Feeding Disorders

Misconceptions

1. A child will eat when hungry.

It is extremely stressful for a parent when their child does not eat, because their primary job is to ensure the wellbeing of their children. Many children with feeding disorders will starve themselves to a degree that will put their health in jeopardy.

Most medical professionals do not understand these types of issues because the common perception is that a child will eventually get hungry and eat. Sometimes, the advice given to parents is to not worry about intake because the situation will resolve itself. No parent will put their child in that position just to see what happens.

Not being understood by medical professionals can lead to extreme frustration because a solution cannot be attained.

2. A child will let you know when they are hungry.

Many children with feeding disorders show no signs of hunger; they don’t ask or cry for food. This is fairly counterintuitive for most parents.

Complete Food Refusal

baby not eatingThere are different types of feeding/eating disorders in children. The most obvious problem is when kids don’t eat or drink enough. This can cause extreme weight loss and dehydration among other issues.

Many of these kids fail to show signs of hunger and will go without food or drink for long periods of time if given the choice.

When left untreated, many of these children receive feeding tubes in the nose (a nasogastric, or NG-Tube, which is non-permanent) or in the stomach (a gastric, or G-Tube, which is more permanent). Typically, formula is passed through these tubes to supply the necessary nutrition for adequate weight gain and hydration.

Picky Eating

food-refusal-vegetablesThere are children who will only eat certain food groups such as starches or fruits. Some will only eat foods with certain colors. Others consume foods with particular textures.

Although picky eating is common in young children, kids with feeding disorders may eliminate entire food groups or eliminate all but two or three different foods that they are willing to eat. Some will only drink water or eat goldfish crackers. This can cause severe malnutrition or weight loss.

Sometimes these toddlers, children, or adolescents have a combination of not eating enough and being picky. Some toddlers will take only a small amount of crackers or other soft foods that dissolve easily in the mouth, or drink only tiny amounts of water. It is often difficult to classify a child as a picky eater because they often do not eat enough as well. It is more useful to categorize only by volumes consumed, types of foods consumed, and refusal behaviors exhibited during mealtimes.

Not Drinking Enough

Sometimes, children have problems related to only drinking. Problems with drinking can lead to dehydration or malnutrition.

Some children will only drink water. These children may not be eating any meaningful volume of food. In babies and toddlers, this can lead to malnutrition because drinking only water precludes the drinking of formula-based drinks and/or breast milk, which have nutrition and calories.

Other children will eat meaningful amounts of food, but will not drink any liquids. This is commonly referred to as adypsia. This drinking disorder can lead to dehydration.

Sleep Feeding / Dream Feeding

Sleep feedingSome babies refuse their bottle or will only drink in their sleep. They will not take any food or drink while awake.

When they become hungry, these infants will cry in order to be rocked to sleep. Once asleep, they drink from a bottle or breastfeed.

It can be very taxing on parents to spend so much time getting their child to sleep and to constantly be feeding small amounts of liquid at a time.

Sleep feeding becomes a more significant problem when a baby reaches the age of 6–8 months, when some calories need to come from solids. This can cause a lower intake of calories and the possible omission of necessary nutrition, which comes from solid foods.

Vomiting and Gagging

Gagging while eatingMany children with feeding issues gag and vomit their food out, causing very low levels of food being ingested.

This may result in picky eaters or children who completely refuse to eat.

It is also common among children with feeding tubes. In many cases, when environmental causes are eliminated, so too goes the vomiting.

Dealing with vomiting is not only important from a poor intake perspective, but also because the stomach acid that comes up can irritate or scar the lining of the esophagus.

Packing (sometimes known as Pocketing or Squirreling)

packing, pocketing, or squirreling foodPacking is said to occur when food is held in the mouth for more than 30 seconds without being swallowed after a bite has been placed. This is considered by most experts to be the most difficult feeding disorder to treat. Packing can lead to chronic expelling, vomiting, and extremely low intake. It often occurs in children who have had NG tube placements or prolonged G tube usage, but can also occur without any prior feeding tube placement.

Chronic Expelling of Food and Drink

baby spits out foodExpelling occurs when you place a bite into your child’s or toddler’s mouth, and the child spits out the bite. When spitting food out occurs throughout the meal at every meal throughout the day, it can lead to long meals, lasting 1–3 hours each several times every day.

This can be extremely frustrating for anyone feeding the baby or toddler. Chronic expelling also usually leads to poor intake.

Refusal to Eat Solids

Food refusalSome babies will only take formula. They turn their head, shut their mouth, cry, and bat at the spoon at the sight of solid foods. As mentioned in “Sleep Feeding / Dream Feeding,” at a certain age, babies cannot get all the calories needed from formula or breast milk alone.

In severe cases, these babies or children will drink large amounts of water, but drink or eat little or nothing else.

Toddlers and Children Eating Food and Drinking from Inefficient Utensils or Syringes

Syringe feeding babySome toddlers will only take food or drink from a syringe, which is extremely inefficient due to the long duration of time necessary to get volumes in.

Children may not learn self-feeding or eating food with a thicker texture. To feed with a syringe, the parent or caregiver must put the syringe in the child’s mouth and squeeze out the food or drink. This process stops the child from learning to suck independently. Furthermore, thick textures of food cannot be fed through a syringe, because the syringe will get clogged with food.

These children don’t learn to take food from more appropriate utensils, such as a spoon or cup, because they are not exposed to such utensils.

Texture Selectivity

There are other children who can’t or won’t chew, or who do not eat age-appropriate foods. They typically will eat only mashed or pureed foods. If given normal textures, they may spit the food out or swallow it whole, which can be a choking hazard.

Having to provide food with the correct texture may limit what and where your family can eat. Sometimes, eating in a restaurant or going on vacation can be extremely difficult. The stress of dealing with severe feeding issues can put a strain on the entire family.

Bottle Dependency

bottle dependencySome toddlers or children will only drink or eat from a bottle. This usually entails blending food into a liquid or smoothie form. Some children, as old as 7, will only take nutrition and caloric intake from a bottle. While the consequences are not as severe as using a syringe, it can lead to alienation from other children because it is not an age-appropriate device to consume food. Furthermore, these children do not progress to table-texture foods.

Implications of Feeding Tube Dependency

feeding-tube-dependent-childThere has been much anecdotal evidence to show that children and babies who receive their feedings by tube have global developmental delays. They are slower to talk, crawl, walk, and socialize well among other key developmental delays.

Children, toddlers, and babies may also change physically, such as not growing, changes in hair color and thin hair, and an unhealthy skin tone. This is one of the many obvious downsides to tube feeding.

Other downsides include surgical complications, huge increases in vomiting, increased susceptibility to illness, decreases in the amount of food they will take by mouth, increase of mucous and phlegm, and tube site maintenance, among other issues.

Imagine yourself drinking only Gatorade and Ensure all day. Or imagine hardly consuming anything. How do you think you would feel mentally or physically? How much energy would you have? How focused do you think you would be? How do you think you would perform at any given task?

Importance of Feeding Tube Prevention

ng-tube2It is important to exhaust all avenues before resorting to a tube placement, whether an NG-Tube or G-Tube (unless your child is not safe to eat by mouth).

It is much easier to work with a child without an NG-Tube or G-Tube placement.

Beyond the many issues with tube placement mentioned in the “Implications of Feeding Tube Dependency” section, there is also the issue of putting a child through anesthesia and a surgical procedure.

There are some feeding therapists/specialists who will recommend a feeding tube. This is unethical unless the child is unsafe to eat by mouth.

If a feeding therapist cannot make progress with the child, the feeding therapist should notify the parents before tube placement becomes imminent.

The feeding therapist should state that they do not have an answer for the ongoing feeding problem, and to try a different therapist, clinic, or approach. There is nothing wrong with saying, “I don’t know.” On the other hand, there is a huge ethical problem when the feeding specialist does not know how to deal with a particular feeding issue, and does not convey this to the parents.

When your child has a feeding problem, time is never on your side. Always make sure to demand competence from your feeding clinic or feeding therapist/specialist.

Causes of Feeding Disorders

Causes of Food Refusal

It is often difficult to determine the cause of feeding disorders unless the cause is medical in nature. This makes it imperative to resolve medical issues prior to any feeding therapy.

Many times, even though medical issues have been resolved, the feeding issues still persist. At this point, feeding therapy is required.

Issues that Arise from Feeding Disorders

Low weight is the first of many problems when a child does not consume the proper variety and volumes of food. Low weight can lead to various health and developmental issues.

Sometimes, a feeding tube is placed to help the child gain more weight. This can exacerbate the problem of not eating by mouth, but ultimately there is no choice because the health of the child is at stake.

Types of Feeding Issues:

  1. Bottle refusal
  2. Food refusal
  3. Dream feeding (drinking from bottle only while asleep)
  4. Picky eating
  5. Texture selective

Each child is unique and exhibits different behaviors during mealtimes. For instance, one child who refuses the bottle might turn their head from side to side, while another child might cry or gag repeatedly. It is important to asses which behaviors are impeding your child’s proper intake in order to devise a feeding protocol that will address the feeding issue.

Components of Feeding Issues:

  1. Head turns
  2. Vomiting
  3. Crying
  4. Expressing negative descriptions about food
  5. Spitting food out
  6. Holding food in mouth without swallowing
  7. Holding liquid in mouth without swallowing
  8. Refusing to sit in a high chair or at the table

Often, the specific behaviors that need to occur are not occurring. These eating behaviors need to be taught to ensure that the proper intake is achieved in an efficient manner.

Required Behaviors for Proper Intake:

Feeding behaviors

  1. Sufficiently wide mouth openings
  2. Swallowing
  3. Chewing

Once the interfering behaviors are eliminated and the needed behaviors are trained, the volume intake increases, variety increases, and mealtime durations become adequate. These lead to a healthy child and, of course, a happy parent.