Pediatric Feeding Disorder: Consensus Definition and Conceptual Framework.

Pediatric feeding disorders (PFDs) lack a universally accepted definition. Feeding disorders require comprehensive assessment and treatment of 4 closely related, complementary domains (medical, psychosocial, and feeding skill-based systems and associated nutritional complications). Previous diagnostic paradigms have, however, typically defined feeding disorders using the lens of a single professional discipline and fail to characterize associated functional limitations that are critical to plan appropriate interventions and improve quality of life. Using the framework of the World Health Organization International Classification of Functioning, Disability, and Health, a unifying diagnostic term is proposed: "Pediatric Feeding Disorder" (PFD), defined as impaired oral intake that is not age-appropriate, and is associated with medical, nutritional, feeding skill, and/or psychosocial dysfunction. By incorporating associated functional limitations, the proposed diagnostic criteria for PFD should enable practitioners and researchers to better characterize the needs of heterogeneous patient populations, facilitate inclusion of all relevant disciplines in treatment planning, and promote the use of common, precise, terminology necessary to advance clinical practice, research, and health-care policy.

Longitudinal Study of Sensory Features in Children with Autism Spectrum Disorder.

BACKGROUND: Between 45 and 95% of children with Autism Spectrum Disorder (ASD) present sensory features that affect their daily functioning. However, the data in the scientific literature are not conclusive regarding the evolution of sensory features in children with ASD. The main objective of this study was to analyze the sensory features of children within the age of 3-4 (T1) when they received their ASD diagnosis and two years later (T2) when they started school. METHODS: We conducted a prospective cohort study to assess sensory features in 34 children with ASD over time. The data were collected using a standardized assessment tool, the Sensory Profile. RESULTS: Our analyses show that sensory features in children with ASD are stable from the age of three to six years. The stability of sensory scores is independent of correction by covariates, such as cognitive level and autism severity scores. CONCLUSIONS: Children with ASD have sensory features that persist from the time of diagnosis at the age of 3 to 4 years to school age. This persistence of sensory features from an early age underscores the need to support these children and their parents. Sensory features should be detected early and managed to improve functional and psychosocial outcomes.

Oral and nonoral sensorimotor interventions facilitate suck-swallow-respiration functions and their coordination in preterm infants.

BACKGROUND: Preterm infants are at high risk of encountering oral feeding difficulties. Early sensorimotor interventions may improve oral feeding skills in preterm infants. AIM: To further explore the effects of an oral (O), tactile/kinesthetic (T/K), and combined (O+T/K) sensorimotor intervention on preterm infants' nutritive sucking, swallowing and their coordination with respiration. STUDY DESIGN: Seventy-five infants (29 [0.3, standard error of mean, SEM] weeks gestation, 49 males/26 females) were randomly assigned to an O group involving sensorimotor input to the oral structures; a T/K group involving sensorimotor input to the trunk and limbs; a combined (O+T/K) group; and a control group. OUTCOME MEASURES: Stage of sucking, suction and expression amplitudes (mmHg), suck-swallow ratio, stability of suck-swallow interval, and swallow-respiration patterns. RESULTS: The O group had significantly more advanced sucking stages, and greater suction and expression amplitudes than controls [p≤0.035, effect size (ES) >0.6]. The suck-swallow ratio and stability of suck-swallow intervals did not significantly differ among groups (p≥0.181, ES≤0.3). The three interventions led to fewer swallows bracketed by prolonged respiratory pauses compared to controls (pause-swallow-pause, p≤0.044, ES≥0.7). The T/K and combined (O+T/K) groups had greater occurrence of swallows bracketed by expiration than the control and O groups (expiration-swallow-expiration, p≤0.039, ES≥0.3). CONCLUSION: The O intervention enhanced specific components of nutritive sucking. All three interventions resulted in improved swallow-respiration coordination. Sensorimotor interventions have distributed beneficial effects that go beyond the specific target of input.

Oral and non-oral sensorimotor interventions enhance oral feeding performance in preterm infants.

AIM: The aim of this study was to determine whether oral, tactile/kinaesthetic (T/K), or combined (oral+T/K) interventions enhance oral feeding performance and whether combined interventions have an additive/synergistic effect. METHOD: Seventy-five preterm infants (mean gestational age 29 wk; standard error of the mean [SEM] 0.3 wk; mean birthweight 1340.3g; SEM 52.5 g; 49 males and 26 females) were randomly assigned to one of three intervention groups or a control group. The oral group received sensorimotor input to the oral structures, the T/K group received sensorimotor input to the trunk and limbs, and the combined group received both. The outcomes were time from introduction of nipple feeding to independent oral feeding (d), proficiency (intake in the first 5 min, %), volume transfer (%), rate of transfer (mL/min), volume loss (%), and length of hospital stay (d). RESULTS: Infants in the three intervention groups achieved independent oral feeding 9-10 days earlier than those in the control group (p<0.001; effect size 1.9-2.1). Proficiency (p ≤ 0.002; effect size 0.7-1.4) at the time of one to two and three to five oral feedings per day, volume transfer (p ≤ 0.001; effect size 0.8-1.1) at one to two, three to five, and six to eight oral feedings per day, and overall rate of transfer (p ≤ 0.018; effect size 0.8-1.1) were greater, and overall volume losses were less (p ≤ 0.007; effect size 0.9-1.1), than in the control group (p ≤ 0.042). The combined group attained independent oral feeding at a significantly younger postmenstrual age than controls (p=0.020) and had clinically greater proficiency than the T/K group (p=0.020; effect size 0.7) and oral group (p=0.109; effect size 0.5). Length of hospital stay was not significantly different between groups (p=0.792; effect size 0.02-0.3). INTERPRETATION: Oral and T/K interventions accelerated the transition from introduction to independent oral feeding and enhanced oral feeding skills. T/K has beneficial effects beyond the specific targeted system. The combined sensorimotor intervention led to an additive/synergistic effect for proficiency, further benefiting this population.

Mealtime problems in children with autism spectrum disorder and their typically developing siblings: a comparison study.

Many children with autism spectrum disorders (ASD) have mealtime problems. Diagnosis and the social environment may influence eating behaviours. We examined whether children with ASD have more mealtime problems than their typically developing siblings, and whether age and sex are associated with mealtime problems. Forty-eight families participated in this cross sectional study by completing a questionnaire (Eating Profile) for their child with ASD, 3 to 12 years of age. A second Eating Profile was completed for the sibling nearest in age without ASD. Children with ASD had a mean of 13.3 eating problems, with lack of food variety predominating. Siblings had 5.0 problems. Children with ASD had more eating problems as infants. Older children tended to have fewer problems than younger children. This study points to the importance of screening for mealtime problems. Children with ASD had significantly more mealtime problems than their sibling living in the same social environment.

Association of sensory processing and eating problems in children with autism spectrum disorders.

"Selective" or "picky eating" is a frequent problem in children with autism spectrum disorders (ASD). Many of these children do not treat sensory input, particularly olfactory, auditory, visual, and tactile information in the same manner as their typically developing peers of the same age. The purpose of this paper was to examine the relationship between problems of sensory processing and the number of eating problems in children with ASD. Of 95 children with ASD, 3 to 10 years of age, 65 percent showed a definite difference and 21 percent a probable difference in sensory processing on the total score of the Short Sensory Profile. These results were significantly related to an increase in the number of eating problems measured by the Eating Profile. These results could not be explained by age, sex, mental retardation, attention deficit disorder, or hyperactivity. Timely interventions focusing on the sensory components of eating must now be developed.

Sensorimotor interventions improve growth and motor function in preterm infants.

PURPOSE: To assess the effect of an oral (O+O), a tactile/kinesthetic (T/K+T/K), and a combined (O+T/K) intervention on preterm infants' weight gain and motor function and to determine whether the combined O+T/K intervention has an additive/synergistic effect on outcomes. DESIGN/SAMPLE: Seventy-five preterm infants were randomized into an O+O intervention consisting of oral stimulation, a T/K+T/K intervention involving whole body stimulation, an O+T/K intervention, and a control group. Interventions were administered for 15 minutes, twice a day, for ten days. OUTCOMES: Weight gain, motor function. RESULTS: The O+O and T/K+T/K groups had greater weight gain during the intervention period than did controls (p ≤.025). The T/K+T/K and O+T/K groups had better motor function than did controls (p ≤.017). CONCLUSION: Single and combined interventions improved growth and motor function. The combined intervention, because of the shorter duration of each modality, did not lead to additive/synergistic effects, suggesting that the duration of the sensorimotor input is as important as its target in achieving defined outcomes.

The effectiveness of task-oriented intervention and trunk restraint on upper limb movement quality in children with cerebral palsy.

AIM: The goal of this study was to contribute evidence towards the effectiveness of task-oriented training with and without restriction of trunk movement (trunk restraint) on the quality of upper limb movement in children with cerebral palsy (CP). METHOD: We used a prospective, single-subject research design in 12 children (three males, nine females; aged 6-11 y; median 9 y) with di-, hemi-, or quadriplegia. Movements of the most affected arm were assessed five times: three times before training, immediately after training, and 3 months after training. The main outcome measures were the Melbourne Assessment of Unilateral Upper Limb Function (Melbourne) and upper limb movement kinematics during a functional reaching task. Children were randomly allocated to one of two groups: task-oriented training with or without trunk restraint. Treatment consisted of three 1-hour sessions per week for 5 weeks (total training duration 15 h). Treatment effects were determined using single-subject research design analysis--regression through baseline data and standard mean differences. RESULTS: Although the Melbourne scores were largely unchanged after training, some children in each group improved arm trajectory smoothness (effect size 0.55-1.87), and most children improved elbow extension range (effect size 0.55-4.79). However, more children in the trunk restraint group than in the no restraint group demonstrated reduced trunk displacement (effect size 0.94-2.25) and longer-term improvements in elbow extension and trunk use. Among the group who underwent training without trunk restraint, trunk displacement was unchanged or increased, and fewer carry-over effects were apparent at follow-up. INTERPRETATION: This proof-of-principle study showed that greater improvement in the quality of upper limb movement in children with CP, including less compensatory trunk use and better carry-over effects, was achieved by training with trunk restraint.

Reliability of kinematic measures of functional reaching in children with cerebral palsy.

AIM: The determination of rehabilitation effectiveness in children with cerebral palsy (CP) depends on the metric properties of the outcome measure. We evaluated the reliability of kinematic measures of functional upper limb reaching movements in children with CP. METHOD: Thirteen children (ten females, three males) with spastic hemiplegic, diplegic, or quadriplegic CP affecting at least one arm (mean age 9y, SD 1.6y; range 6-11y; Manual Ability Classification System [MACS] levels II-IV) were evaluated three times over 5 weeks. The kinematics of the more affected arm reaching to grasp a 2cm(3) block placed at three distances from the body midline were analysed. The reliability (test-retest) of six kinematic variables (endpoint trajectory straightness and smoothness, trunk displacement, elbow extension, shoulder horizontal adduction, and shoulder flexion] was tested and expressed as intraclass correlation coefficients (ICC, model 2,K) and 95% confidence intervals. RESULTS: Trajectory smoothness, trunk displacement, elbow extension, and shoulder flexion (far target) had the highest ICCs (0.82-0.95). Other kinematic variables had moderate (0.50< or =ICC< or =0.81) or low (0.17-0.38) reliability. Test-retest reliability was task dependent, as reaches required different degrees of trunk displacement and joint excursion. INTERPRETATION: Kinematic variables can be used as outcomes in clinical trials to test upper limb intervention effectiveness on motor performance and movement quality. As kinematic variables are task specific, reliability should be interpreted in the context of task requirements.

A controlled-flow vacuum-free bottle system enhances preterm infants' nutritive sucking skills.

We have shown that a controlled-flow vacuum-free bottle system (CFVFB) vs. a standard bottle (SB) facilitates overall transfer and rate of milk transfer, and shortens oral feeding duration in very-low-birth-weight (VLBW) infants. We aimed to understand the basis by which this occurs. Thirty infants (19 males; 27 +/- 1 weeks gestation) were randomized to a CFVFB or SB. Outcomes monitored at 1-2 and 6-8 oral feedings/day when infants were around 34 and 36 weeks postmenstrual age, respectively, included: overall transfer (% volume taken/volume prescribed), rate of milk transfer (ml/min), sucking stage, frequency of suction (#S/s) and expression (#E/s), suction amplitude (mmHg), and sucking burst duration (s). At both periods we confirmed that infants using a CFVFB vs. SB demonstrated greater overall transfer and rate of milk transfer, along with more mature sucking stages. Suction and expression frequencies were decreased with CFVFB vs. SB at 1-2 oral feeding/day; only that of suction was reduced at 6-8 oral feedings/day. No group differences in suction amplitude and burst duration were observed. We speculate that oral feeding performance improves without significant change in sucking effort with a CFVFB vs. SB. In addition, we have shown that VLBW infants can tolerate faster milk flow than currently presumed. Finally, the use of a CFVFB may reduce energy expenditure as it enhances feeding performance without increasing sucking effort.

Sensori-motor and daily living skills of preschool children with autism spectrum disorders.

Sensori-motor development and performance of daily living skills (DLS) remain little explored in children with autism spectrum disorders (ASD). The objective of this study was to determine the impact of sensori-motor skills on the performance of DLS in preschool children with ASD. Thirty-five children, 3-4 years of age, were recruited and assessed with a battery of diagnostic and clinical tests. Children showed atypical sensory responses, very poor motor and DLS. Sensory avoiding, an excessive reaction to sensory stimuli, and fine motor skills were highly correlated with DLS, even when cognitive performance was taken into account. Sensori-motor deficits have an impact on the autonomy of children with ASD and interventions should aim at improving and supporting the development of sensori-motor skills.

Interventions and outcomes for children with dysphagia.

Feeding problems are common even in typically developing infants and children. However, they are more frequent and persistent in children with developmental disabilities. This article will provide an overview of current literature and a rationale underlying the interventions used for children with cerebral palsy (CP) who have eating impairments (dysphagia). The review is not intended to be exhaustive, but papers were selected that highlight some of the issues and challenges of the field. Normal oral-motor development is briefly discussed to show how it may inform clinical practice in the understanding of feeding problems. Description of the risk factors and the nature and extent of eating impairments will show how interventions need to be specific to the severity of eating impairments. Examination of sensorimotor therapies, using oral stimulation exercises or an intra-oral appliance, will highlight the range of their effectiveness, as well as their limitations. Similarly, an examination of tube feeding, used for nutritional rehabilitation of the most severely affected children, will address the benefits, controversies as well as moral issues encountered by caregivers and professionals. Multi-center studies will be needed to obtain more homogeneous samples, large enough to address questions of early interventions and their subsequent effect on later development.

Psychometric testing of the McGill Ingestive Skills Assessment.

The goal of this study was to determine the psychometric properties of the McGill Ingestive Skills Assessment. Interrater and intrarater reliability and score stability were tested using repeated administration of this test. The Functional Independence Measure and Modified Mini-Mental State Examination, as well as patient characteristics, were used to determine the validity of the assessment. One hundred and two persons with ingestive skill loss of neurologic origin were evaluated. Intraclass correlations for interrater, intrarater reliability and stability reached or surpassed 0.80 for most subscales. In validity testing, significant relationships were found between McGill Ingestive scores and Functional Independence Measure and Mini-Mental scores, as well as with patient characteristics. It is concluded that the McGill Ingestive Skills Assessment approaches or meets levels of reliability necessary for assessing patients and is valid for adults with neurogenic feeding difficulties residing in tertiary care facilities.

The McGill ingestive skills assessment predicts time to death in an elderly population with neurogenic dysphagia: preliminary evidence.

The McGill Ingestive Skills Assessment (MISA) is a new assessment tool which quantifies the ingestive process by scoring a meal observation. The reliability and the construct validity of the MISA have been documented. However, establishment of the ability of the MISA to predict health outcomes related to feeding difficulties would support its applicability in research and in clinical settings. Seventy-three participants of a large-scale reliability and validity study were followed for up to 563 days following evaluation with the MISA. The date of the first pulmonary infection and the date and cause of death where applicable were obtained from medical records. Individuals with no incident of pulmonary infection and who were not deceased were "censored" at the date of followup. Survival analyses revealed that the MISA scores are predictive of death using a Cox proportional hazards model, and of time to pulmonary infection using a flexible model. Scores on the Solid Ingestion and Self-feeding scales are predictive of death using the Cox model, and the Texture Management scale is predictive of death using the flexible model. This effect remains statistically significant even when MISA scores are adjusted for the participant's age. These findings support the validity of the MISA for use with elderly individuals with neurogenic ingestive skill loss residing in long-term care facilities.