Avaliação e intervenção responsiva e integrativa na criança com distúrbio alimentar pediátrico com Trissomia do 21: Relato de caso / Responsive and integrative assessment and intervention in children with pediatric feeding disorder with Trisomy 21: A case report / Evaluación e intervención receptiva e integradora en un niño con trastorno alimentario pediátrico con Trisomía 21: Reporte de caso

Na criança com Trissomia do 21 a dificuldade alimentar pode estar presente. Alguns sinais são as alterações na habilidade motora-oral, no processamento sensorial, tempo elevado das refeições, recusa alimentar prolongada e falta de autonomia. Ainda pouco se discute sobre as dificuldades alimentares e seu processo terapêutico nesta população. O objetivo deste estudo foi descrever a avaliação e intervenção fonoaudiológica e da terapia ocupacional na dificuldade alimentar de uma criança com Trissomia do 21 com o uso de estratégias de alimentação responsiva e integrativa. Criança 3 anos e 2 meses, sexo masculino. Avaliação fonoaudiológica demonstrou criança com distúrbio alimentar pediátrico, caracterizado por atraso na habilidade motora-oral, baixa percepção intraoral e comportamento alimentar altamente seletivo. Na avaliação da terapia ocupacional verificou-se perfil sensorial alterado. Na fonoterapia foram trabalhados aspectos como a percepção do alimento, ritmo e o tempo de alimentação. Na terapia ocupacional, o objetivo foi adequar nível de alerta, favorecer a independência e o desenvolvimento psicomotor. Após a intervenção, a reavaliação fonoaudiológica demonstrou que houve ampliação do cardápio, melhora da percepção, da habilidade motora intraoral, aceitação de diferentes utensílios e modos de apresentação do alimento, autonomia e prazer nas refeições. A reavaliação da terapia ocupacional mostrou um nível de alerta e atenção mais adequado, uso das mãos e dedos de maneira mais funcional para se alimentar. Foram observadas evoluções positivas em relação à intervenção fonoaudiológica e da terapia ocupacional na dificuldade alimentar de uma criança com Trissomia do 21 com o uso de estratégias de alimentação responsiva e integrativa. (AU)

In children with Trisomy 21 feeding difficulty can be observed, such as changes in oral motor skills, sensory processing, longer mealtimes, food refusal, lack of autonomy and others. However, there is little discussion about feeding difficulties and rehabilitation process in this population. This study aimed to describe speech-language and occupational therapy assessment and intervention in feeding difficulties in a 3-year and 2-month-old male child with a diagnosis of Trisomy 21. Speech-language pathology assessment found that the child had feeding difficulties, delay in oral motor skills, low intraoral perception and acceptance, while the occupational therapy assessment showed an altered sensory profile. The speech-language pathology sessions included aspects such as food perception, rhythm and feeding time. In turn, occupational therapy sessions aimed to adjust the alertness level, promote independence and psychomotor development. After the intervention, the speech-language pathology reassessment showed that there was an expansion of the menu for the ingestion, improvement in perception and intraoral motor skills, acceptance of different utensils and food presentation modes, autonomy and pleasure in meals. The reassessment of occupational therapy showed a better level of alertness and attention, more functional use of hands and fingers to eat. Therefore, a positive progress was observed in the feeding difficulty of a child with Trisomy 21 after a speech-language pathology and occupational therapy intervention with the use of responsive and integrative feeding strategies. (AU)

Niños con Trisomía 21, pueden presentar dificultades de alimentación. Algunos signos son cambios en las habilidades motrices orales, procesamiento sensorial, tiempos prolongados de comida, rechazo prolongado de alimentos y falta de autonomía. Hay poca discusión sobre las dificultades de alimentación y su proceso terapéutico en esta población. El objetivo deste estudio fue describir la evaluación e intervención fonoaudiológica y de terapia ocupacional en la dificultad de alimentación de un niño con Trisomía 21 utilizando estrategias de alimentación receptiva e integradora. Niño de 3 años y 2 meses. La evaluación fonoaudiológica mostró un trastorno alimentario pediátrico, caracterizado por un retraso en las habilidades motoras orales, percepción intraoral baja y comportamiento alimentario altamente selectivo. En la evaluación de terapia ocupacional se observó un perfil sensorial alterado. En fonoaudiología se trabajaron aspectos como la percepción de alimentos, ritmo y tiempo de alimentación. En terapia ocupacional, el objetivo fue ajustar el nivel de alerta, favoreciendo la independencia y desarrollo psicomotor. Después de la intervención, la reevaluación fonoaudiológica se evidenció una ampliación del menú, mejoras en percepción, motricidad intraoral, aceptación de diferentes utensilios y formas de presentar alimentos, autonomía y placer en las comidas. La reevaluación de terapia ocupacional mostró un nivel de alerta y atención más adecuado, uso de manos y dedos de forma más funcional para alimentarse. Fueron observadas evoluciones positivas con relación a la intervención fonoaudiológica y de terapia ocupacional en la dificultad de alimentación de un niño con Trisomía 21 con el uso de estrategias de alimentación receptiva e integradora. (AU)

Assessment of clinical practice procedures among Registered Dietitian Nutritionists for identifying feeding dysfunction in the pediatric population.

BACKGROUND & AIMS: Feeding dysfunction is common in children. Efficient processes to identify and treat feeding dysfunction are not commonly known or used among healthcare practitioners. The aim of this study was to develop and validate a survey tool to assess current practice procedures used by Registered Dietitian Nutritionists (RDN) in identifying, diagnosing, and treating feeding dysfunction in children 0-18 years of age. METHODS: A survey was developed and distributed to gather information on RDN practice procedures, prevalence of pediatric feeding dysfunction, identification of pediatric feeding dysfunction, and method of treatment used to address pediatric feeding dysfunction. Emails were sent to 4449 RDNs in United States. All participants were classified by the Commission on Dietetic Registration (CDR) as clinical dietitians. Distribution and frequency of survey responses were assessed, and in the case of qualitative questions, were categorized according to themes identified. RESULTS: Responses of RDNs from 41 states completed 341 total surveys, 179 surveys were included in data analysis. Eighty percent of participants do not use a specific screening tool to identify feeding dysfunction. Results concerning feeding therapy strategies and terms used by RDNs to describe feeding dysfunction were highly varied or lacking. Increased inclusion of RDNs on interdisciplinary teams was indicated by 80% of participants. The majority of participants indicated they refer patients with feeding dysfunction to other practitioners instead of providing feeding therapy themselves. CONCLUSIONS: Standardized screening, diagnostic, and treatment protocols regarding feeding dysfunction are needed to provide consistent and comprehensive care for the pediatric population. Use of these protocols among RDNs would enable them to improve feeding abilities in more patients earlier in individual child development.

Development, prevention, and treatment of feeding tube dependency.

Enteral nutrition is effective in ensuring nutritional requirements and growth. However, when tube feeding lasts for a longer period, it can lead to tube dependency in the absence of medical reasons for continuation of tube feeding. Tube-dependent children are unable or refuse to start oral activities and they lack oral skills. Tube dependency has health-, psychosocial-, and economy-related consequences. Therefore, the transition to oral feeding is of great importance. However, this transition can be very difficult and needs a multidisciplinary approach. Most studies for treatment of tube dependency are based on behavioral interventions, such as family therapy, individual behavior therapy, neuro-linguistic programming, and parental anxiety reduction. Furthermore, oral motor therapy and nutritional adjustments can be helpful in tube weaning. The use of medication has been described in the literature. Although mostly chosen as the last resort, hunger-inducing methods, such as the Graz-model and the Dutch clinical hunger provocation program, are also successful in weaning children off tube feeding. CONCLUSION: The transition from tube to oral feeding is important in tube-dependent children but can be difficult. We present an overview for the prevention and treatment of tube dependency. What is known: • Longer periods of tube feeding can lead to tube dependency. • Tube weaning can be very difficult. What is new: • Weaning as soon as possible and therefore referral to a multidisciplinary team are recommended. • An overview of treatment options for tube dependency is presented in this article.

Rumination syndrome: pathophysiology, diagnosis, and treatment.

BACKGROUND: Rumination syndrome is a functional gastrointestinal disorder characterized by effortless and repetitive regurgitation of recently ingested food from the stomach to the oral cavity followed by either re-swallowing or spitting. Rumination is thought to occur due to a reversal of the esophagogastric pressure gradient. This is achieved by a coordinated abdominothoracic maneuver consisting of a thoracic suction, crural diaphragm relaxation and an increase in intragastric pressure. Careful history is important in the diagnosis of rumination syndrome; patients often report "vomiting" or "reflux" and the diagnosis can therefore be missed. Objective testing is available with high resolution manometry or gastroduodenal manometry. Increase in intra-gastric pressure followed by regurgitation is the most important characteristic to distinguish rumination from other disorders such as gastroesophageal reflux. The mainstay of the treatment of rumination syndrome is behavioral therapy via diaphragmatic breathing in addition to patient education and reassurance. PURPOSE: The purpose of this review was to critically appraise recent key developments in the pathophysiology, diagnosis and therapy for rumination syndrome. A literature search using OVID (Wolters Kluwer Health, New York, NY, USA) to examine the MEDLINE database its inception until May 2016 was performed using the search terms "rumination syndrome," "biofeedback therapy," and "regurgitation." References lists and personal libraries of the authors were used to identify supplemental information. Articles published in English were reviewed in full text. English abstracts were reviewed for all other languages. Priority was given to evidence obtained from randomized controlled trials when possible.

[Psychomotor education and speech therapy when weaning a child off artificial feeding]. / Psychomotricité et orthophonie lors du sevrage d'une nutrition artificielle chez l'enfant.

To support children and their families with weaning off artificial nutrition, a psychomotor therapist and speech therapist from the 'Pierre Robin syndrome and congenital sucking-swallowing disorders' specialist rare disease centre at Necker-Enfant Malades hospital in Paris, have set up a joint consultation, as a complement to medical consultations. This programme shows how speech therapy and psychomotor education can complement each other in order to help children and their parents during this difficult period.

[Liver disease, gastrointestinal complications, nutritional management and feeding disorders in pediatric cystic fibrosis]. / Atteinte hépatique, digestive, prise en charge nutritionnelle et troubles de l'oralité chez l'enfant atteint de mucoviscidose.

In cystic fibrosis (CF), approximately 5-8% of the patients develop multilobular cirrhosis during the first decade of life. Annual screening (clinical examination, liver biochemistry, ultrasonography) is recommended in order to identify early signs of liver involvement, initiate ursodeoxycholic acid therapy and detect complications (portal hypertension and liver failure). Management should focus on nutrition and prevention of variceal bleeding. The gut may also be involved in children with CF. Gastroesophageal reflux is frequent, although often neglected and should be investigated by pH monitoring and impedancemetry, if available. Acute pancreatitis occurs in patients with persistent exocrine pancreatic activity. Intussusception, appendicular mucocele, distal intestinal occlusion syndrome, small bowel bacterial overgrowth and Clostridium difficile colitis should be considered in case of abdominal pain. Preventive nutritional support should be started as soon as possible after diagnosis of CF. Attainment of normal growth is one of the main goals and can be achieved with hypercaloric and salt supplemented food. Pancreatic enzyme replacement therapy should be started as soon as exocrine pancreatic insufficiency is confirmed and ingested immediately prior to meals with intake of fat-soluble vitamins. Curative nutritional interventions are more likely to be effective in the early stages of pulmonary disease. Feeding disorders, related to the physiopathology and the psychologic aspects of the disease are frequent. Repeated corporeal aggressions, associated with inappropriate medical and parental pressure, may increase the child's refusal of food. The multidisciplinary team should guide parents in order to avoid all intrusive feeding practices and promote pleasant mealtimes.

Biofeedback-guided control of abdominothoracic muscular activity reduces regurgitation episodes in patients with rumination.

BACKGROUND & AIMS: Rumination syndrome is characterized by effortless recurrent regurgitation of recently ingested food into the mouth, with consequent expulsion or re-chewing and swallowing. We investigated whether rumination is under volitional control and can be reversed by behavioral treatment. METHODS: We performed a prospective study of 28 patients who fulfilled the Rome criteria for rumination and had no organic disorders on the basis of a thorough evaluation. The diagnosis of rumination was confirmed by intestinal manometry (abdominal compression associated with regurgitation). Patients were trained to modulate abdominothoracic muscle activity under visual control of electromyographic recordings. Recordings were made after challenge meals, before training (baseline), and during 3 treatment sessions. Outcome was measured by questionnaires administered daily for 10 days before training, immediately after training, and at 1, 3, and 6 months after training. RESULTS: By the end of the 3 sessions, patients had effectively learned to reduce intercostal activity (by 50% ± 2%; P < .001 vs basal) and anterior wall muscle activity (by 30% ± 6%; P < .001 vs basal). Patients reported 27 ± 1 regurgitation episodes/day at baseline and 8 ± 2 episodes/day immediately after treatment. Regurgitation episodes decreased further to 4 ± 1 episodes at 6 months after training. CONCLUSIONS: Rumination is produced by an unperceived somatic response to food ingestion that disrupts abdominal accommodation and can be effectively corrected by biofeedback-guided control of abdominothoracic muscular activity.

Enuresis and more.

We describe Pervasive Refusal Syndrome, an important but rare, debilitating condition that may present to paediatric services. Although previous reports have described improvement seen with care delivered in the mental health setting, we have demonstrated treatment predominately delivered in a paediatric ward environment associated with successful recovery.

Nutritional and psychosocial outcomes of gastrostomy tube-dependent children completing an intensive inpatient behavioral treatment program.

OBJECTIVES: Limited published data describe the long-term effects of behavioral strategies to wean children from gastrostomy tube (GT) feeding dependence. This study presents data relating to nutritional and psychosocial outcomes observed during a 1-year period in medically complex GT feeding-dependent patients who completed an inpatient behavioral-based tube weaning protocol. METHODS: This was a retrospective study of prospectively and retrospectively collected data associated with a clinical cohort of 77 children diagnosed as having a feeding disorder, GT feeding dependence (>1 year), and an inability to maintain acceptable growth via oral feeding completing an inpatient tube weaning protocol. Nutritional data (percentage of ideal body weight, and oral energy intake as percent ofenergy goal) and psychosocial data (mealtime behavior problems, quality of caregiver and child interactions, and parenting stress) were assessed pre- and post-hospitalization. Nutritional data were also monitored longitudinally at 1, 3, 6, and 12 months postreatment. Data were grouped for retrospective analysis. RESULTS: Mealtime environment and feeding behaviors significantly improved, and all of the patients demonstrated reductions in tube dependence aside from 1 treatment failure. Fifty-one percent of patients were fully weaned from tube feeding after 2 weeks and an additional 12% completed weaning in the outpatient follow-up clinic within 1 year. Patients maintained nutritional stability at the 1-year posttreatment follow-up appointment. CONCLUSIONS: Inpatient behavioral interventions are highly effective and safe for transitioning long-term tube feeding children to oral feeding.

Rumination variations: aetiology and classification of abnormal behavioural responses to digestive symptoms based on high-resolution manometry studies.

BACKGROUND: Rumination is the voluntary, albeit subconscious return of gastric contents to the mouth. Currently, rumination syndrome and repetitive belching disorders are considered separate diagnoses, as defined by Rome III criteria and high-resolution oesophageal manometry (HRM). AIM: To test the hypothesis that these conditions represent a common behavioural response to aversive digestive stimuli and that successful treatment can be directed at both the stimulus and the response. METHODS: Case-note review of consecutive patients with a final diagnosis of behavioural digestive disorders between August 2009 and October 2011. RESULTS: Thirty-five of 46 (76%) patients exhibited 'classical' rumination with abdomino-gastric strain (R-waves) driving gastric contents across the lower oesophageal sphincter; 5 (11%) had 'reflux-related' rumination with R-waves seen during gastro-oesophageal common cavity (reflux) events and 6 had (13%) supra-gastric belching. All received at least one biofeedback session at the time of diagnosis with a good response reported by 20/46 (43%) of the patients, which included 3 with supra-gastric belching. Additionally, rumination ceased in cases in which definitive treatment relieved the symptoms that triggered abnormal behaviour (e.g. fundoplication in 'reflux-rumination'). CONCLUSIONS: Rumination and many of its variations, excluding only some cases of supra-gastric belching, are associated with abdomino-gastric strain, a generic abnormal behavioural response to a variety of aversive digestive stimuli. All types of rumination can respond to biofeedback. High-resolution oesophageal manometry identifies subgroups with distinct mechanisms of disease that respond to specific management targeted at the symptoms that trigger the abnormal behaviour.

[How much food for a soul? Psychosomatic treatment of infantile feeding disorders]. / Wieviel Gramm braucht eine Seele--Psychosomatische Behandlung von Fütter- und Gedeihstörungen im Säuglings- und Kleinkindalter.

Severe feeding disorders often require inpatient treatment and need a holistic assessment and treatment approach. This article introduces some of the current literature concerning feeding disorders in infants and toddlers. The philosophy of the Department of Infant Psychosomatics at the University Children's Hospital Zürich emphasizes interdisciplinary teamwork, the application of psychodyamic tools in pediatric liaison psychiatry and utilization of group settings. Clinical approach and course of treatment are illustrated by three case reports, highlighting specific psychotherapeutic interventions with the parent-infant relationship in the context of a paediatric clinic.

Severe pediatric rumination syndrome: successful interdisciplinary inpatient management.

BACKGROUND: Rumination syndrome is a condition that occurs when people constantly regurgitate and expel or reswallow food soon after they eat. The most severe cases of rumination syndrome can be debilitating, requiring total parenteral nutrition or enteral tube feedings. We report our experience with the treatment of children with severe rumination syndrome. PATIENTS AND METHODS: Five patients with severe rumination syndrome received a novel inpatient interdisciplinary approach, which involved pediatric psychology, pediatric gastroenterology, clinical nutrition, child life, therapeutic recreation, and massage therapy. RESULTS: Inpatient hospitalization lasted between 9 and 13 days. The treatment was successful in all 5 of the patients. They left with complete caloric intake orally. CONCLUSIONS: This treatment protocol could benefit pediatric gastroenterologists, pediatricians, and child psychologists in managing both standard and severe cases of rumination syndrome.

Interdisciplinary care for feeding problems in children.

Children with feeding disorders frequently present to primary care practitioners. The causes of these feeding disorders are often a mix of medical, developmental, and behavioral factors. Evaluation and treatment of feeding problems typically require the expertise of physicians, speech and language pathologists, registered dietitians, and psychologists. This article advocates an interdisciplinary, biobehavioral approach for the assessment and treatment of feeding disorders. First, prevalence and causes of feeding problems are discussed. Second, interdisciplinary assessment and treatment strategies are considered, including the specific roles of the interdisciplinary team members. Third, behavioral treatment strategies are described. Fourth, various treatment options are described.

A clinical study of the intergenerational transmission of eating disorders from mothers to daughters.

Clinicians and researchers have long recognized the existence of eating disorders in very young children, including infants whose mothers have eating disorders. This paper combines reviews of the literature relevant to the study of eating disorders from the perspectives of both research and psychoanalytic theory in order to explore the psychodynamics of the intergenerational transmission of eating-disordered pathology from mother to child. A developmental pathway as well as several mechanisms that illuminate the pathogenesis of the intergenerational transmission of eating disorders are proposed and described. Clinical-observational data from a therapeutic play nursery for mothers with eating disorders and their children are presented, and this material is examined in relation to the proposed psychodynamic pathways of transmission.

[Eating disorders in childhood and early adolescence]. / Troubles des conduites alimentaires de l'enfant et du préadolescent.

During childhood and early adolescence, eating disorders are mainly of the restrictive type and general practitioner plays a central role in treatment. Parental counseling and medical care should be administered to selective and restrictive children without growth retardation. When growth and puberty are delayed a multidisciplinary approach is recommended. Somaticians, psychiatrists and psychotherapists will work together in the fight against the eating disorder. Family approaches yielded the best results in the management of these disorders for the younger subjects but individual therapies are also recommended. If vitamin and calcium supplements are necessary, it is not the case for psychotropic medications, which can have a dangerous impact if nutritional status is not stabilized. Outcome of selective and restrictive disorders in childhood is good however picky eaters need special care because of the risk of anorexia nervosa in later adolescence. Outcomes of prepubertal anorexic patients seem to be better than those of pubertal anorexic subjects but it is not the case for subjects affected by very-early-onset anorexia nervosa.

[Infantile rumination]. / Mérycisme infantile.

Infantile rumination can be defined as self-induced regurgitation of previously swallowed food. Because it can lead to potential somatic complications and because it implies dysfunctional mother-child bonding, both a pediatric and psychiatric approach is needed. The treatment must be somatic (nutritional) and psychological (intensive nursing, mother-baby psychotherapy). Two case studies illustrate this rare but impressive picture.

Training parents to implement pediatric feeding protocols.

Four different multicomponent training packages were evaluated to increase the treatment integrity of parents implementing pediatric feeding protocols. In Study 1 we exposed 3 parents to a training package that consisted of written protocols (baseline), verbal instructions, therapist modeling, and rehearsal training. Results suggested that the package was successful in increasing treatment integrity of the feeding protocols to high levels. Study 2 investigated three different parent-training packages comprised of components used in Study 1. Two parents were exposed to written protocols, verbal instructions, and modeling; 2 parents were exposed to written protocols, verbal instructions, and rehearsal; and 2 parents were exposed to written protocols and verbal instructions. Results of Study 2 showed that each parent-training package produced very high treatment integrity. Follow-up data in the clinic and home for 5 participants suggested that the results were durable for up to 3 months. These results demonstrate a first step in the transfer and application of research findings into routine clinical practice because we evaluated several methods for training parents to implement behavioral feeding protocols, and we demonstrated that these methods resulted in high levels of treatment integrity in a controlled clinical setting.

"Whole body" mobility after one year of intraoral appliance therapy in children with cerebral palsy and moderate eating impairment.

The reciprocal influence of body postures on the oral structures, but also of the oral structures on body postures, has been proposed by clinicians and is taken into consideration when treating children with poor postural control and moderate to severe eating impairments. However, this relationship has not been rigorously investigated. The purpose of this study was to document the possible relationships among oral-motor, postural, and ambulatory control. Ambulatory skills [exclusive use of wheelchair (w/c) vs w/c and ambulation], postural control when sitting, "pathologic" reflexes, and lip and tongue posture were recorded before and after one year of therapy with an intraoral appliance (ISMAR) in 20 children with cerebral palsy and moderate eating impairment. Significant improvement occurred in sitting (head-trunk-foot control) following one year of ISMAR therapy. Ambulatory status also significantly improved above the level of maturation. Half of the children showed marked improvement in oral posture, i.e., their resting mouth posture was closed rather than open. These results support an hypothesis of interaction between oral structures and postural control of the "whole body." Further studies are needed to determine the controls of such a relationship.