Feeding impairments in children: diagnosis and effective intervention.

The four main requirements for oral-motor development are stability and mobility of the ingestive system, rhythmicity, sensation, oral-motor efficiency and economy. Ingestion can be divided into oral, pharyngeal and esophageal stages. The main categories of pathology encountered in our swallowing and dysphagia clinic are encephalopathies (including cerebral palsy), genetic disorders (including chromosomal aberrations), syndromes associated with swallowing difficulty (e.g. Rett, Dandy-Walker, DiGeorge), head injuries, brain tumors, developmental delay and the oral deprivation syndrome (e.g. due to prolonged tube feeding on a preterm infant). The behavioral expression of the many different pathologies falls into three categories: (1) resistance to accepting food orally; (2) lack of energy and endurance to do the 'work' of eating; and (3) oral-motor disabilities resulting in an inability to produce the necessary motor skills for ingestion. Expect expression and exacerbation of feeding problems during periods of most active growth, i.e. from birth to 2 years and during the adolescent growth spurt. Identify the source of the feeding problem. Establish its pathology and note the clinical manifestations. Determine if the problem has a strictly physiologic origin or whether it may be exacerbated by the feeding interaction between child and feeder. Determine what diagnostic tests are needed and refer child for testing Formulate the treatment approach based on clinical observations and results of diagnostic tests. Teach and monitor treatment which can be given by caregivers. Set time limits for treatment and clearly state expected results. Evaluate progress by comparing outcome to stated treatment objectives. Refer children with more severe problems to a multidisciplinary treatment team.

Chewing cycles in 2- to 8-year-old normal children: a developmental profile.

Chewing movements of normal 5-, 6-, 7-, and 8-year-old children were measured and compared across age, food textures, and gender. Applesauce, graham cracker, and raisins were used. Measures were taken on 98 children: eighteen 5-year-olds (9 boys, 9 girls); thirty-five 6-year-olds (16 boys, 19 girls); twenty-six 7-year-olds (13 boys, 13 girls); and nineteen 8-year-olds (10 boys, 9 girls). Comparisons were made with data of another twenty 5-year-olds (10 boys, 10 girls) from a previous study. Chewing movements were measured by time, number of cycles, and a time/cycle ratio. Food texture affected time, cycle, and the time/cycle ratio. Age affected time and cycles. Data from earlier studies are used to describe the development of chewing between the ages of 2 and 8 years. Results indicate that eating skills for different food textures mature at different rates. Skills for eating solid foods mature before skills for eating viscous and pureed foods mature. Thus, the consistent use of food textures is important when children's eating skills are evaluated. The normative data presented here may be used by clinicians evaluating children within the given age group.

Tongue movements in normal 2- to 8-year-old children: extended profile of an eating assessment.

In this study tongue movements of 103 normal 5-, 6-, 7-, and 8-year-old children were measured and compared. The 5-year-olds were compared with children of an earlier study and data were combined for 2- to 8-year-old children. Two different tongue positions were measured as three standard textures of food were presented: first, the position of the tongue as the food was 5 cm away from the lips, and second, the position of the tongue or other oral characteristics as the food was swallowed. For the anticipation of food a significant age-texture (p less than .001) as well as an age-sex-texture interaction was noted (p less than .035). For swallowing, significant age (p less than .0001), texture (p less than .0001), and sex-age interactions (p less than .0001) were found. Although food is anticipated in a similar fashion by both sexes, age and texture differences must be taken into account when swallowing is evaluated. A preliminary developmental curve for the two eating behaviors is presented for children 2 to 8 years old.

Development of oral side preference during chewing and its relation to hand preference in normal 2- to 8-year-old children.

Normative data on skills of the tongue used in eating are presented. Normal children 5 to 8 years old were studied regarding their preference of placing food either on the right or left side of the mouth when starting to eat. A developmental curve spanning 2 to 8 years was generated by including data from an earlier study. Data of oral side preference were correlated with data of preferred hand use. In addition, the ability to move a small piece of food from one side of the mouth to the other was studied. It was found that normal children undergo a transition from placing solid food predominantly on the right side at 2 years of age to placing it on the left side at 4 years of age. The left side preference persists until at least 8 years of age for both viscous and solid food textures. Oral side preference did not correlate with hand preference. The ability to move food from one side of the mouth to the other (lateralizing) was found to undergo a developmental progression: The inability to lateralize in a third of 2-year-olds gave way to rolling movements. Concomitantly, a consistent increase in slow and then smooth movements was found to occur from 2 to 8 years of age. These data provide the clinician with a normative baseline against which eating-impaired children can be compared.

Use of substitute food textures for standard eating assessment in children with cerebral palsy and children without disabilities.

OBJECTIVE: Eating assessment is the first step toward amelioration of eating problems in children. A quantitative evaluation tool with three standard textures of food has been developed to determine the severity of an eating problem. However, children occasionally refuse some of the standard textures. Much time and effort could be saved if substitute textures could be used for testing. The purpose of this study was to examine the feasibility of using substitute food textures. METHOD: Twenty children (10 without disabilities, 10 with cerebral palsy and eating impairments) with a mean age of 8.2 years (SD = 4.1) years were tested with three standard and three substitute textures of food (solid viscous, puree. Eating time (in seconds) and chewing cycles were compared between standard and substitute textures as well as between children without disabilities and children with eating impairments. RESULTS: Substitutes for pureed and viscous, but not solid textures could be used for children without disabilities; in children with eating impairments, substitutes for viscous and solid, but not pureed textures could be used. CONCLUSION: Children with eating impairments may be more sensitive than children without disabilities to small changes in food consistencies or other characteristics of the food. Thus, in standardized testing, food textures should not be arbitrarily interchanged.

Tongue movements in normal 2-, 3-, and 4-year-old children: a continuation study.

In this study, tongue movements of normal 2-, 3-, and 4-year-old children were measured and compared. The 4-year-olds were also compared with 4-year-old children in a previous study (Schwartz J: Observation of Tongue and Jaw Movement in Normal Four- and Five-Year-Old Children, master's thesis. Washington University, School of Occupational Therapy, St. Louis, MO, 1982). Measures were taken on 56 children: 17 two-year-olds (8 females, 9 males), 19 three-year-olds (10 females, 9 males), and 20 four-year-olds (10 females, 10 males). Two different tongue positions were quantified: First, the position of the tongue as the food was presented to the child at the moment when the food was 5 cm away from the lips and second, the position of the tongue as the food was swallowed. Younger children held their tongues in a more forward position when the food was presented, although the predominant tongue position was behind the teeth in all three age groups. During swallowing there was also a progression, as age increased, from pursing the lips to puckering at the corners of the mouth. Many children kept their mouth open during swallowing. These results provide further normative data for the assessment of eating-impaired children.

Comparison of chewing cycles in 2-, 3-, 4-, and 5-year-old normal children.

Chewing movements of normal 2-, 3-, and 4-year-old children were measured. Chewing movements of 2- and 3-year-olds were compared with those of 4- and 5-year-olds. Measures were taken on 56 children: 17 were 2 years old (8 female, 9 male); 19 were 3 years old (10 female, 9 male); and 20 were 4 years old (10 female and 10 male). Data of twenty 5-year-olds (10 males, 10 females) were taken from a previous study (9). Chewing movements were measured by time (seconds), number of cycles, and a time/cycle ratio. A chewing cycle was defined as an upward and downward movement of the chin. Total time from the moment food was placed in the mouth until the final swallow occurred was divided by the number of cycles counted for the same period. The type of food eaten affected time, cycles, and the time/cycle ratio, but age and sex did not. A comparison of younger (2- and 3-year-olds) and older children (4- and 5-year-olds) showed significant time differences. During maturation, time was shortened. It was shown earlier that under pathologic conditions (Down's syndrome) time was prolonged. Thus, the time/cycle ratio is an excellent indicator of the developmental status of a child.

Tongue movements in 4- and 5-year-old Down's syndrome children during eating: a comparison with normal children.

This study describes tongue movements of 4- and 5-year-old Down's syndrome children during eating and then compares the movements to those of age-matched normal children. The study is the second in a long-term project to develop a standardized eating assessment for children. Tongue movements were monitored in 26 children: 14 were 4 years +/- 2 months (8 males, 6 females) and 12 were 5 years +/- 2 months (6 males, 6 females). Two different tongue positions were quantified: 1) as food was presented to the child when the food was 5 cm from the lips; and 2) as food was swallowed. The children's ages and gender along with the type of food affected tongue position on food presentation; however, only the children's ages and gender affected tongue position on swallowing. In general, most tongue positions of Down's syndrome children were characterized by 1) a forward placement of the tongue in the mouth, and 2) the absence of the maturational changes in normal children of the same age.

Chewing cycles in 4- and 5-year-old Down's syndrome children: a comparison of eating efficacy with normals.

Chewing movements of Down's syndrome children were measured and compared with those of normal preschool children. Twenty-six Down's syndrome children were monitored: 14 were 4 (8 males, 6 females) and 12 were 5 years old (6 males, 6 females). Chewing movements were measured by time (in seconds), number of cycles, and a time/cycle ratio. A chewing cycle was defined as an upward and downward movement of the chin. The time/cycle ratio is the total time, from the moment food was placed in the mouth until the final swallow occurred, divided by the number of cycles counted for the same period. The children's ages and gender did not affect time, cycles, or the time/cycle ratio. However, the measures were strongly affected by the type of food eaten. Children with Down's syndrome chew at a rate comparable to that of normal children. However, the duration of chewing is significantly prolonged per bite of food. This may be attributed to these children's lack of chewing vigor or their inability, at the ages studied, to chew solid foods. Time/cycle ratios are an excellent index to document such differences. How much sensory differences or deficits contribute to these findings is not known.

Tongue movements in normal preschool children during eating.

This study describes tongue movements of normal preschool children during eating, and is the first phase in a long-term project to develop a standardized eating assessment for children. It is hoped eventually to fill the need for an objective measurement tool in pediatric occupational therapy practice. The movements were monitored in 40 children; 20 were 4 years +/- 1 month, and 20 were 5 years +/- 1 month. Each group consisted of 10 boys and 10 girls. Two different tongue positions were quantified: First, as food was presented to the child when the food was 5 cm from the lips; and second, as food was swallowed. Tongue position upon food presentation and upon swallowing was affected by age, sex, and type of food. Both responses showed maturational changes from 4 to 5 years. It is proposed that important maturational changes take place between 4 and 5 years of age, but that adult patterns of swallowing are attained later in development.

Chewing cycles in 4- and 5-year-old normal children: an index of eating efficacy.

Eating movements in the preschool child undergo change between the ages of 2 and 5 years. There is a lack of objective clinical data from normal children against which eating movements of feeding-impaired children can be compared. In this study, chewing movements were measured to complement tongue movements described in an earlier study. The movements were monitored in 40 children: 20 were four years old and 20 were five years old. Each group had ten boys and ten girls. Chewing movements were measured by time (sec), number of cycles, and a time/cycle ratio. A chewing cycle was defined as an upward and downward movement of the chin. Total time from the moment food was placed in the mouth until the final swallow occurred was divided by the number of cycles counted for the same period. Age and sex did not affect time, cycles, or the time/cycle ratio. However, the measures were strongly affected by the type of food eaten. These findings suggest that the texture of food strongly influences both the number of chewing cycles performed and the time used for chewing. The occupational therapist administering eating evaluations to children should carefully choose the foods offered for initial evaluations and use the same food consistently during re-evaluations.

Lateralization of tongue movements during eating in children 2 to 5 years old.

Normative data on skills of the tongue used in eating are presented. Normal children 2 to 5 years old were studied regarding their preference of placing food either on the right or left side when eating, and they were compared with age-matched Down's syndrome children. In addition, the ability to move food from the right to the left side of the mouth was studied. Normal children underwent a transition from predominantly placing food on the right side at 2 years of age to predominantly placing it on the left side at 4 years of age. Among Down's syndrome children females preferred the right side, and males preferred the left side. The ability to move food from right to left (lateralizing) undergoes a developmental progression from tilting the head to rolling, followed by slow and eventually by smooth movement from one side to the other. Only 15% of the 5-year-olds were able to move food smoothly from side to side. These data provide a baseline against which children with eating problems can be compared.

Effect of an oral stimulation program on sucking skill maturation of preterm infants.

This study assessed the effect of an oral stimulation program on the maturation of sucking skills of preterm infants. Thirty-two preterm infants (13 males, 19 females), appropriate size for gestational age (gestational age at birth 28 wks, SD 1.2wks; birthweight 1002g, SD 251g), were randomly placed into experimental and control groups. The experimental group received a daily 15-minute oral stimulation program, consisting of stroking the peri- and intra-oral structures, for 10 days before the start of oral feedings. Sucking measures were monitored with a specially-designed nipple-bottle apparatus. Results indicate that the experimental group achieved full oral feedings 7 days sooner than the control group, and demonstrated greater overall intake (%), rate of milk transfer (mL/min), and amplitude of the expression component of sucking (mmHg). There was no difference in sucking stage maturation, sucking frequency, and amplitude of the suction component of sucking. Endurance, defined as ability to sustain the same sucking stage, sucking burst duration, and suction and expression amplitudes throughout a feeding session, was not significantly different between the two groups. The stimulation program enhanced the expression component of sucking, resulting in better oral feeding performance.

Oral-motor skills following sensorimotor intervention in the moderately eating-impaired child with cerebral palsy.

The purpose of this study was to determine the efficacy of oral sensorimotor treatment in moderately eating-impaired children with cerebral palsy and to examine the effects of treatment on measures of growth. Six domains of feeding were examined in 35 children 4.3-13.3 years of age. Weight and skinfold measures were taken. Children were observed at lunch time, and spoon-feeding, biting, chewing, cup drinking, straw drinking, swallowing, and drooling were examined. Children underwent 20 weeks of sensorimotor treatment, 5-7 min/day, 5 days/week. Limited improvement was observed in the following eating domains: spoon-feeding, biting, and chewing, but not in drinking. Children as a group maintained the pretreatment weight-age percentile. To meet the increasing growth demands of the teenage years, oral-motor therapy may need to be combined with oral caloric supplementation.

Effect of food texture on the development of chewing of children between six months and two years of age.

One hundred and forty-three healthy children between six months and two years of age were studied to determine the effect of food texture on chewing duration. Texture determined very strongly how long a bite of food was chewed, with solids taking longest, followed by viscous food and purée, respectively. As children got older they became more efficient at chewing a comparable bite of food, i.e. chewing time decreased for each texture. Correlations between chewing duration and growth measures (length, weight, head circumference) were observed mainly for the viscous texture. Growth measures did not significantly influence chewing measures. These results differ from previous findings of a strong association between weight and eating ability of children with severe eating impairments.

Effect of oral sensorimotor treatment on measures of growth and efficiency of eating in the moderately eating-impaired child with cerebral palsy.

Thirty-five children with cerebral palsy and moderate eating impairment were studied to determine the effect of oral sensorimotor treatment (OST) on eating efficiency and measures of growth (weight gain). After taking effects of maturation into account, 11 children who received OST (group A) exceeded their expected centile line by 1.7 percentile points after 10 weeks of treatment. Chewing exercises alone (group B) had no effect on weight gain. Although small decreases occurred in the time needed to eat three standard textures of food (solid, viscous, puree) in groups A and B, these were not significant. Children maintained their weight-for-age percentile line although at the lower end of expected norms. These children will be at risk of growth failure because of the increased energy demands once they enter their teenage growth spurt. The clinical implications of these findings are that prolonged mealtime and oral-motor therapies may be adequate through the childhood years. Thereafter, children's growth must be monitored carefully, and oral caloric supplementation is suggested to provide the necessary energy for growth.

Demonstration of a quiescent period for feeding controls in the developing rat.

Feeding behaviour of rats during development was assessed by weighing pups before and after a 4 h feeding session. During the first postnatal week, fasted pups gained significantly more weight than fed pups. This difference disappeared during the second week, but reappeared during the third week and persisted through the fourth week. In another series, pups were weighed at 2 and 4 h after beginning feeding. This showed that fasted pups aged 6 days compensate by suckling longer than fed pups. At 10 and 14 days of age there were no differences between fed and fasted pups at either 2 or 4 h, but from 16 days onward, fasted pups had eaten significantly more than fed pups at both times. A control experiment showed that the lack of compensation by fasted pups aged 10-14 days did not reflect lack of availability of milk. Video-analysis of suckling behaviour at ages 6, 10 and 15 days provided further evidence for lack of feeding controls during the second postnatal week: at 6 and 15 days fasted pups spent more time actively sucking than did fed pups. Whereas at 10 days, there were no differences between fed and fasted pups. It is concluded that feeding controls are present during the first postnatal week, become quiescent during the second week and reappear during the third week.

Identification of children with cerebral palsy unable to maintain a normal nutritional state.

7 children aged 2-16 with severe cerebral palsy and growth failure were compared with children of the same weight in respect of their eating efficiency. Children with cerebral palsy took 2-12 times longer to chew and swallow a standard amount of puréed food and 1-15 times longer for solid food than did their weight-controls. A behaviour score of feeding characteristics was higher in children with cerebral palsy than in controls. Even long meal times do not compensate for the severity of these childrens' feeding impairment. The measurements of feeding efficiency provides the basis for early identification of children who cannot be adequately nourished without ancillary feeding by nasogastric tube or by enterostomy.