Background Education for Providers
Anatomic problems (e.g., cleft lip and palate, micronathia, arthrogryposis) , neuromuscular conditions (e.g., cerebral palsy, muscular dystrophies), sensory disorders (e.g. familial dysautonomia) and a variety of genetic disorders (e.g. Trisomy 21, velo-cardio-facial syndrome) all are associated with or cause feeding problems. These conditions may cause delays in or complete disruption of oral-motor skill development, limiting a child’s experience with oral feedings due to feeding safety concerns. In some instances, safety concerns prohibit oral experiences during critical/sensitive windows for the neurodevelopment of feeding skills such that later acquisition of these skills is challenging. Caregivers may also be reluctant to promote feeding out of concern that the child will experience hardship or that his or her nutritional status will be compromised. Patients presenting specifically with oral-motor problems require an evaluation by a pediatric speech and language pathologist trained in feeding and swallowing disorders to identify problems and to initiate an appropriate treatment program.
There are other medial conditions that also predispose a child to having a feeding problem. Although acute conditions (such as gastroenteritis, strep infection) may cause decreased appetite, fatigue, nausea, and abdominal pain, these conditions are likely to have only transient effects on nutritional status. Chronic conditions tend to be of greater concern, as they can have longer lasting effects, which can include poor appetite, and/or discomfort with feeding resulting in more serious nutritional compromise. Chronic medical problems presenting during infancy disrupt or delay the introduction of feeding can also cause the child to miss sensitive periods of feeding development. Conditions that require supplemental feeding (e.g., tube feeding) frequently disrupt the child’s association of oral feeding with satiation of hunger. Of particular concern are prematurity, in utero growth retardation, and tracheostomy. Other medical conditions presenting as children develop that can cause negative associations to oral feeding include tooth decay, food allergies, esophagitis due to either eosinophilic esophagitis or gastroesophageal reflux, delayed gastric emptying, dumping syndrome, celiac disease, constipation, cardiac and respiratory disease, cystic fibrosis, and a variety of metabolic disorders.
A number of medicines have side effects that can contribute to feeding problems. Common antibiotics can cause diarrhea and nausea. Medications used to treat gastroesophageal reflux, especially metoclopramide may cause tardive dyskinesia impinging upon feeding skills. Over the counter dietary supplements frequently unwittingly used to treat feeding problems (e.g, vitamins) can cause nausea, constipation, or diarrhea. Cardiac medications can cause anorexia, nausea, dyspepsia, diarrhea, and electrolyte imbalance. Respiratory medications can cause nausea and vomiting. Psychotropic medications, including antidepressants and stimulants, can have unintended side effects that disrupt feeding including nausea, vomiting, and diarrhea. One of the most frequently encountered problems with psychotropic medication stems from the anorexic effects of stimulants used to treat Attention Deficit/Hyperactivity Disorder.
Feeding disorders are prevalent in developmentally disabled populations, with approximately one third of all disabled children having significant feeding problems and as many as 80% of children with severe or profound mental retardation having a feeding disorder. These high prevalence rates are likely due to delay in development or deficiencies of oral motor skills and fine motor skills required for independent feeding with intake of a diet of varied textures. The prevalence rates of feeding problems secondary to medical and developmental problems are expected to rise as the survival rates of children with significant developmental disabilities due to prematurity or underlying medical conditions increases.
Instructions for Provider
If you suspect that a medical etiology for feeding difficulties is present than a thorough medical assessment should be completed prior to attempting any other intervention(s).