How To Approach Feeding Difficulties in Young Children
How To Approach Feeding Difficulties in Young Children
children
Abstract
Feeding is an interaction between a child and caregiver, and feeding difficulty is an
umbrella term encompassing all feeding problems, regardless of etiology, severity, or
consequences, while feeding disorder refers to an inability or refusal to eat sufficient
quantities or variety of food to maintain adequate nutritional status, leading to
substantial consequences, including malnutrition, impaired growth, and possible
neurocognitive dysfunction. There are 6 representative feeding disorder subtypes in
young children: infantile anorexia, sensory food aversion, reciprocity, posttraumatic
type, state regulation, and feeding disorders associated with concurrent medical
conditions. Most feeding difficulties are nonorganic and without any underlying
medical condition, but organic causes should also be excluded from the beginning,
through thorough history taking and physical examination, based on red-flag
symptoms and signs. Age-appropriate feeding principles may support effective
treatment of feeding difficulties in practice, and systematic approaches for feeding
difficulties in young children, based on each subtype, may be beneficial.
Keywords: Feeding difficulty, Feeding disorder, Diagnosis, Management, Child
Introduction
Feeding is an interaction between a child and caregiver, while eating comprises
actions regarding nutritional intake via mouth that are performed only by a child1).
Nutritional intake is an important issue in infancy and early childhood because these
periods are regarded as critical windows for physical growth and neurodevelopment,
which can affect long-term outcomes if not treated properly. The feeding process of
young children is mainly dependent on their parents or caregivers. According to
previous reports, about 20%–30% of infants and toddlers tend to have feeding-related
problems, which increase the risk of nutritional imbalance and failure to grow2).
Infants and toddlers with feeding problems are usually referred to pediatric outpatient
clinics for the evaluation of problematic feeding difficulties or growth faltering
resulting from persistent inadequate intake3). Therefore, a systematic approach to the
evaluation and management of feeding difficulties in young children is critical for
pediatricians in clinical practice.
Definition of feeding difficulties and feeding disorders in children
Feeding difficulty is an umbrella term encompassing all feeding problems, regardless
of etiology, severity, or consequences4). It includes any problems that affect the
process of providing food to the child. Feeding difficulties in children manifest as
prolonged mealtimes, food refusal, disruptive and stressful mealtimes, lack of
appropriate independent feeding, nocturnal eating in infants and toddlers,
introduction of distractions to increase intake, prolonged breast- or bottle feeding in
toddlers and older children, or failure to introduce advanced textures4). Feeding
difficulties are usually classified into three principal categories as suggested by
Kerzner et al.4): (1) limited appetite, (2) selective intake, and (3) fear of feeding. All
of these categories have subtypes, including misperceived feeding problems, as well
as organic and nonorganic feeding difficulties.
Feeding difficulties encompass all spectrums of feeding problems, ranging from a
mild form of picky eating to a severe form of food refusal observed in children with
autistic spectrum disorders, which requires a multidisciplinary feeding-team
approach. According to Kerzner et al.4), about 25% of parents complain that their
children have feeding-related problems. However, most of these problems are either
misperceived feeding problems or a mild form of feeding difficulty, and only 1%–5%
of young children seem to have problematic feeding disorders.
Feeding disorder is defined as difficulty in consuming an adequate amount or variety
of food, that is, an inability or refusal to eat and drink sufficient quantities of food to
maintain an adequate nutritional status. Therefore, feeding disorders may lead to
substantial organic, nutritional, or emotional consequences including impaired
growth.
Feeding disorder of infancy or early childhood is a more specific formal diagnostic
term regarding pathologic feeding-related issues5). At present, by definition, the
diagnosis of feeding disorder requires the identification of food refusal, together with
growth faltering after the exclusion of organic causes for the symptoms, and the
Diagnostic and Statistical Manual of Mental Disorders (DSM) referred to feeding
disorder as a persistent feeding impairment and either a failure to gain weight or a
significant weight loss for at least 1 month, without a lack of available food or
significant medical conditions6).
Table 1
Examples of questions to screen and assess feeding-related problems in practice
Question
Key questions
Are there any feeding-related problems in your child?
How the feeding problem manifest during mealtime?
Does the child have any underlying disease that affects oral intake?
Have the child's growth and development been faltered and retarded?
How is the child's response to food and the interaction between the caregiver and
the child during the mealtime?
How is the caregiver's response when the child refuses to eat?
Are there any significant stress factors in the family that influences oral intake of
the child?
Questions on feeding history
When dose the child eat? Where? With whom?
How does the child eat? Self-feeding with good appetite?
How is the positioning of the child during mealtime?
Are there any distractions such as television viewing, games, and toys that disturb
eating during the mealtime?
Question
Are there any feeding battles between the child and the caregiver?
Does the child have the tendency of selective eating during the mealtime?
Does the child show fear of feeding or depressed mood during the mealtime?
Questions on dietary history
What and how often does the child eat? (Use a 24-hour recall record on 1-day log
of all foods given and fed)
How much is the amount of food and/or formula?
How do you prepare food and/or the formula for the child?
Is there excessive beverage consumption such as milk, juice, sodas, and water?
What specific foods with specific tastes, textures, smells, or appearances does the
child refuse to eat?
What and how often does the child eat snack between the meals?
The next step may be the differentiation between underlying organic and nonorganic
causes of feeding problems7). According to Kerzner et al.4), there are some
noticeable “red flags” indicative of organic feeding disorders. These red flags, in
addition to basic information on children's feeding behaviors, are key points in
treating young children with feeding difficulties. The red flags, based on symptoms
and signs, include dysphagia, choking and aspiration, odynophagia or excessive
crying and pain on feeding, frequent vomiting, profuse diarrhea, developmental
delay, chronic cardiac or respiratory symptoms, skin eczema, growth faltering or
weight loss, prematurity, congenital anomalies, and features of autism4). Children
born as preterm infants and those with neurological impairment or with inborn errors
of metabolism are at high risk for organic feeding disorders, requiring thorough
investigation and proper management.
No laboratory investigations are routinely required in children with normal physical
and neurological examination results, normal growth patterns on standardized growth
curves, and normal developmental milestones. Laboratory tests, such as complete
blood count (white blood cell counts, lymphocyte counts, hemoglobin, and
hematocrit levels), chemistry (serum protein and albumin, iron, iron-binding capacity,
ferritin, liver panel, and renal panel), inflammatory markers (erythrocyte
sedimentation rate and C-reactive protein), and urinalysis, are often beneficial for
children with red flags to screen for concurrent infections and underlying medical
conditions16).
If organic diseases are suspected, underlying medical conditions should be treated
first. This is why the role of pediatricians is critical in assessing and managing infants
and young children with feeding difficulties. If feeding problems persist, even after
organic diseases have been cured medically, or there is no evidence of organic causes
for feeding difficulties, the nature and subtypes of all feeding difficulties should be
determined promptly and managed specifically, based on detailed information for
feeding behaviors and parent-child relationships.
Conclusions
Feeding difficulties are very common health problems in childhood, especially in
infants and toddlers. Although the majority of feeding difficulties are caused by
nonorganic etiologies, underlying organic causes should also be thoroughly ruled out
in children with red flag symptoms and signs through thorough history taking and
physical examination, especially in young children with growth faltering. Age-
appropriate feeding principles may support effective treatment for feeding difficulties
in practice, and systematic approaches to feeding difficulties in young children, based
on each subtype, may be useful. As persistent feeding difficulties may lead to
nutritional deficiency and growth faltering, pediatricians should be aware of proper
nutritional support and feeding strategies in practice, which may improve clinical
outcomes of young children with feeding difficulties.
Footnotes
Conflicts of interest: No potential conflict of interest relevant to this article was
reported.
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