Pediatric Feeding Disorders Research Articles

Network analysis of pediatric eating disorder symptoms in a treatment-seeking, transdiagnostic sample.

Classifying eating disorders in youth is challenging in light of developmental considerations and high rates of diagnostic migration. Understanding the transactional relationships among eating disorder symptoms, both across the transdiagnostic spectrum and within specific diagnostic categories, may clarify which core eating disorder symptoms contribute to, and maintain, eating-related psychopathology in youth. We utilized network analysis to investigate interrelationships among eating disorder symptoms in 636 treatment-seeking children and adolescents (90.3% female) ages 6-18 years (M age = 15.4 ± 2.2). An undirected, weighted network of eating disorder symptoms was created using behavioral and attitudinal items from the Eating Disorder Examination. Across diagnostic groups, symptoms reflecting appearance-related concerns (e.g., dissatisfaction with shape and weight) and dietary restraint (e.g., a desire to have an empty stomach) were most strongly associated with other eating disorder symptoms in the network. Binge eating and compensatory behaviors (e.g., self-induced vomiting) were strongly connected to one another but not to other symptoms in the network. Network connectivity was similar across anorexia nervosa, bulimia nervosa, and otherwise specified feeding or eating disorder subgroups. Among treatment-seeking children and adolescents, dietary restraint and shape- and weight-related concerns appear to play key roles in the psychopathology of eating disorders, supporting cognitive-behavioral theories of onset and maintenance. Similarities across diagnostic categories provide support for a transdiagnostic classification scheme. Clinical interventions should seek to disrupt these symptoms early in treatment to achieve maximal outcomes. (PsycINFO Database Record

The Participation of Mothers, Fathers, and Siblings in Family-Based Treatment for Adolescent Anorexia Nervosa

In family-based treatment (FBT) for adolescent anorexia nervosa, all family members are encouraged to attend sessions with the understanding that absences negatively impact treatment. There are, however, many obstacles to family members’ attendance, and there is no research to indicate whether family member attendance improves treatment outcomes. We examined attendance patterns of 198 families who participated in FBT at a specialist pediatric eating disorders program and assessed the extent to which participation by mothers (n = 194), fathers (n = 175), and siblings (n = 165; 50% female) predicted outcome. All mothers attended at least one session, and 74% attended all sessions. By comparison, 95% of fathers and 73% of siblings attended at least one session, and 33% of fathers and 1% of siblings attended all sessions. The mean proportion of sessions attended was 94% for mothers, 72% for fathers, and 20% for siblings. Over 6 months of treatment, the proportion of mothers who attended each session was largely stable; fathers’ attendance declined slowly, and siblings’ attendance declined more rapidly. Greater attendance by fathers predicted higher weight and lower eating disorder symptoms in adolescents at end of treatment. Remission at end of treatment was associated with higher attendance by fathers (M = 81% vs. M = 69%). Achieving sustained engagement of the whole family system in FBT is a considerable challenge. However, this study demonstrates that implementing processes that encourage and enable family members to attend treatment sessions could have significant benefits for patient outcomes.

Synthesis of Applied Behavior Analytic Interventions for Packing in Pediatric Feeding Disorders.

Packing, which consists of holding food in the mouth for an extended time during meals, is a form of disordered feeding associated with pediatric feeding disorders. The behavior can disrupt the pace and completion of a meal and lead to increased risk of choking, inadequate food and liquid intake, and elevated caregiver stress associated with mealtimes. Applied behavior analysis research has developed and evaluated behavioral interventions to improve feeding by reducing packing. This systematic review extends prior research by synthesizing characteristics of the packing intervention literature, evaluating the certainty of the evidence provided by studies, identifying potential directions for future research, and discussing the results in the context of evidence-based practice.

Feeding Disorders.

Feeding disorders often present in children with complex medical histories as well as those with neurodevelopmental disabilities. If untreated, feeding problems will likely persist and may lead to additional developmental and medical complications. Treatment of pediatric feeding disorders should involve an interdisciplinary team, but the core intervention should include behavioral feeding techniques as they are the only empirically supported therapy for feeding disorders.

Successful pharmacotherapy for the treatment of severe feeding aversion with mechanistic insights from cross-species neuronal remodeling

Pediatric feeding disorders affect up to 5% of children, causing severe food intake problems that can result in serious medical and developmental outcomes. Behavioral intervention (BI) is effective in extinguishing feeding aversions, and also expert-dependent, time/labor-intensive and not well understood at a neurobiological level. Here we first conducted a double-blind, placebo-controlled trial comparing BI with BI plus d-cycloserine (DCS). DCS is a partial N-methyl-d-aspartate (NMDA) receptor agonist shown to augment extinction therapies in multiple anxiety disorders. We examined whether DCS enhanced extinction of feeding aversion in 15 children with avoidant/restrictive food intake disorder (ages 20–58 months). After five treatment days, BI improved feeding by 37%. By contrast, BI+DCS improved feeding by 76%. To gain insight into possible mechanisms of successful intervention, we next tested the neurobiological consequences of DCS in a murine model of feeding aversion and avoidance. In mice with conditioned food aversion, DCS enhanced avoidance extinction across a broad dose range. Confocal fluorescence microscopy and three-dimensional neuronal reconstruction indicated that DCS enlarged dendritic spine heads—the primary sites of excitatory plasticity in the brain—within the orbitofrontal prefrontal cortex, a sensory-cognition integration hub. DCS also increased phosphorylation of the plasticity-associated extracellular signal-regulated kinase 1/2. In summary, DCS successfully augments the extinction of food aversion in children and mice, an effect that may involve plasticity in the orbitofrontal cortex. These results warrant a larger-scale efficacy study of DCS for the treatment of pediatric feeding disorders and further investigations of neural mechanisms.

Pediatric Feeding Disorders and Severe Developmental Disabilities.

Children with severe developmental disabilities face numerous challenges to function and participate in activities of daily life. One of the most significant challenges to accomplishing this goal is that of oral feeding disorders. Indeed, it is estimated that among children with developmental disabilities, up to 80 to 90% present with some level of feeding disorders. In addition, it has been shown that as the level of severity of intellectual disability increases, so does the severity of the oral feeding disorders. Due to the broad range of etiologies that result in developmental disabilities, types of feeding disorders in the population vary greatly. This article is designed to provide information regarding assessment and intervention approaches currently used in this area and to provide an overview of the evidence available to support these approaches. Suggestions for much needed future clinically relevant and immediately transferable research are included.

An evaluation of a caregiver training protocol on the generalization and maintenance of successful pediatric feeding interventions

Previous researchers have documented the positive effects achieved by trained clinicians providing behavioral interventions for pediatric feeding disorders; however, few have evaluated the maintenance of those treatments when subsequently implemented by primary caregivers. Further, the majority of previous caregiver training research has relied on the use of multicomponent training packages making it difficult to determine which components are necessary for success. The purpose of the current investigation was to evaluate the effects of instructions and feedback on caregivers' implementation of feeding protocols in a home setting. Results of the current study suggest that feedback may be the most effective training component in training packages designed to teach caregivers to implement an effective feeding protocol. Potential concomitant changes in child behavior are also discussed.

From questions to answers: Examining the role of pediatric surveillance units in eating disorder research.

Pediatric Surveillance Units (PSUs) provide a unique model for the study of pediatric eating disorders (EDs). Australia, Britain, and Canada have surveillance programs that have generated valuable epidemiological and clinical data on early-onset eating disorders (EOED). The PSUs represent an important collaborative tool that has helped shape our understanding of EOEDs and offers potential to contribute to decisions regarding health resource allocation and public health policy. This paper reviews the role of PSUs as a unique model to study pediatric EDs and its success in translating the knowledge generated by these programs into improving the health of children and adolescents with EDs worldwide.

Acceptability and tolerability of omega-3 fatty acids as adjunctive treatment for children and adolescents with eating disorders

ABSTRACTThe objective of this study was to examine the acceptability and tolerability of omega-3 fatty acids as an adjunctive treatment for children and adolescents with eating disorders (EDs). Children and adolescents with EDs received omega-3 supplements (300 mg eicosapentaenoic acid [EPA] and 200 mg docosahexaenoic acid [DHA]/day) in addition to standard treatment for 8 weeks. Primary outcomes were dropout rate, compliance, and side effects. Secondary outcomes included percent ideal body weight, Eating Disorders Inventory-3 (EDI-3), Children’s Depression Inventory-2 (CDI-2), and Multidimensional Anxiety Scale for Children (MASC). There were 21 participants with mean age of 15.29 ± 2.0 years. There were no dropouts. Omega-3 was well tolerated by all participants. Compared to baseline, at week 8 there was a significant increase in mean percent ideal body weight but no significant difference in scores on the EDI-3, CDI-2, and MASC. We conclude that omega-3 supplements are acceptable and well tolerated in the pediatric ED population.

Children of parents with BED have more eating behavior disturbance than children of parents with obesity or healthy weight.

A limited literature suggests an association between parental eating disorders and child eating-disorder behaviors although this research has focused primarily on restrictive-type eating disorders and very little is known about families with binge-eating disorder (BED). The current study focused on parents (N = 331; 103 fathers and 226 mothers), comparing parents with core features of BED (n = 63) to parents with obesity and no eating disorder (OB; n = 85) and parents with healthy-weight and no eating disorder (HW; n = 183). Parents with BED were significantly more likely than OB and HW parents to report child binge eating, and more likely than HW parents to report child overeating. Parents with BED felt greater responsibility for child feeding than OB parents, and felt more concern about their child's weight than OB and HW parents. Dietary restriction of the child by the parents was related to child binge eating, overeating, and child overweight, and parental group was related to child binge eating (parental BED), overeating (parental BED), and child weight (parental OB). Parents with BED report greater disturbance in their children's eating than OB and HW parents, and OB parents report higher child weight than HW parents. This suggests that it is important to consider both eating-disorder psychopathology and obesity in clinical interventions and research. Our cross-sectional findings, which require experimental and prospective confirmations, provide preliminary evidence suggesting potential factors in families with parental BED and obesity to address in treatment and prevention efforts for pediatric eating disorders and obesity. © 2016 Wiley Periodicals, Inc.(Int J Eat Disord 2017; 50:648-656).

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

To assess models of care and conduct a meta-analysis of program outcomes for children receiving intensive, multidisciplinary intervention for pediatric feeding disorders. We searched Medline, PsycINFO, and PubMed databases (2000-2015) in peer-reviewed journals for studies that examined the treatment of children with chronic food refusal receiving intervention at day treatment or inpatient hospital programs. Inclusion criteria required the presentation of quantitative data on food consumption, feeding behavior, and/or growth status before and after intervention. Effect size estimates were calculated based on a meta-analysis of proportions. The systematic search yielded 11 studies involving 593 patients. Nine articles presented outcomes based on retrospective (nonrandomized) chart reviews; 2 studies involved randomized controlled trials. All samples involved children with complex medical and/or developmental histories who displayed persistent feeding concerns requiring formula supplementation. Behavioral intervention and tube weaning represented the most common treatment approaches. Core disciplines overseeing care included psychology, nutrition, medicine, and speech-language pathology/occupational therapy. The overall effect size for percentage of patients successfully weaned from tube feeding was 71% (95% CI 54%-83%). Treatment gains endured following discharge, with 80% of patients (95% CI 66%-89%) weaned from tube feeding at last follow-up. Treatment also was associated with increased oral intake, improved mealtime behaviors, and reduced parenting stress. Results indicate intensive, multidisciplinary treatment holds benefits for children with severe feeding difficulties. Future research must address key methodological limitations to the extant literature, including improved measurement, more comprehensive case definitions, and standardization/examination of treatment approach.

Feeding problems in infancy and early childhood: evolutionary concept analysis.

The aim of this study was to report an analysis of the concept of pediatric feeding problems. Reviews of the literature on pediatric feeding problems and disorders repeatedly reference the lack of a shared conceptualization of feeding problems. It is difficult to track aetiology, prevalence and incidence of a phenomenon when available definitions and diagnoses lack practical utility. An evolutionary concept analysis. A search was conducted in October 2014 of Google Scholar, CINAHL, PubMed and Web of Science databases, with MeSH terms and key words including: failure to thrive, feeding disorder/difficulty/problems, infantile anorexia, oral aversion, mealtime behaviour and dysphagia. Inclusion criteria were: subject of feeding problems, index children 0-10years of age, English language and full text. The articles (n=266) were sorted into disciplines of authorship, including Psychology, Medicine, Nursing, Nutrition, Occupational Therapy, Speech Language Pathology or Other. The sample was divided into a historical sample (n=42) for pre-2000 articles and current for those published post-2000. The current sample was later reduced to 100 and coded for surrogate terms, related concepts, attributes, antecedents and consequences. The historical view of pediatric feeding problems shows a tradition of mother blame or parental culpability, both direct and indirect. Currently, there exist many different definitions and typologies, but none have sound validity or generalizability. Areas of attribute consensus across disciplines are problematic feeding behaviours and selective or restrictive intake. A spectrum conceptualization of feeding problems is suggested for further development, with attributes that would be critical to have a feeding problem.

A comparison of a modified sequential oral sensory approach to an applied behavior-analytic approach in the treatment of food selectivity in children with autism spectrum disorder.

Treatments of pediatric feeding disorders based on applied behavior analysis (ABA) have the most empirical support in the research literature (Volkert & Piazza, 2012); however, professionals often recommend, and caregivers often use, treatments that have limited empirical support. In the current investigation, we compared a modified sequential oral sensory approach (M-SOS; Benson, Parke, Gannon, & Muñoz, 2013) to an ABA approach for the treatment of the food selectivity of 6 children with autism. We randomly assigned 3 children to ABA and 3 children to M-SOS and compared the effects of treatment in a multiple baseline design across novel, healthy target foods. We used a multielement design to assess treatment generalization. Consumption of target foods increased for children who received ABA, but not for children who received M-SOS. We subsequently implemented ABA with the children for whom M-SOS was not effective and observed a potential treatment generalization effect during ABA when M-SOS preceded ABA.

Intensive, Manual-based Intervention for Pediatric Feeding Disorders: Results From a Randomized Pilot Trial.

The aim of this pilot study was to investigate feasibility and preliminary efficacy of an intensive, manual-based behavioral feeding intervention for children with chronic food refusal and dependence on enteral feeding or oral nutritional formula supplementation. Twenty children ages 13 to 72 months (12 boys and 8 girls) meeting criteria for avoidant/restrictive food intake disorder were randomly assigned to receive treatment for 5 consecutive days in a day treatment program (n = 10) or waitlist (n = 10). A team of trained therapists implemented treatment under the guidance of a multidisciplinary team. Parent training was delivered to support generalization of treatment gains. We tracked parental attrition and attendance, as well as therapist fidelity. Primary outcome measures were bite acceptance, disruptions, and grams consumed during meals. Caregivers reported high satisfaction and acceptability of the intervention. Three participants (1 intervention; 2 waitlist) dropped out of the study before endpoint. Of the expected 140 treatment meals for the intervention group, 137 (97.8%) were actually attended. The intervention group showed significantly greater improvements (P < 0.05) on all primary outcome measures (d = 1.03-2.11) compared with waitlist (d = -1.13-0.24). A 1-month follow-up suggested stability in treatment gains. Results from this pilot study corroborate evidence from single-subject and nonrandomized studies on the positive effects of behavioral intervention. Findings support the feasibility and preliminary efficacy of this manual-based approach to intervention. These results warrant a large-scale randomized trial to test the safety and efficacy of this intervention.

A Little PEP Goes a Long Way in the Treatment of Pediatric Feeding Disorders

Feeding disorder in young children is a growing concern, particularly feeding challenges with sensory and/or behavioral underpinning. These feeding disorders are characterized by food refusal, anxiety when presented with novel foods, failure to advance to textured foods, and inappropriate mealtime behaviors. The Positive Eating Program (PEP) was developed to remediate feeding disorders by providing rich experiences in food vocabulary, positive sensory nonfood and food activities, and structured and predictable through trials.

The Impact of Emerging Liquid Preference in the Treatment of Liquid Refusal

Treatment of liquid refusal in pediatric feeding disorders is essential for decreasing tube dependence, alleviating some medical conditions (e.g., constipation), and increasing caloric and nutritional intake (e.g., formulas). Although investigators have conducted edible preference assessments for solids, there are no studies to our knowledge in which investigators have evaluated liquid preference prior to and during treatment of liquid refusal. In the current study, we evaluated liquid preferences repeatedly over time during behavioral treatment for liquid refusal. Although none of the children demonstrated a preference for liquids during a paired-choice preference assessment, 2 of the 3 children showed a preference when we implemented an avoidance component. However, for all 3 children, latency to acceptance and inappropriate mealtime behavior decreased for liquids during behavioral treatment with undifferentiated responding between liquid types. Future research may evaluate the utility and correlation of liquid preference assessments preceding treatment for liquid refusal.

Conceptualizing Pediatric Feeding Disorder from an Anxiety Disorders Perspective

Conceptualizing Pediatric Feeding Disorder from an Anxiety Disorders Perspective

Eating disorder examination: Factor structure and norms in a clinical female pediatric eating disorder sample.

The factor structure of the eating disorder examination (EDE) has never been tested in a clinical pediatric sample, and no normative data exist. The factor structure of an adapted EDE was examined in a clinical sample of 665 females aged 9-17 years with anorexia nervosa spectrum (70%), bulimia nervosa spectrum (12%), purging disorder (3%), and unspecified feeding and eating disorders (15%). The original four-factor model was a good fit in a confirmatory factor analysis as well a higher order model with three dimensions of restraint, eating concern, and combined weight concern/shape concern. Normative data are reported for clinicians to identify the percentiles in which their patients' score. The findings support dimensions of restraint, eating concern, weight concern, and shape concern in a clinical pediatric sample. This supports the factorial validity of the EDE, and the norms may assist clinicians to evaluate symptoms in females under 18 years.

Current findings in pediatric non organic feeding disorders (nofeds): the gastroenterologist point of view

The process of taking in and swallowing food or drink involves three linked anatomical and physiological regions connected to each other both anatomically and neurologically. The non-nutritive suck is first seen in the fetus between 18 and 24 weeks. The second type of suck is the nutritive or “active feeding suck”, which is more mature and complex and is designed to deal with fluid. It is estimated that non-organic feeding disorders (NOFEDs) occur in 25% of healthy infants and 80% of young children with developmental disability [1]. Furthermore, infants born preterm and/or with a birth weight below the 10th percentile for gestational age are at high risk for developing NOFEDs. This implies that feeding disorders could be related to intrauterine growth retardation [2]. About 20-60% of parents report that their children are not eating optimally, that is, that they are picky, have food phobia, eat too little and have weight loss [3]. Several studies have suggested that only 16-30% of feeding disorders are organic and that up to 80% of cases referred to specialist pediatric services have a significant behavioral component [4]. NOFED is a formal diagnostic term used to indicate a condition in children younger than 6 years of age. It usually presents as food refusal, aversion to feeding, selective eating, low food intake or failure to thrive [5]. NOFEDs often result from multifactorial etiologies and the classification of disorders based on an organic versus non-organic dichotomy fails to provide a system that can represent the often complex interactions between medical problems, the family system and behavioral difficulties associated with feeding disorders. Some classifications are simplistic and do not help differentiate between NOFEDs and organic disorders, whereas others do not have a single set of criteria for diagnosis. The most serious complication of NOFEDs is failure to thrive (FTT) which requires a medical or nutritional approach (Figure 1). There is often confusion, misdiagnosis and under-diagnosis with regard to NOFED and the patient is often initially diagnosed with another medical condition [6]. Differential diagnosis can include gastroesophageal reflux disease (GERD), food allergy or swallowing disorders [7]. Medical assessment should include family, social, feeding, past and current medical histories and a complete physical examination. It is necessary to emphasize the difficulties in recognizing NOFED by primary care physicians. FTT is present in 40-50% of NOFED patients correlated with a delayed diagnosis.

Escape Extinction and Negative Reinforcement in the Treatment of Pediatric Feeding Disorders: a Single Case Analysis.

Pediatric feeding disorders are common among children with developmental disabilities and can have detrimental effects on growth and development. An escape extinction and negative reinforcement-based approach to treating food refusal was examined in a child with cerebral palsy. A changing criterion treatment design was implemented, which allowed the child to exit the treatment area contingent upon the acceptance and ingestion of a pre-determined number of bites. Food acceptance ranged from one to three bites at baseline and exceeded the pre-set criteria for mastery, at 14 bites during the final intervention phase.The study will contribute to the current literature on negative reinforcement procedures used in the treatment of pediatric feeding problems.The study will contribute to increasing the availability of literature pertaining to pediatric feeding problems among children with complex disabilities such as cerebral palsy.The intervention is brief with components to the treatment package which increases utility and ease of implementation.The study demonstrates the applicability of changing criterion design within clinical settings.