Analysis of feeding and eating disorders in 191 children according to psychiatric or gastroenterological recruitment: The PEDIAFED cohort study

OBJECTIVE

The DSM-5 classification introduced new Feeding and Eating Disorders (FED) diagnostic categories, notably Avoidant and Restrictive Food Intake Disorder (ARFID), which, like other FED, can present psychiatric and gastrointestinal symptoms. However, paediatric clinical research that focuses on children below the age of 12 years remains scarce. The aim of this study was first to investigate the clinical features of FED in a cohort of children, second to compare them according to their recruitment (gastroenterology or psychiatry unit).

METHOD

This non-interventional retrospective cohort study analysed 191 patients in a French paediatric tertiary care centre (gastroenterology n = 100, psychiatry n = 91). The main outcome variables were clinical data (type of FED, BMI, nutritional support, chronic diseases, psychiatric comorbidities, sensory, sleep, language disorders, gastrointestinal complaints, adverse life events, family history). The outcome was defined by a Clinical Global Impression of Change-score.

RESULTS

FED diagnoses were ARFID (n = 100), Unspecified FED (UFED, n = 57), anorexia nervosa (AN, n = 33) and one pica/rumination. Mean follow-up was 3.28 years (SD 1.91). ARFID was associated with selective and sensory disorders (p < 0.001); they had more anxiety disorders than patients with UFED (p < 0.001). Patients with UFED had more chewing difficulties, language disorder (p < 0.001), and more FED related to chronic disease (p < 0.05) than patients with ARFID and AN. Patients with AN were female, underweight, referred exclusively to the psychiatrist, and had more depression than patients with ARFID and UFED (p < 0.001). The gastroenterology cohort included more UFED, while the psychiatry cohort included more psychiatric comorbidities (p < 0.001). A worse clinical outcome was associated with ARFID, a younger age at onset (p < 0.001), selective/sensory disorders and nutritional support (p < 0.05).

CONCLUSION

ARFID and UFED children were diagnosed either by gastroenterologists or psychiatrists. Due to frequently associated somatic and psychiatric comorbidities, children with FED should benefit from a multidisciplinary assessment and care.

New consensus definition on defining and measuring care for children with paediatric feeding disorder

AIM

This study addresses the absence of a definition of care for children with feeding disorders, limited agreement on key performance indicators (KPIs), and the lack of data linked to those KPIs.

METHODS

Clinicians, consumers and researchers involved in outpatient feeding care in New South Wales (NSW), Australia were invited to participate in a two-Phase study. In Phase 1, a modified Delphi method was used. Two rounds of voting resulted in a new consensus definition of a multidisciplinary paediatric feeding clinic. Three further rounds voting determined relevant KPIs. In Phase 2, the KPIs were piloted prospectively in 10 clinics.

RESULTS

Twenty-six clinicians, consumers and researchers participated in Phase 1. Participation across five voting rounds declined from 92% to 60% and a valid definition and KPI set were created. In Phase 2, the definition and KPIs were piloted in 10 clinics over 6 weeks. Data for 110 patients were collected. The final KPI set of 28 measures proposed covers clinical features, patient demographics and medical issues, parent-child interaction and outcome measures.

CONCLUSIONS

A new definition of a multidisciplinary paediatric feeding clinic is now available, linked to a standardised KPI set covering relevant performance measures. These proved viable in baseline data collection for 10 clinics across NSW. This sets a foundation for further data collection, systematic measurement of care provision and outcomes, and research needed to deliver care improvement for children with paediatric feeding disorder.

Parents' experiences of living with a child with Paediatric Feeding Disorder: An interview study in Sweden

INTRODUCTION

Children affected by Paediatric Feeding Disorder (PFD) cannot consume enough nourishment by mouth. PFD is highly prevalent and can affect the child's growth and development as well as family life.

AIM

To illuminate Swedish parents' experiences of living with a child with PFD.

METHOD

Semi-structured interviews via telephone or video calls were conducted with 14 purposefully recruited mothers and six fathers. The interviews were analysed using content analysis. Ethics approval was obtained, and the parents all gave informed consent.

RESULTS

Four overarching themes emerged: Living with stress; Advocating for the child; Adapting family life; and Gaining hope. Parents described fearing for their child's life and health, feeling pressure over meals and being emotionally affected. They told of experiencing a lack of understanding from healthcare professionals, friends and family. Parents expressed a struggle for help, the need for early interventions and more effective treatment, and developed strategies for coping with the demands of feeding and caring for their child, accepting their living reality. Finding support from a network helped, but the adaptation of daily life affected their family relations. They felt gratitude towards helpful professionals and relief and joy when their child was doing better.

CONCLUSIONS

A more cohesive chain of care is important for children with PFD, and guidelines and educational support for healthcare providers are needed. Parental experiences provide a base for knowledge for further development of early detection and intervention for children with PFD.

Early diagnosis of neonatal-onset cyclic vomiting syndrome

Cyclic vomiting syndrome (CVS) is characterized by recurrent episodes of severe vomiting with a completely asymptomatic interictal interval. Relatively few patients develop CVS in the neonatal period, and an early diagnosis is difficult. We experienced an infant who was diagnosed with neonatal-onset CVS in early infancy. An 8-day-old girl was admitted to our neonatal intensive care unit because of frequent vomiting beginning 12 h after birth and weight loss reaching 84.2% of her birth weight. Despite extensive examinations, no abnormalities to explain the vomiting were found. She continued to vomit, and a cyclical pattern with a vomiting phase lasting for three days followed by a non-vomiting phase lasting for about one to two weeks became obvious. Based on her clinical course, the family history of migraine and the effectiveness of Phenobarbital, she was diagnosed with CVS at three months old. Although CVS is a diagnosis of exclusion, a family history of migraine can aid its early diagnosis. If the illness is suspected in the neonatal period, diagnostic treatment with Phenobarbital may be considered. The case suggests the need to include CVS in the differential diagnosis of neonates with unexplained repetitive vomiting.

Impact of COVID-19 in relation to the outpatient pediatric feeding therapy experience: A speech-language pathologist's review of literature and professional experience

It is well known in the medical and pediatric feeding community how parental stress affects outcomes of pediatric nutrition and feeding behaviors. There is growing literature suggesting the impact of the COVID-19 pandemic in relation to caregiver and child stress. It could be suggested that this increase in stress contributed to or exacerbated pediatric feeding difficulties. In addition, the COVID-19 pandemic resulted in pediatric rehabilitation therapists quickly transitioning from in-person to virtual evaluation and treatment models. The purpose of this article is to review current literature regarding the definition and prevalence of pediatric feeding disorder, the impact of the COVID-19 pandemic on parent/child stress and relationships surrounding feeding, and this speech-language pathologist's perception of both the positive and negative aspects of providing ongoing outpatient feeding evaluations and treatments in the context of the COVID-19 pandemic, as well as clinical considerations for ongoing feeding therapy after the COVID-19 pandemic.

Self-reported expertise and confidence in diagnosing and treating avoidant restrictive food intake disorder among Swedish clinicians

OBJECTIVE

To assess self-reported knowledge and confidence regarding avoidant restrictive food intake disorder (ARFID) diagnosis and treatment in Swedish clinicians from various disciplines.

METHOD

The study included 489 clinicians who attended educational lectures about ARFID. Participants responded to 20 ARFID-related questions and statements using the online audience engagement platform Mentimeter. Items assessed ARFID-related knowledge, education, and experience, as well as treatment methods offered to ARFID patients at clinicians' healthcare units.

RESULTS

We found predominantly correct responses to three basic knowledge-based items about ARFID. However, most participants (64.0%) reported never having received education about ARFID, and few participants reported feeling confident in their ability to diagnose (13.4%) and treat (10.7%) ARFID. Nearly half the sample reported either not knowing which ARFID treatments their unit offered (22.3%) or that no treatment was offered (21.3%).

CONCLUSION

Experience and confidence in diagnosing and treating ARFID are generally low in Swedish clinicians, and many individuals with ARFID do not receive treatment. We identify a pressing need for resources, clearer organisation, and structure, and for additional education and training opportunities for clinicians meeting individuals with ARFID.

Cisplatin-Induced Nausea and Vomiting: Effect of Herbal Medicines

Cisplatin is a chemotherapeutic agent that is widely used to treat various types of cancers. However, its side effects, most commonly nausea and vomiting, limit its widespread use. Although various drugs, such as ondansetron and aprepitant, are used to alleviate these side effects, their efficacy is still debated. This review aims to summarize the results of 14 studies on the effects of seven single herbal extracts, one multiple herbal extract, and one ginger sub-component (i.e., [6]-gingerol) on cisplatin-induced nausea and vomiting. The results of the included studies were subdivided into four categories: kaolin consumption, retching and vomiting, food intake, and weight loss. Most studies used rodents, whereas four studies used minks or pigeons. The doses of cisplatin used in the studies varied from 3 mg/kg to 7.5 mg/kg, and only a single injection was used. Nine studies analyzed the mechanisms of action of herbal medicines and assessed the involvement of neurotransmitters, cytokines, enzymes, and various hematological parameters. Although further research is needed, this review suggests herbal medicine as a viable treatment option for cisplatin-induced neuropathic pain.

Presence of Increased Mast Cells in Infants and Children with Volume and Variety Limited Intake

Background: Reports indicate patients with feeding difficulties demonstrate signs of inflammation on biopsies, notably eosinophilia, but it is unknown whether mast cell density contributes to variety or volume limitation symptoms. The aim of our study was to evaluate eosinophil and mast cell density of EGD biopsies in pediatric patients with symptoms of decreased volume or variety of ingested foods. Methods: We conducted a single-center, retrospective chart review of EMRs for all new feeding clinic patients between 0 and 17 years of age. Patients were categorized by symptoms at the initial visit as well as eosinophil and mast cell densities in those with EGD biopsies. Ten patients were identified as controls. Results: We identified 30 patients each with volume and variety limitation. Antral mast cell density was increased in 32.1% of variety-limited patients, 37.5% of volume limited patients, and in no controls; Duodenal mast cell density was increased in 32.1% of variety-limited patients, 40.6% of volume-limited patients, and in no controls. Conclusions: In both variety- and volume-limited patients, antral and duodenal mast cell densities were increased. These associations warrant further investigation of the mechanism between mast cells and development of feeding difficulties, allowing more targeted pediatric therapies.

Are feeding disorders and feeding tube dependency the same?: A discrimination study between feeding disorders, feeding tube dependency and healthy eaters

AIM

Feeding disorders (FD) and feeding tube dependency (FTD) are defined by a persistent pattern of food aversion, but data regarding the frequency of food aversion symptoms are scarce. In this study, the frequency of aversion symptoms for FD, FTD and healthy eaters (HE) were compared.

METHODS

We compared the frequency of food aversion symptoms in a group with FD (n = 32) and FTD (n = 39) to HE (n = 38) using the AFT questionnaire. This includes growth data as well as the feeding aversion scale and the frequency of food aversion symptoms.

RESULTS

HE were reported to have minor frequency of symptoms, while FD children were reported to have daily aversive symptoms. FTD patients had the highest frequency in total. There were significant differences between FD and FTD regarding the frequency of food refusal, vomiting and bizarre eating patterns, and there were different correlative patterns of food aversion.

CONCLUSIONS

Children with FD and FTD show significantly different patterns of feeding behaviour compared to healthy norms as well as to each other. This suggests individualised assessment and treatment programs may be most beneficial for the needs of children with FD and FTD.

On the role of operant contingencies in the maintenance of inappropriate mealtime behavior: An epidemiological analysis

Functional analysis is the primary assessment used to determine the function of inappropriate mealtime behavior in children with feeding disorders. Based on single-case experimental design studies and recent reviews, the prevalence of negative reinforcement alone in the maintenance of inappropriate mealtime behavior appears to be much greater than positive reinforcement alone. We conducted a retrospective consecutive-controlled case series to determine the generality of previous findings. Results of the epidemiological analysis support prior research in that negative reinforcement in the form of escape (44.8%), and multiple control (i.e., positive and negative reinforcement) in the forms of escape and attention (37.2%), are considerably more prevalent than positive reinforcement alone (2.5%). We discuss the relationship between functional analysis of inappropriate mealtime behavior and treatment utility. Further, we describe avenues of future research designed to advance the application of functional analysis in feeding disorders beyond inappropriate mealtime behavior.

The relationship between chronic paediatric feeding disorders and caregiver stress

Paediatric feeding disorders (PFDs) are common. Earlier studies have shown an association between PFD and caregiver stress, but these studies have been hampered by insufficient power. This study reports stress for caregivers of children diagnosed with PFD. These caregivers were then compared to community norms of the Parental Stress Index-Short Form. Caregivers also completed the Mealtime Behaviour Questionnaire, Child Behaviour Checklist and Child Development Inventory. Linear regression and hierarchical regression analyses assessed the relationship among the variables. Caregivers of 840 children with PFD responded. Negative child behaviours and lower child developmental function predicted higher levels of total parenting stress, parental distress, parent-child dysfunctional interaction and caregiver perceptions of their child as difficult. Higher rates of child internalizing and externalizing problems and child mealtime aggression were associated with parent perceptions of their child as difficult and contributed to total parental stress. Parents of older children reported higher levels of stress, whereas parents of younger children were more likely to be defensive responders. Overall, parents of children with PFD have more caregiver-related stress. These caregivers may benefit from consultations with mental health professionals to provide the most appropriate care to affected families.

An evaluation of a renewal-mitigation procedure for inappropriate mealtime behavior

Renewal, the increase in behavior during extinction following context changes, may be particularly concerning during intervention for feeding disorders because context changes are often necessary for intervention generality and maintenance (Podlesnik et al., 2017). In the current study, we tested for renewal and evaluated a renewal-mitigation procedure when we transferred intervention from a therapist to a caregiver, from clinic to the home, and changed the foods the feeder presented. We used an ABA arrangement to evaluate the generality of the renewal effect with 7 participants who engaged in inappropriate mealtime behavior. Context A was functional reinforcement. Context B was function-based extinction during the control and mitigation conditions and our renewal-mitigation procedure in the mitigation condition. The renewal test was function-based extinction in Context A. We observed renewal of inappropriate mealtime behavior in 4 of 7 participants, and our renewal-mitigation procedure was effective for 4 of 4 participants.

Pediatric Feeding Disorder: A Nationwide Prevalence Study

OBJECTIVE

To assess the prevalence of pediatric feeding disorder (PFD) in US children.

STUDY DESIGN

We conducted a retrospective cohort study of Medicaid Databases from Arizona (2009-2017) and Wisconsin (2005-2014) (public insurance databases) and The Truven Health Analytics MarketScan Commercial Claims and Encounters Database (2009-2015) (a nationwide private insurance database). Diagnoses and procedures were identified from inpatient and outpatient claims using the International Classification of Diseases (ICD)-9 and ICD-10 diagnostic codes and ICD and Current Procedural Terminology-4 procedure codes. Children with PFD were identified by presence of 1 or more PFD diagnosis and absence of any eating disorder diagnoses within a calendar year.

RESULTS

We identified 126 002 and 367 256 children 5 years of age or younger with PFD with public and private insurance, respectively. Over a 5-year period (2009-2014) the prevalences of PFD in children with public insurance in Arizona and Wisconsin were 32.91 (95% CI, 32.61-33.20) and 34.73 (95% CI, 34.37-35.09) children per 1000 child-years, respectively. Similarly, the prevalence of PFD in private insurance carriers was 21.07 (95% CI, 21.00-21.14) children per 1000 child-years. The prevalence trends showed a significant linear increase in children within both insurance cohorts. In 2014, the annual prevalence of PFD was 1 in 23, 1 in 24, and 1 in 37 in children under 5 years in the publicly insured cohorts in Wisconsin, Arizona, and the privately insured cohort, respectively.

CONCLUSIONS

The prevalence of feeding disorders in the US rivals that of commonly diagnosed conditions such as eating disorders and autism.

Avoidant/restrictive food intake disorder symptoms are frequent in patients presenting for symptoms of gastroparesis

INTRODUCTION

Patients with symptoms of gastroparesis/dyspepsia often avoid foods or restrict eating for symptom management. There is growing interest in understanding risk for feeding/eating disorders (FEDs) like avoidant/restrictive food intake disorder (ARFID). Among patients presenting with gastroparesis/dyspepsia symptoms, we aimed to determine: (a) FED symptom frequency, and (b) relation of FED symptoms to gastrointestinal symptom severity and gastric retention abnormalities.

METHODS

Adult patients (N = 288; 78% female) referred for gastroparesis/dyspepsia symptoms at two academic medical centers from January 2018-February 2019 completed self-report surveys for gastrointestinal symptom severity and FED symptoms. Gastric retention data were available for 210 patients, using 4-hour EggBeater gastric emptying scintigraphy (GES).

RESULTS

Clinically significant FED symptoms were present in 158 patients (54.9%). Interestingly, 115 patients (39.9%) met conservative self-report cutoff for ARFID symptoms, with 67 (23.3%) patients having documented psychosocial/medical impairment. Of those with survey data for other FEDs (n = 239), only 28 patients (11.7%) had restrictive eating disorders (anorexia nervosa; unspecified FED). Likelihood of having FED symptoms was significantly associated with greater gastroparesis symptom severity (OR = 2.23, P < .001), but not GES. In addition, gastroparesis symptom severity was moderately and significantly associated with greater ARFID symptom severity (b = 0.45, P < .001), but neither GES nor other FED symptoms.

DISCUSSION

In patients presenting with gastroparesis/dyspepsia symptoms, FED symptoms were frequent (55%), particularly ARFID, and were associated with greater gastrointestinal symptom severity, but not gastric retention. Gastroparesis/dyspepsia symptoms may mimic FEDs, particularly ARFID. Clinicians should be cautious about diagnosing ARFID in gastroparesis/dyspepsia patients, and screening for ARFID could assist behavioral treatment referral.

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.

Psychometric properties of the Persian version of the oral motor assessment scale in children and adolescents with cerebral palsy

The Oral Motor Assessment Scale (OMAS) is a diagnostic tool used to assess the oral motor skills in individuals with neurological and neuromuscular disorders. This assessment was developed by Brazilian researchers and for the first time, its validity and reliability was examined in Brazil. The purpose of the present study was to examine the validity and reliability of the adopted Persian version of the OMAS (OMAS-P) to assess the oral skills of Iranian individuals with cerebral palsy (CP). In this non-experimental descriptive-analytical study 120 people (60 children and adolescents with CP) aged 3 to 15 years and 60 healthy subjects) participated. The research was carried out in number of stages including translation and adaptation of the OMAS to Persian (OMAS-P) in a forward-backward way. The oral motor skills functionality of the 120 people was examined using the OMAS-P. To assess the repeatability and reliability of the OMAS-P the assessments was repeated on the participants with CP disorder after two weeks. Results corresponding to this study indicated a reasonable agreement (Kappa >0.7) for all the OMAS-P items. The mean values of the OMAS-P items were appreciably different between the two groups (p < 0.001). The Persian version of the OMAS (OMAS-P) indicated consistent psychometric properties and can be used as a reliable tool for oral motor skills assessment in people with CP. However, it seems that by specifying factors such as the time frame for the OMAS, the position of the child during assessment, and whether or not parents use facilitating techniques, the comprehensiveness and efficiency of the OMAS data will also upgrade.

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 Eating and Feeding Disturbances

Eating and feeding disturbances are prevalent yet understudied health conditions in youth. They are characterized by aberrant eating behaviors, cognitive and emotional dysfunctions, and dysregulated body weight. The Diagnostic and Statistical Manual of Mental Disorders Fifth Edition defines several feeding and eating disorders with a common onset in youth; however, data on their clinical validity at young ages are lacking. Further non-normative eating behaviors exist, but their clinical relevance needs elucidation. This Special Issue compiles state-of-the-art reviews and empirical research on the presentation, development, course, and maintenance of diverse eating and feeding disturbances as a prerequisite for delineating evidence-based interventions for treatment and prevention.

Nutritional interventions improve quality of life of caregivers of children with neurodevelopmental disorders

Introduction: Children with neurodevelopmental disorders are at high risk for malnutrition. We aimed to investigate the impact of nutritional interventions to children with neurodevelopmental disorders and the quality of life of caregivers.Materials/Method: This is a prospective interventional study of 91 children with neurodevelopmental disorders. The children were separated into two groups: the intervention group and control group. The intervention group was selected from among children who had not been evaluated for nutrition and feeding problems by a pediatric gastroenterologist or dietician for the past one year. Children in the intervention group were called for follow-up visits and their nutritional intervention and anthropometric measurements were initiated by a pediatric gastroenterologist and dietician, at one month, three months, six months, and one year. The WHOQoL-BREF quality of life scale was completed by the caregivers of the children at baseline and at one year.Results: The intervention group had increased malnutrition (p < 0.001) and gastrointestinal system pathologies such as dysphagia (p < 0.001), constipation (p = 0.02), gastroesophageal reflux (p = 0.03) at baseline. After the nutritional intervention, 77.7% of the intervention group gained weight and 55.5% reached the target weight. The quality of life scale scores at baseline were lower among caregivers of the intervention group; however, they reached those of the control group after the nutritional intervention.Conclusion: Close multidisciplinary nutrition monitoring enables children with neurodevelopmental disorders to thrive appropriately and improves the quality of life of caregivers.

Food preferences before and during treatment for a pediatric feeding disorder

Little is known about the food preferences of children with a feeding disorder and medical diagnoses. Therefore, we conducted repeated paired-stimulus-preference assessments with foods to which we either exposed or did not expose 3 children with a feeding disorder and medical diagnoses during clinical treatment. Responding was relatively equivalent for exposure and nonexposure foods throughout the preference assessments, suggesting that preferences for foods did not change due to exposure during treatment.

A clinical description of children with solid organ transplants who present with feeding disorder

Pediatric solid organ transplant recipients have long-standing malnutrition concerns related to their pretransplant medical status. The targeted nutrition therapy utilized pre-, peri-, and post-transplantation may have the adverse effect of impeding normally developing feeding skills, particularly in very young children. Little is known about the relationship between transplantation and feeding disorders of childhood. The purpose of this study was to describe severity of feeding disorder and parental stress in patients with transplant compared to children followed in a specialty feeding clinic and the general community. Sixty-four children, comprised of 32 children with solid organ transplant ages 2 months to 12 years and 32 matched control patients diagnosed with a feeding disorder without history of solid organ transplant, were reviewed. All children were from the Feeding, Swallowing, and Nutrition Clinic at a single children's hospital. Findings indicate that patients who received a transplant and presented with a feeding problem had worse symptoms of feeding disorder than are typically found in the general community. These feeding problems disrupt mealtime behavior, caregiver and child relationship within a mealtime context, and may result in maladaptive feeding strategies used by families. When transplanted children present with feeding disorders, they are severe and have multiple effects on both the child and the feeding dynamic between the child and the child's caregivers. Further investigation may help us to better understand the relationship between transplantation and symptoms of feeding disorder.

Interview-based assessment of avoidant/restrictive food intake disorder (ARFID): A pilot study evaluating an ARFID module for the Eating Disorder Examination

OBJECTIVE

Although avoidant/restrictive food intake disorder (ARFID) has been included as a new diagnostic entity of childhood feeding and eating disorders, there is a lack of measures to reliably and validly assess ARFID. In addition, virtually nothing is known about clinical characteristics of ARFID in nonclinical samples.

METHOD

The present study presents the development and validation of an ARFID module for the child and parent version of the Eating Disorder Examination (EDE) in a nonclinical sample of N = 39 children between 8 and 13 years with underweight and/or restrictive eating behaviors. For evaluating the ARFID module's reliability, the convergence of diagnoses between two independent raters and between the child and parent module was determined. The module's validity was evaluated based on the full-length child version of the EDE, a 24 h food record, parent-reported psychosocial functioning and self-reported quality of life, and objective anthropometric measures.

RESULTS

In total, n = 7 children received an ARFID diagnosis. The ARFID module showed high interrater reliability, especially for the parent version, and high convergence between child and parent report. Evidence for the module's convergent, divergent, and discriminant validity was provided. Specifically, children with versus without ARFID reported significantly less macro- and micronutrient intake and were more likely to be underweight.

DISCUSSION

This pilot study indicates the child and parent version of the EDE ARFID module to be promising for diagnosing ARFID in a structured way but still necessitates a validation in a larger clinical and community-based sample.

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.

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.

Prevalence in primary school youth of pica and rumination behavior: The understudied feeding disorders

OBJECTIVE

Little epidemiological evidence exists on rumination disorder behavior (RB) and pica behavior (PB). We examined prevalence of RB and PB and presence of comorbid feeding/eating disorder symptoms among school-aged children.

METHOD

In elementary schools in Switzerland, 1,430 children (54.0% female) ages 7-13 completed the Eating Disorder Examination-Questionnaire for children (ChEDE-Q) and the Eating Disturbances in Youth Questionnaire (EDY-Q).

RESULTS

EDY-Q behavior frequency showed 9.7% reported RB only, 10.0% reported PB only, and 3.1% reported RB + PB (≥1 on 0-6 Likert scale). At a clinical cut-off score of ≥ 4, 1.7% had RB only, 3.8% had PB only, and 1.1% had RB + PB. Avoidant/restrictive food intake disorder symptoms were most common in those with RB + PB, and more common in those with RB or PB than those without. The degree of eating disorder symptoms (by ChEDE-Q) over the past 28 days were similar among those with RB, PB, or RB + PB, but less common in those without RB or PB.

DISCUSSION

RB and PB were commonly reported in our sample of school-aged children, even at a potential clinically significant cut-off. Our findings also suggest that the degree of eating disorder symptom comorbidity is similar between those with RB and PB.

Eosinophilic Esophagitis Is an Underlying Cause for Gastrointestinal Concerns in Children

Eosinophilic esophagitis (EoE) is a chronic immune antigen-mediated disorder characterized by symptoms of esophageal dysfunction in combination with dense esophageal eosinophilia. The clinical presentation of EoE can vary depending on children's age and their ability to report symptoms, therefore a high index of suspicion for EoE is required because children and teenagers may develop coping strategies around eating. The development of symptoms measurement tools in EoE assists in not only assessing symptoms, but also coping strategies children may have developed. While the diagnosis of EoE requires endoscopic evaluation with histologic assessment of esophageal mucosal biopsy samples, several emerging methods to assess and survey the esophageal mucosa have been developed. Advances in the field to better understand the natural history, clinical and molecular features of phenotypes in EoE will be important in considering novel therapeutic options and assessing outcomes.

Adjunctive Use of Olanzapine in the Treatment of Avoidant Restrictive Food Intake Disorder in Children and Adolescents in an Eating Disorders Program

OBJECTIVE

There is little information about the pharmacological treatment of avoidant and restrictive food intake disorder (ARFID), a challenging feeding disorder associated with marked impairment and developmental arrest. This brief clinical report seeks to fill this gap.

METHODS

A retrospective chart review of nine patients with ARFID treated in an eating disorder (ED) program (residential, partial hospital, and intensive outpatient levels of care) with adjunctive olanzapine was undertaken.

RESULTS

The mean initial and final olanzapine doses were 0.9 + 0.63 mg/day and 2.8 + 1.47 mg/day, respectively. There was a statistically significant difference in weight gain pre- versus post-olanzapine treatment (3.3 ± 7.3 lbs vs. 13.1 ± 7.9 lbs [2.99 ± 6.62 lb SI vs. 11.88 ± 7.17 lb SI], paired t-test (p < 0.04, t = -2.48). Clinically, adjunctive olanzapine was helpful for not only weight gain but also reduction of associated anxious, depressive, and cognitive symptoms. Clinical Global Impressions scale scores indicated marked improvement in patients receiving adjunctive olanzapine.

CONCLUSION

These cases illustrate that judicious use of low-dose olanzapine, when used as an adjunct to other treatment modalities, may facilitate eating, weight gain, and the reduction of anxious, depressive, and cognitive symptoms in ARFID patients. Future randomized, placebo-controlled studies in ARFID are warranted.

Effect of a new treatment protocol called Functional Chewing Training on chewing function in children with cerebral palsy: a double-blind randomised controlled trial

Cerebral palsy (CP) is a group of permanent sensorimotor impairments. Children with CP have various feeding difficulties including chewing disorder, which may affect their nutritional status. Functional Chewing Training (FuCT) was designed as a holistic approach to improve chewing function by providing postural alignment, sensory and motor training, and food and environmental adjustments. This study aimed to investigate the effect of FuCT on chewing function in children with CP. This study was designed as a double-blind, randomised controlled trial. Eighty CP children with chewing disorder were randomised and split between the FuCT group (31 males, 19 females; mean age 3·5 ± 1·9 years) and the control group (16 males, 14 females; 3·4 ± 2·3 years) receiving traditional oral motor exercises. Each group received the training programme for 12 weeks with weekly follow-up and with two evaluations at baseline and end of 12 weeks. Chewing function was evaluated by analysing video recordings and scored with the Karaduman Chewing Performance Scale (KCPS). The Behavioral Pediatrics Feeding Assessment Scale (BPFAS) was used to evaluate feeding behaviours of children. A significant improvement was observed in KCPS scores at 12 weeks after training in the FuCT group (P < 0·001), but no change was found in the control group (P = 0·07). A significant improvement was detected in all parameters of BPFAS at 12 weeks after training in the FuCT group (P < 0·001) and in four parameters of BPFAS in the control group (P = 0·02, P = 0·02). FuCT is an effective method to improve chewing function compared with traditional oral motor exercises.

Prevalence of DSM-5 avoidant/restrictive food intake disorder in a pediatric gastroenterology healthcare network

OBJECTIVE

Few published studies have evaluated the clinical utility of new diagnostic criteria for avoidant/restrictive food intake disorder (ARFID), a DSM-5 reformulation of feeding and eating disorder of infancy or early childhood. We examined the prevalence of ARFID and inter-rater reliability of its diagnostic criteria in a pediatric gastrointestinal sample.

METHOD

We conducted a retrospective chart review of 2,231 consecutive new referrals (ages 8-18 years) to 19 Boston-area pediatric gastroenterology clinics for evidence of DSM-5 ARFID.

RESULTS

We identified 33 (1.5%) ARFID cases; 22 of whom (67%) were male. Most were characterized by insufficient intake/little interest in feeding (n = 19) or limited diet due to sensory features of the food (n = 7). An additional 54 cases (2.4%) met one or more ARFID criteria but there was insufficient information in the medical record to confer or exclude the diagnosis. Diagnostic agreement between coders was adequate (κ = 0.72). Common challenges were (i) distinguishing between diagnoses of ARFID and anorexia nervosa or anxiety disorders; (ii) determination of whether the severity of the eating/feeding disturbance was sufficient to warrant diagnosis in the presence of another medical or psychiatric disorder; and (iii) assessment of psychosocial impairment related to eating/feeding problems.

DISCUSSION

In a pediatric treatment-seeking sample where ARFID features were common, cases meeting full criteria were rare, suggesting that the diagnosis is not over-inclusive even in a population where eating/feeding difficulties are expected.

Pica and rumination behavior among individuals seeking treatment for eating disorders or obesity

OBJECTIVE

Pica and rumination disorder (RD)-formerly classified within DSM-IV Feeding and Eating Disorders of Infancy or Early Childhood-are now classified within DSM-5 Feeding and Eating Disorders. Though pica and RD have been studied in select populations (e.g., pregnant women, intellectually disabled persons), their typical features and overall prevalence remain unknown. This study examined the clinical characteristics and frequency of DSM-5 pica and RD among individuals seeking treatment for eating disorders and obesity.

METHOD

We conducted structured interviews with adolescent and young adult females from a residential eating disorder center (N = 149), and adult males and females with overweight or obesity from an outpatient weight-loss clinic (N = 100).

RESULTS

Several participants reported ingesting non-nutritive substances (e.g., ice) for weight-control purposes. However, only 1.3% (n = 2; 95% CI: .06% to 5.1%) at the residential eating disorder center and 0% at the weight-loss clinic met DSM-5 criteria for pica, consuming gum and plastic. Although no eating disorder participants were eligible for an RD diagnosis due to DSM-5 trumping rules, 7.4% (n = 11; 95% CI: 4.0% to 12.9%) endorsed rumination behavior under varying degrees of volitional control. At the weight-loss clinic, 2.0% (n = 2; 95% CI: 0.1% to 7.4%) had RD.

DISCUSSION

DSM-5 pica and RD were rare in our sample of individuals seeking treatment for eating disorders and obesity, but related behaviors were more common. The wide range of pica and rumination presentations highlights the challenges of differential diagnosis with other forms of disordered eating.

Mealtime Disruption and Caregiver Stress in Referrals to an Outpatient Feeding Clinic

BACKGROUND

This investigation explores the feeding behaviors, comorbidities, and parenting stress in young children referred to an outpatient feeding clinic.

MATERIALS AND METHODS

Eligible participants (n =72) were primary caretakers of children ages 2-6 years referred to an interdisciplinary outpatient feeding disorder clinic, subcategorized according to the absence (n = 18) or presence (n = 54) of caretaker-reported medical or developmental comorbidities. This group was compared with an equivalent control sample of caretakers of age-matched children (n = 72). Measures included the Children's Eating Behavior Inventory (CEBI) and the Parenting Stress Index-Short Form (PSI-SF).

RESULTS

The CEBI and PSI scores were higher in the feeding disorder group than in the control group. PSI total was incrementally increased for control vs feeding disorder without comorbidity vs feeding disorder with comorbidity.

CONCLUSION

Increased maladaptive behaviors and parenting stress were evident in children with feeding disorder regardless of the presence of comorbidity. Parenting stress was exacerbated by the presence of comorbidity.

Using negative reinforcement to increase self-feeding in a child with food selectivity

We examined the effects of a negative reinforcement-based treatment on the self-feeding of 1 child with food selectivity by type and texture. Self-feeding increased when the child could choose to either self-feed 1 bite of a target food or be fed 1 bite of the target food and 5 bites of another food. Possible mechanisms that underlie the effectiveness of the intervention and implications for future research are discussed.

Chin prompt plus re-presentation as treatment for expulsion in children with feeding disorders

Expulsion (spitting out food) is a problem behavior observed in many children with feeding disorders. In the current investigation, we identified 4 children diagnosed with a feeding disorder who exhibited high rates of expulsion. Treatment with re-presentation (placing expelled liquids or solids back into the child's mouth) was not effective in reducing expulsion. Therefore, we added a chin-prompt procedure (the feeder applied gentle upward pressure to the child's chin and lower lip) for the initial presentation and the re-presentation. Chin prompt plus re-presentation resulted in low rates of expulsion for all 4 children. The results are discussed in terms of the potential underlying mechanisms behind the effectiveness of the chin-prompt procedure.

Spoon distance fading with and without escape extinction as treatment for food refusal

Little is known about the characteristics of meals that serve as motivating operations (MOs) for escape behavior. In the current investigation, we showed that the distance at which a therapist held a spoon from a child's lips served as an MO for escape behavior. Based on these results, we implemented spoon distance fading, compared fading with and without escape extinction (EE), and compared fading plus EE to EE alone. Initially, inappropriate mealtime behavior decreased during fading, but this effect was not maintained as fading progressed. Inappropriate mealtime behavior was lower initially when we combined fading and EE relative to EE alone, but acceptance increased more rapidly with EE than with fading plus EE. These results suggest that a number of mealtime characteristics might function as MOs for escape behavior and that analyses of MOs may be useful for developing treatments for food refusal.

Neuropeptide Y influences acute food intake and energy status affects NPY immunoreactivity in the female musk shrew (Suncus murinus)

Neuropeptide Y (NPY) stimulates feeding, depresses sexual behavior, and its expression in the brain is modulated by energetic status. We examined the role of NPY in female musk shrews, a species with high energetic and reproductive demands; they store little fat, and small changes in energy can rapidly diminish or enhance sexual receptivity. Intracerebroventricular infusion of NPY enhanced acute food intake in shrews; however, NPY had little affect on sexual receptivity. The distribution of NPY immunoreactivity in the female musk shrew brain was unremarkable, but energy status differentially affected NPY immunoreactivity in several regions. Similar to what has been noted in other species, NPY immunoreactivity was less dense in brains of ad libitum shrews and greater in shrews subjected to food restriction. In two midbrain regions, both of which contain high levels of gonadotropin releasing hormone II (GnRH II), which has anorexigenic actions in shrews, NPY immunoreactivity was more sensitive to changes in food intake. In these regions, acute re-feeding (90-180 min) after food restriction reduced NPY immunoreactivity to levels noted in ad libitum shrews. We hypothesize that interactions between NPY and GnRH II maintain energy homeostasis and reproduction in the musk shrew.