Approach to feeding problems in children

Santosh Kondekar; Shweta Shettiwar; Charmi Bhanushali; Rishi Bothara; Abhishek Mandal

doi:10.4103/jpai.jpai_15_21

REVIEW ARTICLE

Year : 2020 | Volume : 9 | Issue : 4 | Page : 127-130

Approach to feeding problems in children

Santosh Kondekar, Shweta Shettiwar, Charmi Bhanushali, Rishi Bothara, Abhishek Mandal
Department of Paediatrics, TNMC and B.L. Nair Medical College Hospital, Mumbai, Maharashtra, India

Date of Submission	11-Jun-2021
Date of Decision	20-Jun-2021
Date of Acceptance	27-Jun-2021
Date of Web Publication	22-Dec-2021

Correspondence Address:
Santosh Kondekar
Topiwala National Medical College and B.Y.L Nair Ch Hospital, Mumbai Central, Mumbai - 400 008, Maharashtra
India

Source of Support: None, Conflict of Interest: None

DOI: 10.4103/jpai.jpai_15_21

Abstract

Feeding small children had been a daunting experience by most parents, particularly for those having behavioural issues. Several patterns have been reported. History taking is considered invaluable in these cases. Many patterns have been described. Of interest is when associated with autism spectrum disorder. Behaviour modification and counseling with patience are rewarding. It is important to rule out organic causes of feeding difficulties while planning for definitive intervention.

Keywords: Approach, classification, diagnostic criteria, feeding, prevalence

How to cite this article:
Kondekar S, Shettiwar S, Bhanushali C, Bothara R, Mandal A. Approach to feeding problems in children. J Pediatr Assoc India 2020;9:127-30

How to cite this URL:
Kondekar S, Shettiwar S, Bhanushali C, Bothara R, Mandal A. Approach to feeding problems in children. J Pediatr Assoc India [serial online] 2020 [cited 2023 May 30];9:127-30. Available from: http://www.jpai.in//text.asp?2020/9/4/127/333366

Introduction

Interaction between child and caregiver is called feeding, while actions taken regarding nutritional intake through mouth that are performed only by a child is called eating.^[1] Infancy and early childhood are important periods regarding critical points in physical growth and neurodevelopment, thus nutritional intake becomes an important issue and can have long-term effects if not treated properly. Feeding process in young children is mostly dependent on parents. The feeding process of young children is mainly dependent on their parents.

Definition of Feeding Difficulties and Feeding Disorders in Children

Feeding difficulty is a term encompassing all feeding problems, regardless of etiology and severity.^[1] Feeding difficulties are usually classified into three principal categories as suggested by Kerzner et al.: (1) limited appetite, (2) selective intake, and (3) fear of feeding. There are subtypes in all of these including misperceived feeding problems and also organic and nonorganic feeding difficulties.

Difficulty in consuming an adequate amount or variety of food is called a feeding disorder. It means there is an inability or refusal to eat and drink sufficient quantities of food to maintain an adequate nutritional status. Feeding disorders have serious effects such as substantial organic, nutritional, or emotional consequences including impaired growth. According to the definition, at present, the diagnosis of feeding disorder requires identification of food refusal, along with growth faltering after there is an exclusion of organic causes for the symptoms. The Diagnostic and Statistical Manual of Mental Disorders (DSM) refers to feeding disorder as a persistent impairment and either a failure to gain weight or a significant weight loss for at least 1 month, without any lack of available food or significant conditions.^[2]

Diagnostic Criteria and Classification of Feeding Disorders in Children

The diagnostic criteria according to DSM-IV focus more on behavioral problems: (1) failure to eat adequately persistently reflected in significant failure to gain persistent failure to eat adequately as reflected in significant failure to gain weight or weight loss >1 month; (2) the disturbance seen is not due to gastrointestinal disorders or other medical conditions such as gastroesophageal reflux disease; (3) the disturbance is not better explained by other mental disorders, like rumination disorder, or by lack of available food; and (4) the age of onset must be <6 years.^[3] Recently, the diagnostic criteria in the DSM-V revised early childhood feeding disorders under the umbrella term of avoidant/restrictive food intake disorder (ARFID)^[4] because feeding disorders, formerly diagnosed in infants and children, were recognized even beyond early childhood.^[5] According to the DSM-V, ARFID is defined as follows: (1) a disturbance in eating or feeding, as evidenced by one or more of substantial weight loss or absence of expected weight gain, nutritional deficiency, dependence on a feeding tube or dietary supplements, and significant psychosocial interference; (2) the disturbance is not due to limitations in food availability; (3) the disturbance is not due to anorexia nervosa or bulimia nervosa; and (4) the disturbance is not explained by other medical conditions or mental disorders, or is not occurring concurrently with another condition.^[5]

There are six subtypes of feeding disorders according to Chatoor classification and diagnostic criteria: infantile anorexia, sensory food aversion, feeding disorder of reciprocity, posttraumatic feeding disorder (e.g., fear of feeding), and feeding disorder associated with concurrent medical conditions, in addition to feeding disorder of state regulation in early infancy.^[6]

Every one of these feeding disorder subtypes has a diagnostic criterion. The definition for infantile anorexia type of feeding disorder is as follows: (1) child refuses to eat adequate amount of food for >1 month, (2) the onset usually occurs when there is transition to spoon and self-feeding between 6 months and 3 years of age, (3) child lacks interest in food and does not express hunger but shows strong interest in exploration, (4) there is significant growth faltering, (5) food refusal does not follow a traumatic event, and (6) food refusal is not caused by an underlying medical illness.^[6],[7]

Sensory food aversion is described as follows: (1) there is refusal to eat specific foods with specific tastes, textures, smells, or appearance; (2) the onset occurs during the introduction of a different type of food; (3) child eats better and more when offered preferred foods; and (4) child has specific nutritional deficiencies or oral motor delay.^[7] Children have a tendency of picky eating with this type of feeding disorder.

Posttraumatic feeding disorder, referred to as the fear of feeding type, has the subsequent diagnostic criteria: (1) there is food refusal following a traumatic event or repeated traumatic insults to the oropharynx or alimentary canal which trigger intense distress in an infant, such as choking, severe vomiting, insertion of nasogastric or endotracheal tubes, or repeated suctioning; (2) consistent refusal to eat, which is in one among the subsequent ways: child refuses to drink from the bottle when awake, but accepts food offered by spoon and drinks from the bottle when asleep; child refuses solid food, but accepts bottle feeding; or child refuses all kinds of oral feeding.^[7]

Feeding disorder of state regulation in early infancy may be almost like infantile colic. Infants experience difficulties in reaching and maintaining a relaxed state during feeding, this sort of feeding difficulty starts within the newborn period, and infants may fail to gain adequate weight or even lose weight.^[8]

Feeding disorder is claimed to be related to another medical condition when a child starts feeding readily, but shows distress during the course of feeding, and there is refusal to continue feeding ahead. Medical treatment for the underlying condition like gastroesophageal reflux disease, may improve the condition but does not solve the feeding problem itself.

A recent report suggested that the most prevalent type of feeding disorder was infantile anorexia (55.4%), followed by organic feeding disorder (16.9%), posttraumatic type (12.3%), reciprocity type (9.2%), and sensory food aversion and state regulation type of feeding disorders (3.1% each).^[7]

Prevalence of Feeding Difficulties in Young Children

In children with normal intellectual, the prevalence of feeding problems is about 25%–35%; the prevalence of feeding difficulties is approximately 25%–35% in children with normal intellectual.^[9]

According to an Indian study done by Kumar et al. in preschool children, as the age increases, the prevalence of picky eating behavior increases from 32.2% to 69.2%, with the highest prevalence in 6-year age group children (69.2%) followed by 68% in 5-year age group, 64.7% in 4-year age group, 66.1% in 3-year age group, 53.2% in 2-year age group, and 32.2% in 1-year age group.^[10]

Clinical Approach to Feeding Difficulties in Children

Thorough history taking, including dietary history and feeding-related behaviors, is the first step for treating a child who is suspected of feeding difficulties. When a child shows one or more of the following symptoms and signs: food refusal lasting more than 1 month, prolonged mealtimes, stressful mealtimes, distractions to increase intake, lack of appropriate independent feeding, prolonged breast or bottle feeding, nocturnal feeding, and failure to progress to advanced textures, feeding difficulties can be suspected. To screen for and detect feeding problems, thorough history taking and standardized questionnaires for parents or caregivers, physical examination to detect signs of underlying organic diseases or malnutrition, as well as anthropometric measurement, including body weight, height, and head circumference, may all be helpful in practice. According to Kerzner et al., there are some noticeable “red flags” indicative of organic feeding disorders.^[1] The red flags, based on symptoms and signs, include dysphagia, choking and aspiration, odynophagia or excessive crying and pain on feeding, frequent vomiting, profuse diarrhea, developmental delay, chronic cardiac or respiratory symptoms, skin eczema, growth faltering or weight loss, prematurity, congenital anomalies, and features of autism.^[1]

Children born as preterm infants and those with neurological impairment or with inborn errors of metabolism are at high risk for organic feeding disorders, requiring thorough investigation and proper management. No laboratory investigations are routinely required in children with normal physical and neurological examination results, normal growth patterns on standardized growth curves, and normal developmental milestones. Laboratory tests, such as complete blood count (white blood cell counts, lymphocyte counts, hemoglobin, and hematocrit levels), chemistry (serum protein and albumin, iron, iron-binding capacity, ferritin, liver panel, and renal panel), inflammatory markers (erythrocyte sedimentation rate and C-reactive protein), and urinalysis, are often beneficial for children with red flags to screen for concurrent infections and underlying medical conditions. If organic diseases are suspected, underlying medical conditions should be treated first.

Modifications to be Made for Children with Feeding Difficulties

Maintain appropriate boundaries
Avoid all types of distraction (e.g., television viewing, games, cell phones, toys, and books)
Feed the child at intervals of 3–4 h to encourage and maximize appetite and avoid snacks and beverages between meals
Maintain a pleasant neutral attitude with a smiling face throughout meals and never become anxious, angry, or excited
Limit mealtime duration to no longer than 20–30 min
Serve age-appropriate food according to the child's oral motor development and use reasonably small helping sizes
Systematically introduce a new food one at a time and step by step, and offer a food repetitively, at least 5 to 15 times, before giving up
Encourage independent feeding in toddlers, ensuring they have their own spoon
Allow age-appropriate messes during mealtimes by using a bib and not wiping the mouth with a napkin every time a child eats or drinks.

The sensory food aversion type requires different treatment strategies. At first, “food neophobia,” which is a normal resistance to the introduction of new food in a healthy child, should be distinguished from true sensory food aversion or selective picky eating. Because of the taste, texture, smell, temperature, or appearance, children with sensory food aversion tend to refuse to eat foods and also tend to have additional sensory problems, including adverse responses to textures, lights, and noises.^[4] For children with a mild degree of selective and picky eating, simple feeding techniques (e.g., substitutional food provision by hiding food in sauces or using attractive designs) and the basic feeding principles described above may be helpful to correct picky eating behaviors. For highly selective children, long-lasting intense systematic and stepwise approaches (e.g., offering a desired food on the progressive acceptance of less desired foods, food chaining by replacing one food with a similar one, fading and shaping of taste, color, texture, and gradual exposure to the food) in conjunction with positive reinforcement are required.^[4] In children with neurological impairment or with developmental oral motor delays, oromotor therapy by a speech and language therapist may be beneficial.

Posttraumatic feeding disorder or fear of feeding develops after single or repeated aversive experiences related to ongoing or previous feeding, such as choking, vomiting, and nasogastric tube feeding. Treatment strategies for this type of feeding difficulty aim to reduce preceding feeding-related anxiety. At first, the cause of pain should be eliminated so that the pain is resolved. Then, an individualized approach that applies deconditioning techniques (e.g., feeding while asleep and proper sleep–feeding schedules) or involves early transition to cup or early introduction of weaning foods may be helpful to relieve anxiety and fear in babies.

Conclusions

Feeding difficulties are very common health problems in childhood, especially in infants and toddlers. Although the majority of feeding difficulties are caused by nonorganic etiologies, underlying organic causes should also be thoroughly ruled out in children with red flag symptoms and signs through thorough history taking and physical examination, especially in young children with growth faltering. Age-appropriate feeding principles may support effective treatment for feeding difficulties in practice, and systematic approaches to feeding difficulties in young children, based on each subtype, may be useful.

Commonest causes of child feeding problems in practice

Commonest disease state: Hidden autism with hidden sensory issues, IBS

Commonest infection: Tonsillitis

Commonest appetite killer: Milk and dry fruits

Commonest deficiency: Iron

Commonest parental habit: Morning energy drink, forced feeding, mobile//TV distractions

Commonest spoiler: Television advertisement

Commonest environmental cause: Less parental time, more parental anxiety.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

References

1.	Kerzner B, Milano K, MacLean WC, Berall G, Stuart S, Chatoor I. Practical approach to classifying and managing feeding difficulties. Pediatrics 2015;135:344-53.
2.	Bryant-Waugh R, Markham L, Kreipe RE, Walsh BT. Feeding and eating disorders in childhood. Int J Eat Disord 2010;43:NA.
3.	Nicely TA, Lane-Loney S, Masciulli E, Hollenbeak CS, Ornstein RM. Prevalence and characteristics of avoidant/restrictive food intake disorder in a cohort of young patients in day treatment for eating disorders. Eat Disord 2014;2:21.
4.	Call C, Walsh BT, Attia E. From DSM-IV to DSM-5. Curr Opin Psychiatry 2013;26:532-6.
5.	Rybak A. Organic and nonorganic feeding disorders. Ann Nutr Metab 2015;66:16-22.
6.	Benjasuwantep B, Chaithirayanon S, Eiamudomkan M. Feeding problems in healthy young children: Prevalence, related factors and feeding practices. Pediatr Rep 2013;5:38-42.
7.	Chatoor I. Feeding disorders in infants and toddlers: diagnosis and treatment. Child Adolesc Psychiatr Clin N Am 2002;11:163-83.
8.	Levy Y, Levy A, Zangen T, Kornfeld L, Dalal I, Samuel E, et al. Diagnostic clues for identification of nonorganic vs organic causes of food refusal and poor feeding. Pediatr Gastroenterol Nutr 2009;48:355-62.
9.	Shim JE, Kim J, Mathai RA; STRONG Kids Research Team. Associations of infant feeding practices and picky eating behaviors of preschool children. Am Diet Assoc 2011;111:1363-8.
10.	Pavan Kumar K, Srikrishna S, Pavan I, Chary E. Prevalence of picky eating behavior and its impact on growth in preschool children. Int J Contemp Pediatr 2018;5:714-9. Available from: http://dx.doi.org/10.18203/2349-3291.ijcp20181036. Last accessed on 10 June, 2001.