A Systematic Review and Meta-Analysis of Intensive Multidisciplinary Intervention for Pediatric Feeding Disorders: How Standard Is the Standard of Care?

Family mealtime behaviors in children who are tube fed and preparing to transition to oral eating: A comparison to other pediatric populations

This study examined differences in observed mealtime behaviors between children preparing to transition to oral feeding and children with various other chronic illnesses using a standardized measure of mealtime beaviors. The parent-child mealtime relationship can become strained due to problematic mealtime behaviors that limit food intake, as well as inadvertent reinforcement of disruptive behavior by caregivers. Frequency/rate of behaviors were compared between children with tube feeding (CwTF) and from previous studies of children with chronic illnesses using the Dyadic Interactive Nomenclature for Eating (DINE). Parents of CwTF used more coaxing, physical prompts, and reinforcement during meals, while parents of children with chronic illnesses used more direct commands and engaged in more parent talk. Findings support differences in parent-child mealtime interactions and eating behaviors across pediatric illness subgroups.

Treatment for Younger Siblings of Participants in a Home-Based Intensive Paediatric Feeding Programme in Australia

Early childhood feeding problems can be challenging. Children who limit their food consumption may significantly impact multiple critical areas of development. Effective treatment should be accessed as early as possible but has been limited to a handful of US hospital programmes. Feeding problems affect both children with and without disability, and families may struggle with multiple children having feeding difficulties. We provided short-term (less than 2 weeks), in-home, intensive, behaviour-analytic feeding intervention to two children with typical development who were younger siblings of children already in the programme. We used a withdrawal/reversal design to assess the effects of nonremoval of the spoon, re-presentation, contingent and noncontingent access to tangibles, differential attention, and response cost. This multi-component intervention was effective in increasing the consumption of a wide variety of foods at regular texture and self-feeding for both participants. Variety was increased to over 60 foods from all food groups. Admission goals were met (100%). We trained caregivers to high procedural integrity and generalised the protocol. We provided actual plate picture examples of family meals consumed where the brothers and parents ate the same meal. Caregiver satisfaction and social acceptability were high. Gains were maintained at 3-year follow-up where parents reported problems were fully resolved.

Nutritional Deficiency Disease Secondary to ARFID Symptoms Associated with Autism and the Broad Autism Phenotype: A Qualitative Systematic Review of Case Reports and Case Series

BACKGROUND

The demographics, weight statuses, and dietary patterns of people with autism or the broad autism phenotype who experience a severe nutrient deficiency disease due to symptoms of avoidant/restrictive food intake disorder have not been well established.

OBJECTIVE

The primary objective of this review was to examine the relationship between the demographics, weight statuses, dietary patterns, and nutrient deficiency diseases that characterize the most severe manifestations of avoidant/restrictive food intake disorder symptomology associated with autism or the broad autism phenotype.

METHODS

A systematic review of English and non-English articles published up to August 29, 2019, on the Scopus, PubMed, and Cumulative Index to Nursing and Allied Health Literature Plus electronic databases was conducted. Additional cases were identified through the reference list of all included articles. The search terms used were "autis^∗ AND (deficiency OR scurvy)". Only case reports or case series in which a person of any age who had been identified as having a formal diagnosis of autism or autism symptoms and a disease of nutritional deficiency due to self-imposed dietary restrictions were included. Data were independently extracted by 8 authors using predefined data fields.

RESULTS

A total of 76 cases (patients were aged 2.5 to 17 years) from 63 articles that were published from 1993 through 2019 were found. More than 85% cases (65 of 76 patients) were from articles published in the past 10 years. The largest percentage of published cases (69.7% [53 of 76]) involved scurvy, a vitamin C deficiency. The second-largest percentage of published cases (17.1% [13 of 76]) involved eye disorders secondary to vitamin A deficiency. Other primary nutrient deficiencies reported were thiamin, vitamin B-12, and vitamin D. In 62.9% (22 of 35) of the patients for which a body mass index or a weight percentile for age was provided, the patient was within normal weight parameters, per Centers for Disease Control weight status categories.

CONCLUSIONS

Based on the 63 articles extracted for this systematic review, nutritional deficiency diseases related to inadequate intakes of vitamin A, thiamin, vitamin B-12, vitamin C, and vitamin D were found in individuals with autism and the broad autism phenotype who had severe self-imposed dietary restrictions. When weight information was provided, most of the youth in these cases were not reported to be underweight. Individuals of any weight who present with symptoms of avoidant/restrictive food intake disorder can benefit from early and frequent screening for adequacy of micronutrient intake, regardless of whether they have a clinical diagnosis of autism.

Using telehealth to provide outpatient follow-up to children with avoidant/restrictive food intake disorder

The COVID-19 global health crisis compelled behavior analysts to consider alternatives to face-to-face services to treat children with feeding disorders. Research suggests telehealth is one method behavior analysts could use to initiate or continue assessment of and treatment for feeding disorders. In the current paper, we conducted pilot studies in which we analyzed chart records of patients with Avoidant/Restrictive Food Intake Disorder; who graduated from an intensive, day-treatment program; and transitioned to an outpatient follow-up program. In Experiment 1, we analyzed the data of participants who received follow-up both in-clinic and via telehealth. In Experiment 2, we analyzed goal attainment for participants who received outpatient follow-up either in-clinic exclusively or via telehealth exclusively. Results of both studies showed that outcomes were equivalent along most dimensions for in-clinic and telehealth services. We provide recommendations for telehealth feeding services and discuss other considerations relevant to telehealth service delivery.

Feeding, Eating, and Emotional Disturbances in Children with Avoidant/Restrictive Food Intake Disorder (ARFID)

Avoidant/restrictive food intake disorder (ARFID) is a relatively new diagnostic category. We sought to determine whether the Stanford Feeding Questionnaire (SFQ), an instrument for assessing picky eating, can differentiate children with ARFID from control children, and whether children with ARFID would show more nonfeeding/eating emotional problems than controls. Fifty children with ARFID were compared to 98 controls. Parents completed the SFQ, Screen for Child Anxiety Related Emotional Disorders (SCARED), Strength and Difficulties Questionnaire (SDQ), and Sensory Responsiveness Questionnaire (SRQ). On the SFQ, 12 items represented child ARFID behaviors (SFQ-ARFID Scale), and another 15 items represented parental feeding problems (SFQ-PFP Scale). We found that the SFQ-ARFID and SFQ-PFP Scale scores were significantly higher in children with ARFID vs. controls. Children with ARFID demonstrated higher SDQ-Total-Difficulties, higher SDQ-Internalizing-Difficulties and lower SRQ-Hedonic scores compared with controls. Of all parameters, the SFQ-ARFID Scale best differentiated children with ARFID from control children (area under receiver operating characteristics curve = 0.939, 95% CI, 0.895–0.983, p < 0.001). These findings suggest that parental reports show more eating problems and emotional disturbances in children with ARFID vs. controls, and more parental feeding problems. Further research is required to determine whether the SFQ-ARFID Scale may serve as an effective screening tool for the identification of ARFID.

Botulinum Toxin as a Treatment for Feeding Difficulties in Young Children

OBJECTIVE

To determine the effectiveness of intrapyloric botulinum toxin injection (IPBI) for treatment of feeding disorders and associated gastrointestinal symptoms in very young children.

STUDY DESIGN

A single-center retrospective study of patients 2 months to 5 years old who received IPBI at Boston Children's Hospital from May 2007 to June 2019 was performed. Charts were reviewed for demographic data, comorbidities, symptoms leading to IPBI, oral and tube feeding data, symptom improvement after IPBI, and need for repeat injections. The primary outcome was symptom improvement at the first gastroenterology clinic visit following IPBI. Secondary outcomes included improvement in oral feeding, decreases in tube feeding, and need for repeat injections. The χ² or Fisher exact tests and multivariate logistic regression were used to identify factors associated with symptomatic improvement.

RESULTS

A total of 85 patients who received 118 injections were included in the final analysis; 57 patients (67%) had partial or complete improvement in symptoms after IPBI. Among the 55 patients with enteral tubes, there was an improvement in feeding, with more patients receiving at least some oral feeds after IPBI compared with before (26/55 vs 15/55; P = .004) and fewer patients receiving postpyloric feeds after IPBI compared with before (12/55 vs 21/55; P = .01). Twenty-six patients (31%) received repeat IPBI within 1 year, with only 6 patients receiving IPBI more than twice.

CONCLUSIONS

IPBI is safe and effective in young children. Children with enteral tubes show improvement in oral feeding and reduction in need for postpyloric feeding after IPBI.

Assessment of clinical practice procedures among Registered Dietitian Nutritionists for identifying feeding dysfunction in the pediatric population

BACKGROUND & AIMS

Feeding dysfunction is common in children. Efficient processes to identify and treat feeding dysfunction are not commonly known or used among healthcare practitioners. The aim of this study was to develop and validate a survey tool to assess current practice procedures used by Registered Dietitian Nutritionists (RDN) in identifying, diagnosing, and treating feeding dysfunction in children 0-18 years of age.

METHODS

A survey was developed and distributed to gather information on RDN practice procedures, prevalence of pediatric feeding dysfunction, identification of pediatric feeding dysfunction, and method of treatment used to address pediatric feeding dysfunction. Emails were sent to 4449 RDNs in United States. All participants were classified by the Commission on Dietetic Registration (CDR) as clinical dietitians. Distribution and frequency of survey responses were assessed, and in the case of qualitative questions, were categorized according to themes identified.

RESULTS

Responses of RDNs from 41 states completed 341 total surveys, 179 surveys were included in data analysis. Eighty percent of participants do not use a specific screening tool to identify feeding dysfunction. Results concerning feeding therapy strategies and terms used by RDNs to describe feeding dysfunction were highly varied or lacking. Increased inclusion of RDNs on interdisciplinary teams was indicated by 80% of participants. The majority of participants indicated they refer patients with feeding dysfunction to other practitioners instead of providing feeding therapy themselves.

CONCLUSIONS

Standardized screening, diagnostic, and treatment protocols regarding feeding dysfunction are needed to provide consistent and comprehensive care for the pediatric population. Use of these protocols among RDNs would enable them to improve feeding abilities in more patients earlier in individual child development.

A systematic review of physical guidance procedures as an open-mouth prompt to increase acceptance for children with pediatric feeding disorders

This article reviews behavioral treatments of pediatric feeding disorders using physical guidance procedures as an open-mouth prompt (i.e., jaw prompt, finger prompt, Nuk prompt, side deposit) to increase food acceptance. We identified 9 articles containing 35 systematic evaluations. We coded participant and study characteristics and assessed the experimental rigor, quality, and outcomes of each evaluation. Of the high-quality research present, the finger prompt variation and side deposit reliably increased acceptance. We found mixed results on the efficacy of the jaw prompt, although it was the most widely researched procedure. Further, authors reported interobserver agreement for 100% of the participants, procedural integrity for 60%, social validity for 80%, fading for 5%, and follow-up for 55%. Based on the invasive nature of physical guidance, we provide recommendations for researchers and clinicians to increase the quality of their treatment evaluations. We discuss limitations, implications for practice, and future research.

Occupational Therapy Practice Guidelines for Early Childhood: Birth-5 Years

IMPORTANCE

This Practice Guideline provides stakeholders with a condensed summary of a large number of effectiveness studies. It is a valuable tool for facilitating decision making related to occupational therapy interventions for children ages birth-5 yr.

OBJECTIVE

Early childhood (birth-5 yr) is a critical period in which the foundation of key life occupations is developed (e.g., eating, dressing, play, learning, social participation, rest and sleep, and chores). The development of cognitive, motor, social-emotional, and self-care skills is important to support these occupations. This Practice Guideline synthesizes recent systematic reviews (SRs) on these areas of development to promote decision making for and high-quality interventions with this population.

METHOD

Four SRs related to cognition, mental health, motor function, and ADLs analyzed studies published from 2010 to 2017 retrieved from six electronic databases (MEDLINE, PsycINFO, CINAHL, ERIC, OTseeker, and Cochrane).

RESULTS

A total of 196 articles were included in the SRs, which served as a guide to final clinical recommendations. Case studies describe translation and application to practice.

CONCLUSION

and Recommendations: A variety of interventions within the domain of occupational therapy were found to support the development of cognitive, social-emotional, motor, and self-care skills. Although some of these interventions are typically implemented by occupational therapy practitioners, others can be implemented by parents after training or by teams working in preschool settings. These findings should be used to inform evidence-based practice provided by occupational therapy practitioners working in various early childhood settings.

WHAT THIS ARTICLE ADDS

This Practice Guideline gives occupational therapy practitioners clear information about which interventions will be effective for specific outcomes. Better intervention choices mean better outcomes for young children and their families.

Outcomes for Feeding Tube-Dependent Children With Oral Aversion in an Intensive Interdisciplinary Treatment Program

Purpose Feeding challenges in children are common, at times reaching a severity that requires the placement and long-term use of enteral feedings. A significant barrier to advancing the oral eating of some tube-dependent children is the presence of oral aversion. Although some research exists regarding the treatment of tube-dependent children who are averse to food or the process of eating, specifically, there has yet to be an examination of children who are truly "orally" averse-resisting not just the presentation of food or liquid but also nonnutritive stimuli presented extra- or intra-orally. Method Using a retrospective chart review, the current study aimed to examine the treatment outcomes of 18 feeding tube-dependent children with significant oral aversion (nine boys, nine girls; M _age = 46.7 months, SD = 20.0 months, range: 11.4-89.3 months) as compared to 29 tube-dependent, but nonorally averse, clinical controls. Children completed approximately 6-8 weeks of intensive interdisciplinary feeding treatment. Results Analyses revealed significant improvements in all measured treatment outcomes for both patient groups, including children's rates of acceptance and maladaptive mealtime behavior. Significant reductions in tube use were also observed across both groups, with tube utilization decreasing, on average, by 76.2% for orally averse and by 64.3% for nonorally averse children by program discharge. Conclusion Results demonstrate the therapeutic benefits of intensive interdisciplinary intervention for both groups of tube-dependent children, highlighting that orally averse children, believed to be an especially challenging subset of pediatric feeding patients, demonstrate similarly positive treatment responses. Interestingly, in this preliminary examination, orally averse children demonstrated significantly greater reductions in tube utilization following discharge when compared with their nonorally averse clinical peers.

Intensive Multidisciplinary Intervention for Young Children with Feeding Tube Dependence and Chronic Food Refusal: An Electronic Health Record Review

OBJECTIVE

To assess characteristics and outcomes of young children receiving intensive multidisciplinary intervention for chronic food refusal and feeding tube dependence.

STUDY DESIGN

We conducted a retrospective study of consecutive patients (birth to age 21 years) admitted to an intensive multidisciplinary intervention program over a 5-year period (June 2014-June 2019). Inclusion criteria required dependence on enteral feeding, inadequate oral intake, and medical stability to permit tube weaning. Treatment combined behavioral intervention and parent training with nutrition therapy, oral-motor therapy, and medical oversight. Data extraction followed a systematic protocol; outcomes included anthropometric measures, changes in oral intake, and percentage of patients fully weaned from tube feeding.

RESULTS

Of 229 patients admitted during the 5-year period, 83 met the entry criteria; 81 completed intervention (98%) and provided outcome data (46 males, 35 females; age range, 10-230 months). All patients had complex medical, behavioral, and/or developmental histories with longstanding feeding problems (median duration, 33 months). At discharge, oral intake improved by 70.5%, and 27 patients (33%) completely weaned from tube feeding. Weight gain (mean, 0.39 ± 1 kg) was observed. Treatment gains continued following discharge, with 58 patients (72%) weaned from tube feeding at follow-up.

CONCLUSIONS

Our findings support the effectiveness of our intensive multidisciplinary intervention model in promoting oral intake and reducing dependence on tube feeding in young children with chronic food refusal. Further research on the generalizability of this intensive multidisciplinary intervention approach to other specialized treatment settings and/or feeding/eating disorder subtypes is warranted.

Family-centered Outcomes that Matter Most to Parents: A Pediatric Feeding Disorders Qualitative Study

OBJECTIVE

The purpose of this study was to examine the perspectives of caregivers of children with feeding disorders. We sought to understand their child's feeding impairment through the lens of caregivers, including the impact impairments had on daily life and social participation, what outcomes matter most to caregivers, contextual determinants that affect achieving desired outcomes, and how treatment approaches can optimally support families.

METHODS

We interviewed caregivers of children, ages 2 to 5 years, who received care at the Center for Feeding and Nutrition at MassGeneral Hospital for Children in Boston, MA. All children had a feeding disorder diagnosis, defined as an impairment in oral intake. We analyzed interview transcripts using principles of immersion-crystallization.

RESULTS

We reached thematic saturation after interviewing 30 caregivers (25 female). 66.7% of the children were white, 13.3% Asian, 10.0% black, and 10.0% were more than 1 race. Thirty percent were Hispanic. We identified four themes: feeding impairments impact the daily life and social participation of children; improving their child's health and quality of life is most important to caregivers; child, caregiver, and community factors are facilitators of achieving desired outcomes; whereas time, financial, access, and knowledge factors are barriers; and caregivers prefer treatment approaches that incorporate principles of family-centered care.

CONCLUSIONS

Given the daily life and social participation impacts of pediatric feeding disorders, treatment approaches should be family-centered, focus on functional and meaningful outcomes to improve the health and quality of life of children and their families, and address modifiable sociocontextual determinants.

A Multidisciplinary Approach to Pediatric Feeding Disorders: Roles of the Speech-Language Pathologist and Behavioral Psychologist

Purpose Pediatric feeding disorders (PFDs) present as a complex clinical challenge because of the heterogeneous underlying etiologies and their impact on health, safety, growth, and psychosocial development. A multidisciplinary team approach is essential for accurate diagnosis and prompt interventions to lessen the burdens associated with PFDs. The role of the speech-language pathologist (SLP) as a member of the multidisciplinary team will be highlighted. Method This clinical focus article reviews the definition of PFDs and pertinent literature on factors that contribute to the development of PFDs, the accurate diagnosis, and current interventions for infants and children. As part of the multidisciplinary team, the SLP has an integral role in determining whether a child cannot or will not eat and working with the team to identify and carryout appropriate interventions. Collaboration between SLPs and psychologists/behavioral specialists in conjunction with the parents/caregivers as part of the multidisciplinary team is essential to the advancement of therapeutic goals. Conclusions Due to their complex nature, the successful management of PFDs is only possible with the care and expertise of a multidisciplinary team, which includes parents/caregivers. SLPs are important members of these multidisciplinary teams and provide valuable input for the accurate identification and effective remediation of PFDs.

An Economic Analysis of Intensive Multidisciplinary Interventions for Treating Medicaid-Insured Children with Pediatric Feeding Disorders

Background. Intensive multidisciplinary intervention (IMI) represents a well-established treatment for pediatric feeding disorders (PFDs), but program availability represents an access care barrier. We develop an economic analysis of IMI for weaning from gastronomy tube (G-tube) treatment for children diagnosed with PFDs from the Medicaid programs' perspective, where Medicaid programs refer to both fee-for-service and managed care programs. Methods. The 2010-2012 Medicaid Analytic eXtract claims provided health care data for children aged 13 to 72 months. An IMI program provided data on average admission costs. We employed a finite-horizon Markov model to simulate PFD treatment progression assuming 2 treatment arms: G-tube only v. IMI targeting G-tube weaning. We compared the expenditure differential between the 2 arms under varying time horizons and treatment effectiveness. Results. Overall Medicaid expenditure per member per month was $6814, $2846, and $1550 for the study population of children with PFDs and G-tube treatment, the control population with PFDs without G-tube treatment, and the no-PFD control population, respectively. The PFD-diagnosed children with G-tube treatment only had the highest overall expenditures across all health care settings except psychological services. The expenditure at the end of the 8-year time horizon was $405,525 and $208,218 per child for the G-tube treatment only and IMI arms, respectively. Median Medicaid expenditure was between 1.7 and 2.2 times higher for the G-tube treatment arm than for the IMI treatment arm. Limitations. Data quality issues could cause overestimates or underestimates of Medicaid expenditure. Conclusions. This study demonstrated the economic benefits of IMI to treat complex PFDs from the perspective of Medicaid programs, indicating this model of care not only holds benefit in terms of improving overall quality of life but also brings significant expenditure savings in the short and long term.

Childhood Avoidant/Restrictive Food Intake Disorder: Review of Treatments and a Novel Parent-Based Approach

Avoidant/Restrictive food intake disorder (ARFID) is characterized by dietary restrictions that are not based on weight or shape concerns but that result in marked interference in feeding, growth, or psychosocial functioning (American Psychiatric Association, 2013; Eddy et al., 2019). The aim of the current article was to review available reports of treatment for childhood ARFID published since its inclusion in the 5th edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM), and to introduce a novel parent-based treatment for child ARFID through a case presentation. Empirical support for psychosocial treatments for child ARFID currently stems from two small-scale pilot randomized control trials, one pilot open trial, case reports, case series, and retrospective chart reviews. Treatment approaches for outpatient care generally apply family-based therapy, child-centered cognitive behavioral therapy, or parent-based behavioral approaches. SPACE-ARFID is a novel outpatient parent-based treatment that focuses on parental responses to child problematic eating habits. SPACE-ARFID aims to promote flexibility and adjustment in food related situations. The treatment helps parents to systematically reduce family accommodation, or changes that they make to their own behavior to help their child avoid or alleviate distress related to the disorder, while increasing supportive responses to the child's symptoms.

Pediatric Prevention: Feeding Disorders

Applied behavior analysis has the most empirical support as intervention for pediatric feeding disorders, when a child does not eat or drink a sufficient quantity or variety of food to maintain proper nutrition. Interdisciplinary collaboration is crucial for diagnosis, referral, and management of pediatric feeding disorders because the etiology is complex and multifactorial. Thus, our aim is to provide information about how to recognize a feeding disorder, to delineate the environmental variables implicated in the etiology and maintenance of feeding disorders, and to provide recommendations for prevention and intervention for feeding disorders based on the applied-behavior analytic literature.

Avoidant/restrictive food intake disorder: A systematic scoping review of the current literature

Avoidant/restrictive food intake disorder (ARFID) was recently introduced to psychiatric nosology to describe a group of patients who have avoidant or restrictive eating behaviours that are not motivated by a body image disturbance or a desire to be thinner. This scoping review aimed to systematically assess the extent and nature of the ARFID literature, to identify gaps in current understanding, and to make recommendations for further study. Following an extensive database search, 291 unique references were identified. When matched against pre-determined eligibility criteria, 78 full-text publications from 14 countries were found to report primary, empirical data relating to ARFID. This literature was synthesised and categorised into five subject areas according to the central area of focus: diagnosis and assessment, clinical characteristics, treatment interventions, clinical outcomes, and prevalence. The current evidence base supports ARFID as a distinct clinical entity, but there is a limited understanding in all areas. Several possible avenues for further study are indicated, with an emphasis placed on first parsing this disorder's heterogeneous presentation. A better understanding of the varied mechanisms which drive food avoidance and/or restriction will inform the development of targeted treatment interventions, refine screening tools and impact clinical outcomes.

Characterizing International Approaches to Weaning Children From Tube Feeding: A Scoping Review

Approaches to tube weaning enterally fed children and evaluating outcomes vary widely. This limits the utility of research for identifying both "what works" and successful implementation of research outcomes. We used a qualitative scoping review methodology to examine internationally published research. Our primary aim was to identify the main philosophies underpinning intervention design and the main outcome variables used to demonstrate success of existing programs. This information can be used to inform future research design and clinical practice. Literature up until June 2019 was sourced via Medline, Scopus, Ovid, and CINHAL databases; hand searching; and gray literature using Google Advanced Search. Three predominant approaches to tube-weaning interventions were identified: behavioral, child- and family-centered, and biomedical. A wide range of intervention variables were identified, with the level of parental involvement and the use of hunger provocation varying between approaches. Our Review also confirms that there is no consistency in outcome measures used, limiting comparability between programs. We suggest that the role of parents in the weaning process and its impact on both the child and the parent/carer while transitioning from enteral to oral eating are insufficiently understood. We discuss these findings in the context of a suggested framework for future research.

Side Deposit with Regular Texture Food for Clinical Cases In-Home

Objective Research has shown effectiveness of nonremoval of the spoon and physical guidance in increasing consumption and decreasing inappropriate mealtime behavior. The side deposit has been used to treat passive refusal in 2 studies (1 in a highly specialized hospital setting) using lower manipulated-texture foods on an infant gum brush. Methods We extended the literature by using regular texture bites of food with a finger prompt and side deposit (placing bites inside the side of the child's mouth via the cheek) in an intensive home-based program setting in Australia, demonstrating that attention and tangible treatments alone were ineffective prior, fading the tangible treatment, showing caregiver training, and following up. 2 male children with autism spectrum disorder (with texture/variety selectivity; one with liquid dependence) participated in their homes. We used a reversal design to replicate effectiveness of the side deposit added to a treatment package. Results For both participants, we observed a >98% decrease in latency to acceptance, a 100% decrease in inappropriate mealtime behavior, and a 100% increase in consumption with the side deposit added. Variety was increased to over 85 regular texture foods. 100% of admission goals were met. Caregivers were trained to high procedural integrity and the protocol was generalized to school and the community. Gains maintained to 3 and 1.5 years. Conclusion This is important work in adding to the literature and support for the side deposit and expanding to regular texture, as well as replicating and extending empirically supported treatments for feeding internationally to the home setting.

Re-imagining the physicians' role in the assessment of feeding challenges in children with autism spectrum disorder

While feeding challenges in autism spectrum disorder (ASD) are prevalent, they continue to pose a significant diagnostic challenge, leading to misdiagnosis and under diagnosis of factors, both contextual and inherent, that may lead to negative health outcomes. Early identification of feeding difficulties in ASD is necessary to minimize negative health outcomes and strained parent-child relationships. Family physicians and paediatricians are positioned to reduce the impact of such disordered feeding behaviours on the child, family, and health care system. Providing clinicians with a conceptual framework to systematically identify factors contributing to the 'feeding challenge' construct will ensure the appropriate intervention is provided. We present the MOBS^E conceptual framework, a multidisciplinary lens for assessing feeding challenges in ASD. This will aid in the proper diagnosis of feeding challenges seen in ASD.

Family-Based Treatment for a Preadolescent With Avoidant/Restrictive Food Intake Disorder With Sensory Sensitivity: A Case Report

BACKGROUND

Individuals with Avoidant/Restrictive Food Intake Disorder (ARFID) experience eating problems that cause persistent failure to meet appropriate nutritional and/or energy needs. These eating problems are not driven by body image concerns but rather by persistent low appetite, sensory sensitivity, or fear of aversive consequences of eating (e.g., choking or vomiting). Although increasing numbers of youth are being referred for treatment of ARFID, no evidence-based treatments yet exist for the disorder. Given family-based treatment (FBT) has demonstrated effectiveness with other pediatric eating disorders (anorexia nervosa, bulimia nervosa), a manualized version of FBT adapted for use with ARFID patients has been developed and is currently under study.

CASE PRESENTATION

The following case report demonstrates how FBT was used to treat a 9-year-old patient with ARFID characterized by sensory sensitivity. Similarities and differences with FBT for anorexia nervosa are illustrated. After 17 sessions across 6 months, the patient no longer met DSM criteria for ARFID, she demonstrated major declines in measures of clinical symptoms, and she gained 2.1 kg.

CONCLUSIONS

FBT for ARFID relies upon the same key interventions as FBT for AN. However, we discuss critical differences in the application of these interventions given the unique challenges of ARFID, particularly when characterized by sensory sensitivity.

Evaluation of a finger prompt variation in the treatment of pediatric feeding disorders

Children with feeding disorders often engage in refusal behavior to escape or avoid eating. Escape extinction combined with reinforcement is a well-established intervention to treat food refusal. Physical guidance procedures (e.g., jaw prompt, finger prompt) have been shown to increase food acceptance and decrease inappropriate mealtime behavior when more commonly employed escape extinction (e.g., nonremoval of the spoon) procedures are ineffective. The finger prompt, however, has not been extensively evaluated as a treatment adjunct to target food refusal, thus necessitating further examination. The purpose of this prospective study was to assess a variation of a finger prompt procedure to treat food refusal and to assess caregivers' acceptability of the procedure. Three children age 1 to 4 years admitted to an intensive feeding disorders program and their caregivers participated. The finger prompt was effective in increasing bite acceptance across all participants and decreasing or maintaining low levels of inappropriate behavior for 2 participants. The procedure was also acceptable to all caregivers.

Treatment of avoidant/restrictive food intake disorder for a teenager with typical development within the home setting

INTRODUCTION

Avoidant/restrictive food intake disorder (ARFID) can occur in children with typical development and persist past childhood. This significantly impacts most areas of children's lives, but may become more evident in teenage years, especially socially. There is an empirically supported treatment for ARFID with 40 years of research backing, this being behaviour-analytic feeding interventions. However, application to individuals over age 12 is lacking, and needs to be investigated for effectiveness. This is important as the addition of ARFID (formerly called feeding disorders) to the DSM-V has seen an increase in new treatments for ARFID by attempting to apply eating disorder treatments to this population including children. More research is needed to identify if already established behavioural intervention procedures are effective for ARFID in individuals with selectivity, without disabilities, older ages, and in settings outside of intensive specialised feeding hospital admissions in the United States.

METHOD

A 13-year-old female with ARFID and years of failed treatment attempts participated in her home in Australia. We conducted multiple stimulus without replacement preference assessments and used a changing criterion design with multiple baseline probes. Treatment consisted of demand fading, choice, differential attention, and contingent access. We did not use cognitive or family based treatment.

RESULTS

Consumption increased to 100%. Variety reached 61 foods across all food groups. She met 100% of goals and ate at a restaurant. Caregivers reported high satisfaction and social acceptability. Gains were maintained at 9 months.

CONCLUSION

This brief, behaviour-analytic in-home treatment was effective in increasing food group variety consumption.

Modified-Bolus Placement as a Therapeutic Tool in the Treatment of Pediatric Feeding Disorders: Analysis From a Retrospective Chart Review

Purpose Recognizing the need to advance the treatment of pediatric feeding disorders, an emerging area of inquiry focuses on therapeutic techniques that address expulsion and packing possibly associated with oral-motor dysfunction. In the current study, we documented the use of modified-bolus placement in the treatment of pediatric feeding disorders at an intensive, multidisciplinary day-treatment center over a 26-month period. Method The retrospective observational cohort study involved patients admitted for the assessment and treatment of chronic food refusal from August 2013 to October 2015. Results Patients (n = 23) who received modified bolus placement displayed moderate-to-severe oral-motor deficits. Use of modified-bolus placement was associated with reduced expulsion and packing of bites during meals, and treatment gains coincided with a threefold increase in grams consumed per meal. Conclusion Results provide additional support for the potential therapeutic benefits of enhancing bolus placement onto the tongue as a means to improve mealtime performance in children with pediatric feeding disorders when included as an adjunct to more traditional behavioral approaches.

Interventions for Increasing Acceptance of New Foods Among Children and Adults with Developmental Disorders: A Systematic Review

People with developmental disorders (DD) often display high levels of selective eating, which can result in micronutrient deficiencies. It is therefore essential to explore ways to increase dietary variety in this population. To identify different types of interventions promoting increased acceptance of new foods or dietary variety for DD populations and to determine their effectiveness. Thirty-six studies met criteria for inclusion in the review. Twenty-two types of intervention were identified with 34 studies being reported as effective and 33 of these incorporating components drawn from learning theory. Multi-component interventions centred on operant conditioning, systematic desensitisation and changes to environment and familial practices were reported as effective for individuals.

A Functional Approach to Feeding Difficulties in Children

PURPOSE OF REVIEW

This review provides an approach for resolving a variety of feeding difficulties in children, ranging from normal eating behavior that is misperceived as a problem to substantial feeding disorders.

RECENT FINDINGS

Criteria to identify pediatric feeding disorders have been thoroughly addressed in the newly established designations of avoidant restrictive food intake disorder (ARFID) and pediatric feeding disorder (PFD). These diagnostic criteria improve the accuracy of identifying, classifying, and managing significant feeding disorders in young children. While recent definitions of feeding difficulties are particularly appropriate in multidisciplinary settings, in this paper, we advocate for a progressive approach of managing feeding problems in all clinical settings. It begins by identifying red flags indicative of serious threats to the child, screening for oral motor dysfunction, stabilizing nutrient intake, and eliminating aversive feeding practices. The next step, if eating behavior does not improve, involves strategies that target specific eating behaviors and parental feeding styles. In severe or resistant cases, referral to specialists or interdisciplinary feeding teams is advised.

The Autism Managing Eating Aversions and Limited Variety Plan vs Parent Education: A Randomized Clinical Trial

OBJECTIVE

To assess the feasibility and initial efficacy of a structured parent training program for children with autism spectrum disorder and moderate food selectivity.

STUDY DESIGN

This 16-week randomized trial compared the Managing Eating Aversions and Limited variety (MEAL) Plan with parent education. MEAL Plan (10 core and 3 booster sessions) provided parents with nutrition education and strategies to structure meals and expand the child's diet. Parent education (10 sessions) provided information about autism without guidance on nutrition, meal structure, or diet. In addition to feasibility outcomes, primary efficacy outcomes included the Clinical Global Impression - Improvement scale and the Brief Autism Mealtime Behaviors Inventory. Grams consumed during a meal observation served as a secondary outcome.

RESULTS

There were 38 eligible children (19 per group, 32 males). For MEAL Plan, attrition was <10% and attendance >80%. Therapists achieved >90% fidelity. At week 16, positive response rates on the Clinical Global Impression - Improvement scale were 47.4% for the MEAL Plan and 5.3% for parent education (P < .05). The adjusted mean difference (SE) on Brief Autism Mealtime Behaviors Inventory at week 16 was 7.04 (2.71) points (P = .01) in favor of MEAL Plan. For grams consumed, the adjusted standard mean difference (SE) was 30.76 (6.75), also in favor of MEAL Plan (P = .001).

CONCLUSIONS

The MEAL Plan seems to be feasible, and preliminary efficacy results are encouraging. If further study replicates these results, the MEAL Plan could expand treatment options for children with autism spectrum disorder and moderate food selectivity.

TRIAL REGISTRATION

Clinicaltrials.gov: NCT02712281.

Socio-demographic Determinants and the Family Ability to Care for Children with Avoidant Restrictive Food Intake Disorder (ARFID)

Background: The ability of families to care for avoidant restrictive food intake disorder children is still low. There is only few studies that examined relationship between family factor to ability to care children with avoidant restrictive food intake disorder. The purpose of this study was to identify the influence of socio-demographic factors on the ability of families to represent children with avoidant restrictive food intake disorder.Method: The study design was cross-sectional, and the majority of samples were gathered using the rule of the thumb, totaling 245 participants. The sampling technique used a type of multistage sampling. Data were collected by questionnaire. We then conducted an analysis of the univariate data using frequency distribution, while for the bivariate data, we used the chi-square technique. All of the data was processed using IBM SPSS 23.0 statistics.Results: The results showed that the ability of care from the families (health promotion behavior) of children with avoidant restrictive food intake disorder  was influenced by the socio-demographic factors, namely maternal age (p= 0.010), the number of children (p= 0.047) and education (p= 0.036).Conclusion: Young mothers need appropriate guidance and direction through good health education. Good health education in young mothers can reduce the pressure faced by the mothers when caring for their children with avoidant restrictive food intake disorder. Health promotion behavior is influenced by maternal education and maternal age. Through good mother's education, the mother will be able to provide a good pattern of care to children who experience avoidant restrictive food intake disorder.

Gastrointestinal Conditions in Children With Severe Feeding Difficulties

Feeding aversion in children may progress to severe feeding difficulties. While oral-motor and sensory issues are usually the leading causes, organic etiologies should be considered. This study aimed to assess the prevalence of gastrointestinal conditions in children with severe feeding difficulties. We conducted a retrospective study of 93 children requiring an intensive feeding program. The medical records, radiologic and diagnostic tests, use of gastric tube feedings, preexisting medical conditions, and medications were reviewed. Fifty-two percent (52%) had esophagitis, 26.2% gastritis, and 40.7% lactase deficiency in upper endoscopy. In those who underwent an upper endoscopy, 26% of patients that were also tested for small intestinal bacterial overgrowth were found to be positive. Allergy testing was abnormal in 56.6% of those tested, while 27.5% and 75% had abnormal gastric emptying times and pH impedance results, respectively. Constipation was present in 76.3%. Thirteen of 32 were weaned off tube feedings. We conclude that gastrointestinal conditions are common in children with feeding disorders and should be investigated prior to feeding therapy.

Radcliffe ARFID Workgroup: Toward operationalization of research diagnostic criteria and directions for the field

OBJECTIVE

Since its introduction to the psychiatric nomenclature in 2013, research on avoidant/restrictive food intake disorder (ARFID) has proliferated highlighting lack of clarity in how ARFID is defined.

METHOD

In September 2018, a small multi-disciplinary pool of international experts in feeding disorder and eating disorder clinical practice and research convened as the Radcliffe ARFID workgroup to consider operationalization of DSM-5 ARFID diagnostic criteria to guide research in this disorder.

RESULTS

By consensus of the Radcliffe ARFID workgroup, ARFID eating is characterized by food avoidance and/or restriction, involving limited volume and/or variety associated with one or more of the following: weight loss or faltering growth (e.g., defined as in anorexia nervosa, or by crossing weight/growth percentiles); nutritional deficiencies (defined by laboratory assay or dietary recall); dependence on tube feeding or nutritional supplements (≥50% of daily caloric intake or any tube feeding not required by a concurrent medical condition); and/or psychosocial impairment.

CONCLUSIONS

This article offers definitions on how best to operationalize ARFID criteria and assessment thereof to be tested in existing clinical populations and to guide future study to advance understanding and treatment of this heterogeneous disorder.

A systematic scoping review of diagnostic validity in avoidant/restrictive food intake disorder

OBJECTIVE

Avoidant/restrictive food intake disorder (ARFID) was introduced as a new diagnosis in the DSM-5. This systematic scoping review explores how ARFID as a diagnostic entity is conceptualized in the research literature and evaluates the diagnostic validity according to the Feighner criteria.

METHOD

A systematic scoping review of papers on ARFID in PubMed/MEDLINE and Web of Science was undertaken, following PRISMA and Joanna Briggs Institute guidelines.

RESULTS

Fifty-one original research publications, 23 reviews and commentaries, and 20 case reports were identified. The use of ARFID as a conceptual category varies significantly within this literature. At this time, the ARFID diagnosis does not fulfil the Feighner criteria for evaluating the validity of diagnostic constructs, the most urgent problem being the demarcation toward other disorders. A three-dimensional model-lack of interest in food, selectivity based on sensory sensitivity, and fear of aversive consequences-is gaining support in the research literature.

DISCUSSION

The introduction of the ARFID diagnosis has undoubtedly increased the recognition of a previously largely neglected group of patients. However, this article points to an inability of the current DSM-5 diagnostic criteria to ensure optimal diagnostic validity, which risks making them less useful in clinical practice and in epidemiological research. To increase the conceptual validity of the ARFID construct, several possible alterations to the current diagnostic criteria are suggested, including a stronger emphasis of the three identified subdomains and further clarifying the boundaries of ARFID.

Avoidant/restrictive food intake disorder: A diagnosis at the intersection of feeding and eating disorders necessitating subtype differentiation

Avoidant/restrictive food intake disorder (ARFID) is a diagnosis that sits squarely at the cross roads of feeding disorders and eating disorders. It is historically tied to feeding disorders as a replacement of the DSM-IV diagnosis of feeding disorder of infancy or early childhood. The revision process, however, extended the diagnostic umbrella by removing its predecessor's weight loss requirement and age of onset restriction (i.e., 6 years). Implications of this extension include capturing an older cohort of patients with ARFID accessing care at eating disorders clinics, as well as providing a diagnostic home to previously orphaned pediatric subgroups with feeding disorders that lacked a diagnostic home prior to DSM-5. While recognizing notable strengths of this now 5-year-old diagnostic entity, ARFID is largely recognized as a very heterogeneous condition that lacks specificity to best guide clinical and research activities. The current commentary discusses the implications of ARFID as a replacement and extension of the DSM-IV diagnosis of feeding disorder of infancy or early childhood and provides the rationale and guidance for developing a subtype taxonomy.

Hospital course of underweight youth with ARFID treated with a meal-based behavioral protocol in an inpatient-partial hospitalization program for eating disorders

OBJECTIVE

Information on nutritional rehabilitation for underweight patients with avoidant/restrictive food intake disorder (ARFID) is scarce. This study characterized hospitalized youth with ARFID treated in an inpatient (IP)-partial hospitalization behavioral eating disorders (EDs) program employing an exclusively meal-based rapid refeeding protocol and compared weight restoration outcomes to those of patients with anorexia nervosa (AN).

METHOD

Data from retrospective chart review of consecutive underweight admissions (N = 275; age 11-26 years) with ARFID (n = 27) were compared to those with AN (n = 248) on clinical features, reason for discharge, and weight restoration variables. For patients with ARFID, presenting phenomenology was further characterized by detailed chart review.

RESULTS

At admission, 53% of patients with ARFID were vomiting regularly. The predominant ARFID subtype was ARFID-aversive, with close to a third being mixed subtype. Gastrointestinal (GI) symptomatology (81.5%) was the most commonly endorsed reason for restriction. A third had undergone unsuccessful parenteral or enteral tube feeding. Patients with ARFID were more likely male, had higher admission BMI, and slower IP weight gain (1.36 kg /week vs 1.92) compared to patients with AN. Fewer patients with ARFID transitioned to the partial hospitalization program, although the proportion discharged for clinical improvement did not differ and both groups had a mean program discharge BMI >18.5.

DISCUSSION

GI symptoms appear a common contributor to restrictive eating amongst hospitalized youth with ARFID. Despite a slightly lower rate of IP weight gain, clinical improvement and weight restoration at discharge were similar for patients with ARFID compared to AN.

Applying family-based treatment (FBT) to three clinical presentations of avoidant/restrictive food intake disorder: Similarities and differences from FBT for anorexia nervosa

OBJECTIVE

This article uses three brief case reports to illustrate how family-based treatment (FBT) can be used to treat pre-adolescents with avoidant/restrictive food intake disorder (ARFID).

METHOD

We present case material illustrating how FBT can be used in three different clinical presentations of ARFID: (1) low appetite and lack of interest; (2) sensory sensitive eaters; and (3) fear of aversive consequences eaters-all without shape or weight concerns.

RESULTS

This case material illustrates that the main principles of FBT-agnosticism as to the cause of the illness, externalization, emphasizing the seriousness of ARFID, parental empowerment, behavioral consultation, and practical behavioral focus-are applicable for a range of ARFID clinical presentations. Common challenges in this patient group include (1) promoting urgency; (2) challenging long term behavioral accommodation; (3) lack of parental alignment, parental fatigue, (4) and co-morbid psychiatric problems in the patients. Strategies to address these problems are described.

CONCLUSION

FBT can be adapted for children with ARFID using the main principles of the approach.

Feeding and Eating Disorders in Children

This article provides an update based on recently published literature and expert consensus on the current state of knowledge regarding feeding and eating disorders in children aged 2 to 12 years. It covers the 6 main diagnostic categories-pica, rumination disorder, avoidant/restrictive food intake disorder, anorexia nervosa, bulimia nervosa, and binge eating disorder-discussing issues and findings specific to this age group. It highlights the need for ongoing research in a number of key areas, to include improved understanding of etiologic pathways, characterization of presenting disorders, and the development of standardized evidence-based assessment tools and treatment interventions.

Feeding practices and growth of infants with Pierre Robin Sequence

OBJECTIVES

To assess the impact of feeding practices on growth in infants with Pierre Robin Sequence (PRS) during their inpatient stay in a neonatal intensive care unit in a large tertiary paediatric hospital setting.

METHODS

A retrospective review of feeding practices in infants with PRS was conducted between January 2006 and September 2017. Baseline demographics, nutrition-related and general outcomes were collected. Feeding difficulties, length of stay (LOS) and malnutrition were the primary outcome measures. Feeding difficulties included absence or poor-quality suck, episodes of aspiration, use of proton pump inhibitors or multiple episodes of vomiting. Malnutrition was classified as a weight-for-age Z score of < -1.

RESULTS

Analysis was conducted on 49 infants with PRS that met eligibility criteria. Feeding difficulties correlated with a longer LOS (24.1 vs 6.8 days (p = 0.001)) Z-scores differed significantly between birth and discharge (0.21(1.84) vs -1.27(2.14)) (p < 0.001*) with malnutrition being evident in 26 infants of which only 17 infants were seen by a dietitian. Presence of intrauterine growth restriction (IUGR) increased the likelihood of malnutrition (OR 1.40(CI-1.11-1.77)).

CONCLUSION

Infants with PRS are highly likely to have feeding difficulties and malnutrition. Early intervention by a dietitian is recommended to reduce the impacts of feeding difficulties, meet elevated energy requirements and facilitate growth. Infants with a longer inpatient stay or presence of IUGR should have their growth and feeding routinely monitored.

Avoidant Restrictive Food Intake Disorder

Avoidant restrictive food intake disorder (ARFID) is a rearticulated eating disorder diagnosis in the Diagnostic and Statistical Manual of Mental Disorders (fifth edition) (DSM-5), published in 2013. The purpose of this article is to review what is known about ARFID; specifically outline the DSM-5 diagnostic criteria; review the epidemiology; describe the clinical characteristics of patients with this disorder; and discuss evolving treatment approaches. Although this disorder occurs across the lifespan, the focus of recent research has been primarily in children and adolescents with ARFID. Therefore, most of this article is devoted to children and adolescents with ARFID.

Pediatric Feeding Disorder: Consensus Definition and Conceptual Framework

Pediatric feeding disorders (PFDs) lack a universally accepted definition. Feeding disorders require comprehensive assessment and treatment of 4 closely related, complementary domains (medical, psychosocial, and feeding skill-based systems and associated nutritional complications). Previous diagnostic paradigms have, however, typically defined feeding disorders using the lens of a single professional discipline and fail to characterize associated functional limitations that are critical to plan appropriate interventions and improve quality of life. Using the framework of the World Health Organization International Classification of Functioning, Disability, and Health, a unifying diagnostic term is proposed: "Pediatric Feeding Disorder" (PFD), defined as impaired oral intake that is not age-appropriate, and is associated with medical, nutritional, feeding skill, and/or psychosocial dysfunction. By incorporating associated functional limitations, the proposed diagnostic criteria for PFD should enable practitioners and researchers to better characterize the needs of heterogeneous patient populations, facilitate inclusion of all relevant disciplines in treatment planning, and promote the use of common, precise, terminology necessary to advance clinical practice, research, and health-care policy.

Application of the Scale for the Assessment of Feeding Interaction (SVIA) to Children With Autism Spectrum Disorder

Background and Objectives: Feeding problems occur more frequently among children with Autism spectrum disorder (ASD). The aim of this study was to analyse eating difficulties of ASD children through the direct observation of the caregiver-child co-regulation system. Methods: We compared 60 ASD children with a control group of 50 typically developing Italian children on the Scale for the Assessment of Feeding Interaction (SVIA). The Brief Autism Mealtime Behaviour Inventory (BAMBI) was used to define the presence of an eating disorder. Results: The ASD group showed higher scores on all dimensions of the SVIA compared to the control group. The SVIA and the BAMBI showed significant correlations. In a second step, the ASD sample was divided into two subgroups, children with and without feeding difficulties. The comparison between the ASD subgroups with the control group on the SVIA scales showed significant differences on all dimensions. Finally, significant differences emerged between the two ASD subgroups in three SVIA dimensions. Conclusion: These data suggest the importance of direct observation of feeding in the assessment of children with ASD. The SVIA seems to be able to point out some feeding difficulties in these subjects and to discriminate ASD with and without an eating disorder. Critical aspects of the application of SVIA to autistic children are discussed.