:
- Addressing weight gain and growth as the priority of a feeding program.
- Treating constipation and establishing a routine of daily soft stooling.
- Treating gastroesophageal reflux and hypersensitivity in the GI tract.
- Using hydrolyzed formulas that are easier to digest and promote gastric emptying and stooling.
- Adjusting tube feeding rates and schedules to promote comfort.
- Using appetite stimulants to boost hunger.
Some children’s feeding skills improve dramatically with medical management alone. Other children will need feeding therapy using techniques to improve acceptance of volume and variety of foods as well as oral motor therapy to progress to age appropriate oral motor patterns. No matter what type of feeding therapy approach you are using, the child will respond better if they feel better.
Many therapists have been taught to start with the mouth. That means addressing the oral motor hypersensitivity or oral motor delay first. Many clinicians feel that the doctor or medical specialists are addressing the reflux and constipation issues. However, it really is a team effort. Most physicians do not watch the child eat or see a child as often as we do as therapists. Therefore, it is important to work closely with the referring physicians to assist with proper diagnosis and treatment in order to assure the best outcomes for our patients.
Depending on the child, using medical management strategies can take multiple visits over time with the physician. If the child’s symptoms persist despite using medicines for reflux and constipation, a pediatrician may decide to refer the child to a gastroenterologist or feeding team for specialized care. A child also may undergo further testing to rule out medical diagnoses that can negatively effect eating such as anemia, food allergy, eosinophillic esophagitis, malrotation, and motility disorders.
The most important reason to recognize and treat the underlying medical issues of children with pediatric feeding problems is to help them progress. As SLPs, we need to recognize and identify GI issues prior to starting therapy so that we are not reinforcing pain or discomfort for the child. Our goals for most clients involve weight gain and growth, age appropriate oral motor patterns, and acceptance of a variety of foods from all food groups for healthy eating. These are attainable goals for many of our clients. Using medical strategies to help the child feel better will improve response to feeding therapy and eventually outcomes.
Krisi Brackett MS, CCC-SLP, is a feeding specialist with over 20 years of experience working with children with feeding difficulties. Krisi is co-director of the pediatric feeding team at the NC Children’s Hospital, UNC Hospitals, Chapel Hill, N.C. Follow her at www.pediatricfeedingnews.com. The blog is dedicated to up to date pediatric feeding information. Krisi teaches a two-day workshop on using a medical/motor/behavior approach, is an adjunct instructor teaching a pediatric dysphagia seminar at UNC-Chapel Hill, and has co-authored a chapter in Pediatric Feeding Disorders: Evaluation and Treatment, Therapro, 2013.