"Still work?" Design and effect of interventions used to modify feeding problems in children with autism: A systematic review of studies employing group designs.

BACKGROUND: Feeding problems in children with autism jeopardize the well-being of both children with autism and their families. Mixed findings were reported from previous interventions, which were mostly evaluated by single subject research design (SSRD) studies. Moreover, feasibility assessment and social validity measurement were unaddressed by these SSRD studies. To fill this substantial knowledge gap, the present review systematically summarized and evaluated feeding interventions implemented in children with autism, which were assessed by studies employing group designs. METHOD: An extensive literature search in eight established online databases was conducted, and a total of 17 eligible studies published in 2009-2021 were included for further analysis. A descriptive account of the features of the investigations is provided, including assessment of study quality. RESULTS: A total of 449 children with autism and 203 parents/caregivers participated in the included studies. The multiple use of five strategic intervention components were highlighted in this review, including nutrition education/consultations, environmental modifications, sensory exposure, cognitive components, and behaviour interventions. The reviewed interventions showed a preliminarily positive effect for modifying feeding problems in children with autism. Furthermore, the evaluation based on the RE-AIM framework (reach, efficacy, adoption, implementation, and maintenance) demonstrated that an interdisciplinary multi-component intervention strategy may achieve high effectiveness and feasibility in improving feeding problems in a wide range of children with autism. CONCLUSIONS: This review found that interventions achieved and maintained a positive effect on modification of feeding problems in groups of children with autism. Information and gaps identified and summarized in the implementation process may assist both researchers and stakeholders to further support these vulnerable children.

Online occupational therapy group training for mothers of children with feeding problems: A randomized controlled trial.

AIM: The aim of this study was to scrutinize how online occupational therapy group training for mothers influenced their attitudes and stress levels relating to feeding their children and the eating behaviours of the children. The secondary purpose of the study is to evaluate the satisfaction of the participants of this program. Twenty-nine mothers of children aged 3-6 years, experiencing feeding issues, were randomly allocated to either an intervention or control group. BACKGROUND: Feeding problems including selective eating, loss of appetite, and mealtime behaviour problems are prevalent during childhood. Parents play a fundamental role in acquiring knowledge about feeding. Problems in the feeding process may lead to parental stress, feelings of despair, and incorrect attitudes. RESULTS: The mothers in the research group participated in the 4-week training. Results indicated positive effects on both maternal attitudes and their children's eating behaviours (p < 0.05). No significant change was found in mothers' state and trait anxiety levels (p > 0.05). Participants were asked to score their satisfaction level with the program between 1 and 10, and the average of the scores was 9.78 ± 0.42. CONCLUSION: This study shows that online group education for mothers can support existing treatments and guide clinicians working with children with feeding problems.

Versión argentina de la herramienta de evaluación de la alimentación pediátrica PediEAT / Argentine version of the PediEAT, a pediatric eating assessment tool

Introducción. Durante la infancia, los niños pueden experimentar algún grado de dificultad al comer. Existe una herramienta, desarrollada en Estados Unidos, de evaluación de la alimentación pediátrica (PediEAT), que permite identificar síntomas problemáticos. Objetivo. Realizar una adaptación transcultural para una versión argentina, con adecuación cultural y equivalencia semántica respecto a su versión original. Población y métodos. Se utilizó una versión autoadministrada del PediEAT que fue respondida por familias y/o cuidadores de niños de 6 meses a 7 años. Se realizó una primera fase de evaluación de validez del contenido con un grupo de expertos. Luego, una fase de pretest con familias mediante entrevistas cognitivas para comprobar la comprensión de las palabras y frases. Se realizaron las modificaciones necesarias para que quedara adaptada al contexto. Resultados. En la fase de evaluación de validez del contenido con el grupo de 8 expertos, de los 80 ítems se modificaron 36. En el pretest, se realizaron entrevistas cognitivas a 18 cuidadores; se realizaron cambios en 11 ítems para mejorar la comprensión por parte de la población argentina. La versión argentina fue aprobada por los autores originales. Conclusiones. El instrumento PediEAT versión argentina resulta lingüísticamente equivalente a su versión original, lo que permite su uso para la detección de problemáticas alimentarias en niños.

Introduction. During childhood, children may experience some degree of difficulty eating. A tool (PediEAT) has been developed in the United States and is available to assess pediatric eating and to identify problematic symptoms. Objective. To obtain an Argentine version that is transculturally adapted, culturally adequate, and semantically equivalent to the original version. Population and methods. A self-administered version of the PediEAT was used and completed by families and/or caregivers of children aged 6 months to 7 years. In the first phase, content validity was assessed by a group of experts. This was followed by a pre-test phase with families using cognitive interviews to test word and phrase comprehension. The necessary changes were made to obtain a version adapted to the context. Results. The tool's content validity was assessed by a group of 8 experts; as a result, 36 of the 80 items were changed. During the pre-test phase, cognitive interviews were conducted with 18 caregivers; 11 items were changed to improve comprehension by the Argentine population. The Argentine version was approved by the original authors. Conclusions. The Argentine version of the PediEAT tool is linguistically equivalent to the original version, and this allows its use to screen for feeding problems in children.

Noncontingent reinforcement in the treatment of pediatric feeding disorder: A concise review.

This concise review summarizes the literature on noncontingent reinforcement in the treatment of pediatric feeding disorder from 2018 to 2022. We reviewed 15 published behavior-analytic feeding studies to identify how often the term noncontingent reinforcement is used, what form of noncontingent reinforcement is delivered, and what the effects of noncontingent reinforcement are on behavior when it is included in treatment. Implications and directions for future research are discussed.

Feeding difficulties in childhood: A narrative review. / Dificultades alimentarias en la infancia: una revisión narrativa.

It has been estimated that between 25% and 40% of healthy children show symptoms of feeding difficulties (FDs) during their growth and development; many times, these are not adequately diagnosed. The objective of this study was to conduct a narrative review that collected the available information on feeding difficulties. Assessment and management algorithms were developed based on the bibliographic evidence. Most feeding problems in young children (feeding selectivity, loss of appetite, fear of feeding) are often concurrent, and a clinical risk assessment is necessary to plan an individualized intervention. Having standardized definitions and common terms to address these difficulties in an appropriate and multidisciplinary manner is one of the ways to optimize their treatment. The involvement of different health care providers and parents is critical to address feeding difficulties.

Se estima que entre el 25 % y el 40 % de los niños sanos presentan algún síntoma de dificultad alimentaria (DA) durante su crecimiento y desarrollo, y muchas veces no son adecuadamente diagnosticadas. El propósito de este trabajo consistió en realizar una revisión narrativa que reuniera la información disponible sobre las dificultades alimentarias. Se desarrollaron algoritmos de evaluación y abordaje a partir de la evidencia en la literatura. La mayoría de los problemas de alimentación en los niños pequeños (selectividad alimentaria, falta de apetito, miedo a la alimentación) a menudo coexisten y es necesario evaluar el riesgo clínico para planificar una intervención individualizada. Contar con definiciones estandarizadas y terminología común para abordar estas dificultades de manera adecuada y multidisciplinaria es uno de los caminos para optimizar su tratamiento. Involucrar a los diferentes profesionales de la salud y a los padres es fundamental para abordar las dificultades alimentarias.

Evaluation of two physical guidance procedures in the treatment of pediatric feeding disorder.

Children with pediatric feeding disorder may refuse to consume an adequate variety and/or volume of food to maintain expected growth. They can consume food but may actively or passively refuse, resulting in escape or avoidance of eating. Behavioral interventions like positive reinforcement with escape extinction can increase consumption. However, sometimes these interventions are insufficient, especially in treating passive refusal. In these cases, physical guidance may be used to prompt an open mouth to deposit food. Research indicates open-mouth prompts are effective and rated as acceptable. This study replicated an existing physical guidance procedure, the finger prompt, and compared its efficacy and acceptability with that of a spoon prompt. This study extended research by defining and measuring passive refusal as a dependent variable and assessing social validity among different stakeholders and times. Both prompts were effective in treating food refusal, and caregivers rated the finger prompt as more preferred.

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)

Grupo multifamiliar em transtornos alimentares durante a primeira onda da pandemia de covid-19: transição para a modalidade online / Multifamily group on eating disorders during the first wave of the covid-19 pandemic: transitioning to the online modality / Grupo multifamiliar de trastornos alimentarios durante la primera ola de la pandemia de la covid-19: transición a la modalidad en línea

As restrições impostas pela pandemia de covid-19 levaram os serviços de saúde a reorganizarem seu funcionamento, ajustando-se à modalidade remota. A transição repentina e sem o devido preparo técnico impôs desafios adicionais para usuários e profissionais. Para aprimorar as estratégias assistenciais, torna-se imprescindível dar voz aos usuários dos serviços, para que narrem suas experiências e possam manifestar suas facilidades e dificuldades com essa passagem. Este estudo tem como objetivo investigar como os principais cuidadores familiares de pessoas com transtornos alimentares vivenciaram a transição do grupo de apoio para o formato remoto e identificar vantagens e desvantagens percebidas nesse modelo. Estudo clínico-qualitativo, exploratório, realizado em um serviço de atendimento especializado de um hospital terciário. O cenário investigado foi o grupo de apoio psicológico aberto a familiares que, desde o início da pandemia de covid-19, passou a ser oferecido na modalidade online. Participaram do estudo cinco mães e três pais presentes em 13 sessões grupais consecutivas. Entrevistas individuais foram aplicadas com a Técnica do Incidente Crítico logo após o término de cada encontro grupal, totalizando 26 entrevistas audiogravadas, transcritas e submetidas à análise temática. A transição para o online foi vivenciada pelos participantes como um recurso válido para permitir que o grupo funcionasse em tempos de grave crise sanitária. Como vantagens, foram mencionadas: a continuidade do cuidado, maior acessibilidade e facilidade em relação à logística da participação. Como limitações do formato online, foram destacadas: nem todos os familiares contam com conexão de internet de qualidade e possível dificuldade para manusear a tecnologia digital. Apesar dos desafios impostos pela súbita mudança para a modalidade online, na perspectiva dos usuários do serviço os esforços de adaptação foram bem-sucedidos, possibilitando a continuidade do cuidado à saúde mental.(AU)

The constraints imposed by the COVID-19 pandemic led health services to reorganize their operation, adjusting to the online modality. The sudden and unprepared technical transition has imposed additional challenges for both users and professionals. To improve care strategies, it is essential to give voice to services users, so that they can narrate their experiences and express their facilities and difficulties with this transition. This study aims to investigate how main family caregivers of people with eating disorders experienced the transition of the support group to the remote modality and to identify perceived advantages and disadvantages in this model. This is a clinical-qualitative, exploratory study carried out in a specialized care service of a tertiary hospital. The investigated setting was the psychological support group open to family members, which since the beginning of the COVID-19 pandemic has been offered online. Five mothers and three fathers who attended 13 consecutive group sessions participated in the study. Individual interviews were carried out with the Critical Incident Technique shortly after the end of each group meeting with all members, totaling 26 audio-recorded interviews. Data were subjected to thematic analysis. Transition was experienced as a valid resource to maintain the group active in times of a severe health crisis. As advantages of the remote modality were mentioned: continuity of care, greater accessibility, and ease in relation to the logistics of participation. As limitations of the online format were highlighted: not everyone has a good-quality connection to the internet, and difficulty in handling the digital technology. Despite the challenges imposed by the sudden shift to the online modality, from the service users' perspective the adaptation efforts were successful, enabling continuity of mental health care.(AU)

Las limitaciones que impuso la pandemia de la COVID-19 llevaron a los servicios sanitarios a reorganizar su funcionamiento adaptándose a la modalidad remota. El súbito cambio y sin la preparación técnica adecuada implicó retos adicionales a los usuarios y profesionales. Para mejorar las estrategias de atención es fundamental dar voz a los usuarios de los servicios, para que puedan narrar sus experiencias y expresar sus facilidades y dificultades con esta transición. Este estudio pretende investigar cómo han vivido los cuidadores de personas con trastornos alimentarios la transición del grupo de apoyo presencial al formato remoto e identificar las ventajas y desventajas percibidas en este modelo. Se trata de un estudio clínicocualitativo, exploratorio. El escenario investigado fue el grupo de apoyo psicológico abierto a los familiares en la modalidad en línea. Cinco madres y tres padres participaron en 13 sesiones de grupo consecutivas. Se realizaron entrevistas individuales con la técnica de incidentes críticos inmediatamente después de cada reunión del grupo, con un total de 26 entrevistas grabadas en audio, transcritas y sometidas a análisis temático. La transición a la red fue experimentada como un recurso válido para permitir que el grupo funcione en tiempos de crisis sanitaria grave. Las ventajas de la modalidad remota fueron conexión segura en tiempos de confinamiento físico, continuidad, mayor accesibilidad y facilidad en relación con la logística de la participación. Las limitaciones del formato en línea fueron la falta de una conexión de calidad a Internet y la posible dificultad de manejo de la tecnología digital. A pesar de las dificultades impuestas por el cambio repentino a la modalidad en línea, desde la perspectiva de los usuarios del servicio los esfuerzos de adaptación fueron un éxito, lo que permitió seguir con la atención de salud mental.(AU)

On the role of operant contingencies in the maintenance of inappropriate mealtime behavior: An epidemiological analysis.

Functional analysis is the primary assessment used to determine the function of inappropriate mealtime behavior in children with feeding disorders. Based on single-case experimental design studies and recent reviews, the prevalence of negative reinforcement alone in the maintenance of inappropriate mealtime behavior appears to be much greater than positive reinforcement alone. We conducted a retrospective consecutive-controlled case series to determine the generality of previous findings. Results of the epidemiological analysis support prior research in that negative reinforcement in the form of escape (44.8%), and multiple control (i.e., positive and negative reinforcement) in the forms of escape and attention (37.2%), are considerably more prevalent than positive reinforcement alone (2.5%). We discuss the relationship between functional analysis of inappropriate mealtime behavior and treatment utility. Further, we describe avenues of future research designed to advance the application of functional analysis in feeding disorders beyond inappropriate mealtime behavior.

Cartas endereçadas a quem desejar ler: da recusa alimentar em crianças e adolescentes com condições de saúde crônicas complexas às mensagens sobre escolhas e não escolhas / Letters to anyone who wants to read: from food refusal in children and adolescents with complex chronic health conditions to messages about choices and non-choices

A alimentação é essencial à manutenção da vida e está relacionada à construção de valores simbólicos e socioculturais. Apesar de ser uma função vital, o ato de comer não é inato para os seres humanos. Ele resulta de um processo de aprendizagem complexo que se inicia ainda na gestação e continua ao longo do desenvolvimento infantil. No entanto, esse processo pode sofrer perturbações e levar ao desenvolvimento de dificuldades alimentares e à recusa alimentar na infância. Logo, crianças e adolescentes que nascem e crescem em condições de saúde não favoráveis ao desenvolvimento, seja por experiências pessoais relacionadas a nascimentos difíceis, períodos prolongados de internação e/ou uso de tecnologias de saúde, também podem apresentar dificuldades na habilidade de ingerir e de se relacionar com os alimentos. Partindo desta criança/ adolescente em uma conversa com a cena clínica e assumindo as dificuldades de alimentação e recusa alimentar como uma mensagem a ser transmitida de uma criança/ adolescente ao adulto, este estudo investigou o universo de significados presentes nas interações de crianças e adolescentes com condição de saúde crônica complexa no seu contexto alimentar. Interessou-nos compreender como as expressões e interações da criança/adolescente falavam dela/dele como sujeito na cena de alimentação e como ela/ele era submetida à expressão dos adultos. Tratou-se de uma pesquisa qualitativa, que utilizou a observação participante e a realização de entrevistas dialogadas como técnicas para produção de dados. O local do estudo foi o setor de enfermaria de um hospital universitário pediátrico localizado na cidade do Rio de Janeiro, uma instituição de referência no cuidado de crianças com condição de saúde crônica complexa. A pesquisadora circulou pela enfermaria deste hospital observando cenas de alimentação infanto-juvenil e de cuidado familiar e hospitalar buscando oportunidades de interação e de entrevistas abertas com os cuidadores, com as crianças e os adolescentes internados e com os profissionais de saúde. O registro das observações foi realizado em um diário de campo e as entrevistas tiveram o áudio gravado para posterior transcrição, quando autorizado pelos participantes. O tempo de pesquisa de campo foi de 10 meses, sendo 08 meses destinados à observação participante. Os resultados desta pesquisa falam da trajetória de vida e alimentar de 04 participantes (três crianças e uma adolescente) vivendo em situação de hospitalização prolongada. Embora frequentemente submetidos ao controle e decisões dos adultos de referência para o alcance do bem-estar clínico e nutricional, nesta pesquisa, Eloá, Vitória, Kiara e Luiz revelaram o seu protagonismo sobre a própria ingestão alimentar, mostrando que atitudes geralmente rotuladas e patologizadas, tais como, a recusa e a seletividade alimentar, na verdade se tratam de escolhas e não escolhas do sujeito, que comunicam a sua identidade humana e que se moldam pela medida de cada criança/ adolescente e pelas experiências vividas em seu contexto. Suas histórias se tornaram suportes nesta pesquisa para gerar reflexões sobre outras crianças e adolescentes, que estão em serviços de média e alta complexidade no território brasileiro, cujos chamados distúrbios alimentares se revelam como mensagens que reconectam corpo físico e a constituição intersubjetiva com alimentação, prazer e viver.

Food is essential for the maintenance of life and is related to the construction of symbolic and sociocultural values. Despite being a vital function, the act of eating is not innate to human beings. It results from a complex learning process that begins in pregnancy and continues throughout child development. However, this process can be disrupted and lead to the development of eating difficulties and food refusal in childhood. Therefore, children and adolescents who are born and grow up in health conditions that are not favorable to development, either because of personal experiences related to difficult births, prolonged periods of hospitalization and/or use of health technologies, may also present difficulties in the ability to ingest and relate to food. Starting from this child/adolescent in a conversation with the clinical scene and assuming feeding difficulties and food refusal as a message to be transmitted from child/adolescent to adult, this study investigated the universe of meanings present in the interactions of children and adolescents with complex chronic health condition in their eating context. We were interested in understanding how the expressions and interactions of the child/adolescent spoke of her/him as a subject in the eating scene and how she/he was subjected to the adults' expression. This was a qualitative research, which used participant observation and dialogic interviews as techniques for data production. The study site was the infirmary sector of a pediatric university hospital located in the city of Rio de Janeiro, a reference institution in the care of children with complex chronic health conditions. The researcher circulated through the ward of this hospital observing scenes of infant and juvenile feeding and of family and hospital care seeking opportunities for interaction and open interviews with the caregivers, with the hospitalized children and adolescents, and with the health professionals. The observations were recorded in a field diary and the interviews were audio recorded for later transcription, when authorized by the participants. The field research time was 10 months, 8 of which were for participant observation. The results of this research speak to the life and feeding trajectory of 04 participants (three children and one adolescent) living in a situation of prolonged hospitalization. Although often subjected to the control and decisions of adults of reference for the achievement of clinical and nutritional well-being, in this research, Eloá, Vitória, Kiara and Luiz revealed their protagonism about their own food intake, showing that attitudes usually labeled and pathologized, such as refusal and food selectivity, are actually about choices and non choices of the subject, which communicate their human identity and are shaped by the measure of each child/adolescent and by the experiences lived in their context. Their stories became supports in this research to generate reflections about other children and adolescents, who are in medium and high complexity services in the Brazilian territory, whose so-called eating disorders reveal themselves as messages that reconnect physical body and intersubjective constitution with food, pleasure and living.

A comparison of re-presentation and modified chin prompt to treat different topographies of liquid expulsion.

Treatment of one behavior in the chain of consumption might be associated with the emergence of other problematic behaviors. For example, some children with feeding disorders expel liquid. Moreover, the form in which children expel liquid might vary and influence whether a treatment to reduce liquid expulsion will result in clinically meaningful outcomes. In the current investigation, we first identified topographies of liquid expulsion (e.g., forceful, run out) for each child. We then compared and evaluated the effects of 2 procedures, a modified chin prompt and re-presentation, on the liquid expulsion of 3 children with feeding disorders. For 2 participants, expulsion decreased to clinically meaningful levels with a modified chin prompt or re-presentation. However, for 1 participant, expulsion decreased to clinically meaningful levels only when we combined the modified chin prompt and re-presentation as part of a treatment package. We discuss possible mechanisms underlying the effects of a modified chin prompt and re-presentation, in addition to areas for future research.

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.

CROSS-CULTURAL ADAPTATION AND VALIDATION OF THE MONTREAL CHILDREN'S HOSPITAL FEEDING SCALE INTO BRAZILIAN PORTUGUESE.

OBJECTIVE: To cross-culturally adapt and validate the Montreal Children's Hospital Feeding Scale (MCH-FS) into Brazilian Portuguese. METHODS: The MCH-FS, originally validated in Canada, was validated in Brazil as Escala Brasileira de Alimentação Infantil (EBAI) and developed according to the following steps: translation, production of the Brazilian Portuguese version, testing of the original and the Brazilian Portuguese versions, back-translation, analysis by experts and by the developer of the original questionnaire, and application of the final version. The EBAI was applied to 242 parents/caregivers responsible for feeding children from 6 months to 6 years and 11 months of age between February and May 2018, with 174 subjects in the control group and 68 ones in the case group. The psychometric properties evaluated were validity and reliability. RESULTS: In the case group, 79% of children were reported to have feeding difficulties, against 13% in the control group. The EBAI had good internal consistency (Cronbach's alpha=0.79). Using the suggested cutoff point of 45, the raw score discriminated between cases and controls with a sensitivity of 79.4% and specificity of 86.8% (area under the ROC curve=0.87). CONCLUSIONS: The results obtained in the validation process of the EBAI demonstrate that the questionnaire has adequate psychometric properties and, thus, can be used to identify feeding difficulties in Brazilian children from 6 months to 6 years and 11 months of age.

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.

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.

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.

Further examination of the treatment of multiply controlled inappropriate mealtime behavior.

We systematically replicated Bachmeyer et al. (2009) by examining extinction procedures matched to each function, individually and in combination, to treat the food or liquid refusal of 4 children diagnosed with a feeding disorder whose inappropriate mealtime behavior was maintained by multiple functions (i.e., escape and attention). Previous research suggests that adding differential reinforcement to extinction procedures may result in better treatment outcomes. Therefore, we added differential reinforcement to extinction procedures matched to each function. Differential reinforcement and extinction matched only to escape or attention resulted in low rates of inappropriate mealtime behavior and high, stable levels of acceptance for only 1 child. Consistent with Bachmeyer et al., inappropriate mealtime behavior decreased, and acceptance increased for the remaining 3 children only after we matched differential reinforcement and extinction procedures to both escape and attention.

Cross-cultural adaptation and validation of the montreal children's hospital feeding scale into brazilian portuguese / Adaptação transcultural e validação da montreal children's hospital feeding scale para o português falado no brasil

ABSTRACT Objective: To cross-culturally adapt and validate the Montreal Children's Hospital Feeding Scale (MCH-FS) into Brazilian Portuguese. Methods: The MCH-FS, originally validated in Canada, was validated in Brazil as Escala Brasileira de Alimentação Infantil (EBAI) and developed according to the following steps: translation, production of the Brazilian Portuguese version, testing of the original and the Brazilian Portuguese versions, back-translation, analysis by experts and by the developer of the original questionnaire, and application of the final version. The EBAI was applied to 242 parents/caregivers responsible for feeding children from 6 months to 6 years and 11 months of age between February and May 2018, with 174 subjects in the control group and 68 ones in the case group. The psychometric properties evaluated were validity and reliability. Results: In the case group, 79% of children were reported to have feeding difficulties, against 13% in the control group. The EBAI had good internal consistency (Cronbach's alpha=0.79). Using the suggested cutoff point of 45, the raw score discriminated between cases and controls with a sensitivity of 79.4% and specificity of 86.8% (area under the ROC curve=0.87). Conclusions: The results obtained in the validation process of the EBAI demonstrate that the questionnaire has adequate psychometric properties and, thus, can be used to identify feeding difficulties in Brazilian children from 6 months to 6 years and 11 months of age.

RESUMO Objetivo: Realizar a adaptação transcultural e a validação da escala Montreal Children's Hospital Feeding Scale (MCH-FS) para a língua portuguesa falada no Brasil. Métodos: A MCH-FS, originalmente validada no Canadá, foi validada no Brasil como Escala Brasileira de Alimentação Infantil (EBAI) e desenvolvida a partir das seguintes etapas: tradução, montagem da versão em português brasileiro, teste da versão em inglês e da versão em português brasileiro, retrotradução, análise por experts e autora do questionário original e aplicação da versão final em estudo. A EBAI foi aplicada em 242 pais/cuidadores responsáveis pela alimentação de crianças de seis meses a seis anos e 11 meses de idade no período de fevereiro a maio de 2018, sendo 174 no grupo controle e 68 no grupo dos casos. As propriedades psicométricas avaliadas foram validade e confiabilidade. Resultados: No grupo dos casos, 79% dos pais/cuidadores relataram dificuldades alimentares, e no grupo controle, 13%. A EBAI apresentou boa consistência interna (alfa de Cronbach=0,79). Utilizando-se o ponto de corte sugerido de 45, o escore bruto (raw score) diferenciou casos de controles com sensibilidade de 79,4% e especificidade de 86,8% (área sob a curva ROC=0,87). Conclusões: Os resultados obtidos na validação da EBAI evidenciaram medidas psicométricas adequadas. Portanto, a escala pode ser utilizada na identificação de dificuldades alimentares em crianças brasileiras de seis meses a seis anos e 11 meses idade.