Pediatric Feeding Disorders Research Articles

A time and cost analysis of speech pathology paediatric feeding services delivered in-person versus via telepractice

Introduction Telepractice models of care have the potential to reduce the time and financial burdens that consumers may experience accessing healthcare services. The current study aimed to conduct a time and financial cost analysis of paediatric feeding appointments accessed via telepractice (using videoconferencing) compared to an in-person model. Methods Parents of 44 children with paediatric feeding disorders (PFDs) residing in a metropolitan area completed three questionnaires relating to (a) demographics, (b) time and cost for in-person care and (c) time and cost for telepractice. Both cost questionnaires collected data required for direct and indirect costs comparisons (e.g. out-of-pocket costs associated with the appointment (direct), time away from usual duties (indirect)). Average number of services accessed by each participant, and PFD appointments conducted annually by the service, were collected from service statistics. Analysis involved cost minimisation and cost modelling from a societal perspective. Results The telepractice appointment resulted in significant time (p = 0.007) and cost (AUD$95.09 per appointment, SD = AUD$64.47, p = < 0.0001) savings per family. The health service cost was equivalent for both models (AUD$58.25). Cost modelling identified cost savings of up to AUD$475.45 per family if 50% of appointments in a 10-session block were converted to telepractice. Potential cost savings of AUD$68,750.07 per annum to society could be realised if 50% of feeding appointments within the service were provided via telepractice. Discussion The telepractice model offered both time and cost benefits. Future service re-design incorporating hybrid services (in-person and telepractice) will help optimise benefits and minimise burden for families accessing services for PFDs.

Feeding disorders in children with oesophageal atresia: a cross-sectional study

IntroductionWith advances in surgical and neonatal care, the survival of patients with oesophageal atresia (OA) has improved over time. Whereas a number of OA-related conditions (delayed primary anastomosis, anastomotic stricture...

Adapting and adopting highly specialized pediatric eating disorder treatment to virtual care: a protocol for an implementation study in the COVID-19 context

BackgroundThe COVID-19 pandemic has negatively impacted individuals with eating disorders; resulting in increased symptoms, as well as feelings of isolation and anxiety. To conform with social distancing requirements, outpatient eating disorder treatment in Canada is being delivered virtually, but a lack of direction surrounding this change creates challenges for practitioners, patients, and families. As a result, there is an urgent need to not only adapt evidence-based care, including family-based treatment (FBT), to virtual formats, but to study its implementation in eating disorder programs. We propose to study the initial adaptation and adoption of virtual family-based treatment (vFBT) with the ultimate goal of improving access to services for youth with eating disorders.MethodsWe will use a multi-site case study with a mixed method pre/post design to examine the impact of our implementation approach across four pediatric eating disorder programs. We will develop implementation teams at each site (consisting of therapists, medical practitioners, and program administrators), provide a remote training workshop on vFBT, and offer ongoing consultation during the initial implementation phase. Therapists will submit videorecordings of their first four vFBT sessions. We propose to study our implementation approach by examining (1) whether the key components of standard FBT are maintained in virtual delivery measured by therapist self-report, (2) fidelity to our vFBT model measured by expert fidelity rating of submitted videorecordings of the first four sessions of vFBT, (3) team and patient/family experiences with vFBT assessed with qualitative interviews, and (4) patient outcomes measured by weight and binge/purge frequency reported by therapists.DiscussionTo our knowledge, this is the first study to evaluate an implementation strategy for virtually delivered FBT for eating disorders. Challenges to date include confirming site participation and obtaining ethics approval at all locations. This research is imperative to inform the delivery of vFBT in the COVID-19 context. It also has implications for delivery in a post-pandemic era where virtual services may be preferable to patients and families living in remote locations, where access to specialized services is extremely limited.Trial registrationClinicalTrials.gov NCT04678843, registered on December 21, 2020.

A comparison of function‐ and nonfunction‐based extinction treatments for inappropriate mealtime behavior

Previous literature supports the use of functional analyses to prescribe treatments for children with feeding disorders (Bachmeyer et al., 2009). Nevertheless, clinicians often train caregivers to use healthy contingencies, independent of whether those contingencies are function based. However, it is unclear whether including nonfunction-based contingencies differentially affects inappropriate mealtime behavior. In the current investigation, the caregivers of 3 children with feeding disorders provided escape from bites and drinks and attention following inappropriate mealtime behavior. Results of a functional analysis showed escape from bites or drinks, but not attention, reinforced inappropriate mealtime behavior. We then tested the effects of escape extinction when the feeder either provided or withheld attention following inappropriate mealtime behavior. Inappropriate mealtime behavior decreased and acceptance increased when the feeder implemented escape extinction independent of whether they provided or withheld attention. We discuss the implications of including nonfunction-based components in the treatment of pediatric feeding disorders.

Autism spectrum disorder and anorexia nervosa: an Italian prospective study

BackgroundPotential overlaps exist between psychopathological features of Anorexia Nervosa (AN) and Autism Spectrum Disorder (ASD). The impact of malnutrition on autistic traits in patients with AN should be considered. This study investigates possible associations among the psychopathology of Eating Disorders (EDs), ASD traits and BMI in a group of young patients with AN, using the EDI-3 (Eating Disorder Inventory-3) test and gold-standard measures for ASD.MethodsProspective study involving 23 inpatients admitted to an Italian Centre for paediatric ED. ASD traits and ED psychopathology were assessed administering the ADOS-2 (Autism Diagnostic Observation Schedule-2), AQ (Autism Quotient) and EDI-3 tests. Both present and past autistic traits were investigated using different versions of AQ. Correlations were adjusted for BMI, Obsessive Compulsive Disorder (OCD) comorbidity and concurrent antipsychotic treatments.ResultsAn ASD diagnosis was possible in 22% of patients. Significant correlations were documented between ASD traits and ED psychopathology: AQ total-Interpersonal problems (IPC) (p = 0.041); AQ total-Global psychological maladjustment (GMPC) (p = 0.027); AQ social skills-Ineffectiveness (IC) (p = 0.018); AQ social skills-IPC (p = 0.019); AQ social skills-Affective problems (APC) (p = 0.025); AQ social skills-GMPC (p = 0.007); AQ attention switching-IPC (p = 0.020); ADOS-2 imagination-IC (p = 0.035). These correlations were independent of BMI, OCD and antipsychotic treatments.ConclusionsASD traits presented high prevalence in a group of young inpatients with AN. These traits were significantly correlated to 4 specific EDI-3 subscales and independent of BMI. This is the first study to investigate the relationship between ASD traits as measured with gold-standard measures, EDI-3 scores, and BMI.

Applied Methods for Estimating Transition Probabilities from Electronic Health Record Data.

Electronic health record (EHR) data contain longitudinal patient information and standardized diagnostic codes. EHR data may be useful for estimating transition probabilities for state-transition models, but no guidelines exist on appropriate methods. We applied 3 potential methods to estimate transition probabilities from EHR data, using pediatric eating disorders (EDs) as a case study. We obtained EHR data from PEDsnet, which includes 8 US children's hospitals. Data included inpatient, outpatient, and emergency department visits for all patients with an ED. We mapped diagnoses to 3 ED health states: anorexia nervosa, bulimia nervosa, and other specified feeding or eating disorder. We estimated 1-y transition probabilities for males and females using 3 approaches: simple first-last proportions, a multistate Markov (MSM) model, and independent survival models. Transition probability estimates varied widely between approaches. The first-last proportion approach estimated higher probabilities of remaining in the same health state, while the MSM and independent survival approaches estimated higher probabilities of transitioning to a different health state. All estimates differed substantially from published literature. As a source of health state information, EHR data are incomplete and sometimes inaccurate. EHR data were especially challenging for EDs, limiting the estimation and interpretation of transition probabilities. The 3 approaches produced very different transition probability estimates. Estimates varied considerably from published literature and were rescaled and calibrated for use in a microsimulation model. Estimation of transition probabilities from EHR data may be more promising for diseases that are well documented in the EHR. Furthermore, clinicians and health systems should work to improve documentation of ED in the EHR. Further research is needed on methods for using EHR data to inform transition probabilities.

Home and Parent Training Strategies for Pediatric Feeding Disorders: The Caregivers’ Perspective

Background: Twenty to 45% of the general pediatric population experience feeding problems. When children with disabilities exhibit feeding problems, they are more likely to develop maladaptive mealtime behaviors that may lead to poor nutrition. Home training to help treat a child’s feeding delay or disorder is a vital component of feeding treatment and supports holistic, family-centered treatment models. It is important for occupational therapists working with this population to understand the impact of these behaviors on individual and family functioning. Method: This quantitative study examined caregivers’ perspectives of the training families receive to support their child’s feeding delay or disorder, and how family mealtimes may be affected. One hundred and eight participants completed an online survey using primarily Likert scale questions. Results: Caregivers report that (a) they are receiving current and evidenced-based interventions; (b) they feel supported, yet feel they need more support; (c) family relationships are adversely affected by a child’s feeding challenges; (d) caregivers desire to connect with other caregivers of children with feeding delays or disorders; and (e) they need stress management and coping strategies. Conclusion: Feeding treatment is strengthened with more family-focused topics like family relationships and interactions, caregiver burden and stress management, and increased caregiver support.

Engaging primary care providers in managing pediatric eating disorders: a mixed methods study

BackgroundThe primary care setting offers an attractive opportunity for, not only the identification of pediatric eating disorders, but also the delivery of evidence-based treatment. However, constraints of this setting pose barriers for implementing treatment. For interventions to be successful, they need to take into consideration the perspectives of stakeholders. As such, the purpose of this study was to examine in-depth primary care providers’ perspective of challenges to identifying and managing eating disorders in the primary care setting.MethodsThis mixed methods study surveyed 60 Pediatric and Family Medicine providers across 6 primary care practices. Sixteen of these providers were further interviewed using a qualitative, semi-structured interview.ResultsProviders (n = 60, response rate of 45%) acknowledged the potential of primary care as a point of contact for early identification and treatment of pediatric eating disorders. They also expressed that this was an area of need in their practices. They identified numerous barriers to successful implementation of evidence-based treatment in this setting including scarcity of time, knowledge, and resources.ConclusionsInvestigations seeking to build capacities in primary care settings to address eating disorders must address these barriers.

Using Mixed Methods Research to Better Understand Pediatric Feeding Disorder

PurposeMixed methods research is a relatively new, but growing, research methodology with particular relevance to speech-language pathologists because of its utility in translating research into practice. Mixed methods research involves collection of both qualitative and quantitative data, which is integrated to gain a deeper understanding of a research question, particular population or intervention, or to develop a tool. In particular, pediatric feeding disorder (PFD) research stands to benefit from this methodology to comprehensively and holistically report on this population.ConclusionsThis article focuses on introducing researchers new to mixed methods, as well as clinicians, to the four basic mixed methods study designs and considerations. To establish a foundational understanding, examples of published work specific to PFD are incorporated and a framework for understanding mixed method study design is proposed. Then, the four designs are examined from the lens of critical appraisal, so that clinicians and researchers are well prepared to critically evaluate mixed methods studies. Finally, applications of mixed methods to PFD are explored, with a commentary on how published examples could be extended using mixed methods designs. This article provides researchers and clinicians with a basic understanding of mixed methods as well as a clear avenue for its application to PFD. Mixed methods has the potential to advance our understanding of the heterogenous population PFD impacts, improve our use of interdisciplinary teams, examine holistic interventions, and develop tools for clinical and research use.

Long-term Outcomes of Children With Pediatric Feeding Disorders Treated in an Inpatient Multidisciplinary Program.

The purpose of this longitudinal observational study was to evaluate the effectiveness of a multidisciplinary inpatient treatment model for feeding disorders by analyzing long-term nutritional and health outcomes 12 months following discharge. Fifty patients completed the study. Average caloric intake by mouth as a percentage of goal for gastrostomy tube (GT)-dependent patients (n = 31) increased from pre-admit, week 1, and week 2 of the inpatient program (30%, 70%, and 84%, respectively), and was sustained from week 3 to 12-month follow-up (85% and 86%, respectively). Eighty-one percentage were discharged without GT support and 65% remained off GT support at 12 months. Oral supplement dependence for non-GT patients (n = 19) decreased from pre-admit, discharge, and 12-month follow-up (51%, 31%, and 19% of caloric intake, respectively). BMI z-scores improved during and after treatment. The present study demonstrated an effective approach for treatment of pediatric feeding disorders, including decreased reliance on oral supplementation and GT dependence.

Pediatric feeding disorders research—Special virtual issue

Pediatric feeding disorders research—Special virtual issue

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

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

A systematic review of food preference assessments for children with pediatric feeding disorders: A need for modifications and technological descriptions.

A systematic review of food preference assessments for children with pediatric feeding disorders: A need for modifications and technological descriptions.

Characteristics and Interventions in Pediatric Feeding Disorder with Neuromuscular Diseases

Characteristics and Interventions in Pediatric Feeding Disorder with Neuromuscular Diseases

Pediatric Feeding Disorder in Children With Short Bowel Syndrome.

We aimed to characterize the prevalence of pediatric feeding disorder (PFD) in short bowel syndrome (SBS) and study factors contributing to the persistence of PFD. Single-center retrospective study of patients diagnosed with SBS at age 6 months or younger. Data were collected in 3-month intervals through age 2 years, and every 6 months through age 4 years. Demographic information, anthropometric data, and details regarding nutrition support were recorded and analyzed. We reviewed 28 patients. Of the 21 patients who were weaned off parenteral nutrition, 57.1%, 81.0%, 90.5%, and 100.0% achieved this by 12, 24, 36, and 48 months of age, respectively. Of the 13 patients who were weaned off enteral nutrition, 30.8%, 69.2%, 76.9%, and 100.0% achieved this by 12, 24, 36, and 48 months, respectively. The prevalence of PFD was 100.0%, 76.5%, 68.8%, and 70.0% at 1, 2, 3, and 4 years of age, respectively. All patients who exhibited resolution of PFD had an underlying etiology of necrotizing enterocolitis. Median small bowel percentage remaining was greater in patients who exhibited resolution of PFD compared to those who did not. Except for the group of patients seen at 4 years of age, a larger percentage of patients with vomiting/history of requirement of postpyloric feeds were seen among patients with PFD compared to those without PFD. PFD is prevalent in children with SBS. Although prevalence decreases over time, children with PFD will continue to require more medical attention than children that do not.

Perceived Occupational Performance in Youth with Eating Disorders: Treatment-Related Changes.

This study examined changes in performance and satisfaction with self-identified occupational performance goals during a specialized day treatment admission in children and adolescents with eating disorders. Weight-related outcomes for underweight youth were also examined. A total of 63 youth participated in the study, with admission and discharge data on ratings of self-identified occupational performance goals (measured with the Canadian Occupational Performance Measure) available for 42 participants. Significant improvements were found in ratings of satisfaction and performance with self-identified goals over the course of treatment. The program was also effective in supporting weight restoration for underweight youth, with a large effect size observed. A symptom-focused day treatment program for paediatric eating disorders led to improvements in perceived occupational performance. Collaborating with youth to develop self-identified goals in the context of eating disorders treatment can foster autonomy and potentially improve treatment engagement.

Behavior-Analytic Treatment Progression for a Child With Tube Dependence: Reaching Age-Typical Feeding

The current case study outlines a behavior-analytic treatment progression for a child with a pediatric feeding disorder and tube dependence. The child participated in an intensive day-treatment program for 8 weeks where she transitioned from tube feedings to oral feedings. She successfully transitioned to a less intensive, telehealth outpatient model for follow-up care where she continued to progress to age-typical feeding. Following a systematic and gradual reduction in follow-up appointments, she consumed all meals of age-appropriate foods in both home and school environments. Another important contribution of the case study is that it demonstrated the importance of follow-up services that occur in the child’s natural environment while highlighting the utility of rubrics. With rubrics, caregivers effectively and efficiently progressed toward treatment goals independently. This case study also discusses the importance of ongoing interdisciplinary collaboration and the unique contributions of each team member in employing effective interventions while ensuring client safety.

Further evaluation of modified-bolus-placement methods during initial treatment of pediatric feeding disorders.

Children with feeding disorders might pack or expel food when they lack the oral-motor skills, the motivation, or both, to swallow. Bolus placement directly on the tongue with a Nuk (e.g., Milnes et al., 2019) or flipped spoon (e.g., Sharp et al., 2010) is a treatment that researchers generally implement after such behavior emerges (e.g., Girolami et al., 2007). However, Wilkins et al. (2014) tested the relative efficacy of Nuk presentation and upright-spoon presentation during initial treatment of pediatric feeding disorders. In the current study, we compared the effects of (a) upright-spoon presentation; (b) Nuk presentation; and (c) flipped-spoon presentation on two product measures of swallowing: 15- and 30-s mouth clean, and expulsion during the initial treatment of feeding disorders with 5 children. We also monitored lip closure during bite presentation and following bolus placement. Nuk presentation produced the highest levels of mouth clean and the lowest rates of expels relative to upright-spoon presentation and flipped-spoon presentation. We discuss potential reasons why modified-bolus-placement methods improved feeding behavior and how measures of oral-motor skills might predict its necessity during initial treatment.

Scabies, Fleas, or Bedbugs? Investigation of Skin Rashes in an Inpatient Eating Disorders Treatment Facility Unit

<h3>Background</h3> We investigated a cluster of skin rashes on an inpatient adult and pediatric eating disorders treatment facility (EDTF) unit where group activities occur and include therapy dogs. <h3>Methods</h3> An epidemiological investigation was launched after scabies was diagnosed in patient A (occupying room X). An interprofessional team was engaged and included EDTF leaders, dermatology, environmental services, and infection prevention. Patient A was treated for scabies and persons with epidemiologic links were informed of possible exposure. Within two weeks, patient B (occupying room X) was evaluated by dermatology for a rash deemed inconsistent with scabies, but bed bug bites could not be excluded. Pest control professionals assessed room X for bed bugs, none were found. Four weeks later, a bed bug was visualized in room X (occupied by patient B). Pest control professionals confirmed presence of bed bugs and treated the room with high temperature heat. The investigation was expanded to persons with epidemiological links to patient B. <h3>Results</h3> 92 employees were informed of scabies exposure, no post exposure prophylaxis administered as none reported skin-to-skin contact. 55 patients had a concurrent inpatient stay with patient A. Of these, 9 had possible skin-to-skin contact and received prophylaxis. 25 were discharged and informed of possible exposure, none sought prophylaxis. Therapy dogs were examined, no fleas identified. Heat treatment cost was approximately $1000.00. There were no bedbugs identified outside room X and no additional patients with bed bug-related rashes. Investigative data supports source of bed bugs was outside the facility. Policies are under revision to restrict personal items, such as bedding, brought to EDTF. <h3>Conclusions</h3> This investigation illustrates challenges with identifying etiology of arthropod-related skin rashes in a special population and the need to reevaluate hypotheses as data unfolds over time. An interprofessional team supported timely implementation of control measures.

Pediatric Feeding Disorder: A Nationwide Prevalence Study

To assess the prevalence of pediatric feeding disorder (PFD) in US children. 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. We identified 126 002 and 367 256 children 5years 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 5years in the publicly insured cohorts in Wisconsin, Arizona, and the privately insured cohort, respectively. The prevalence of feeding disorders in the US rivals that of commonly diagnosed conditions such as eating disorders and autism.