Intensive Multidisciplinary Feeding Day Programs in the United States: A Report Regarding the Treatment Landscape.

Intensive multidisciplinary intervention is increasingly recognized as the standard of care for children with complex feeding problems. Much, however, remains unknown about this treatment model. This current qualitative, prospective study sought to identify intensive multidisciplinary day hospital programs operating in the US, describe the treatment approach, and summarize current capacity.

The relationship between food selectivity and stature in pediatric patients with avoidant-restrictive food intake disorder - an electronic medical record review.

BACKGROUND: We aimed to characterize stature in pediatric patients with avoidant/restrictive food intake disorder (ARFID), including associations between body size and nutrient intake and height. METHODS: We conducted a secondary analysis of pre-treatment data from 60 patients diagnosed with ARFID that were collected from the electronic medical record. Anthropometric measurements were converted to age- and sex-specific Z-scores using pediatric CDC growth charts. Spearman correlations were performed to test the relationship between height and weight/BMI Z-scores as well as height Z-score and diet variables. RESULTS: On average, height (-0.35 ± 1.38), weight (-0.58 ± 1.56), and BMI (-0.56 ± 1.48) Z-scores tended to be lower than what would be expected in a generally healthy pediatric population. Percent of individuals with height, weight, or BMI Z-score < -2.0 was 8%, 20%, and 17%, respectively. BMI (P < 0.05) and weight (P < 0.05) were positively associated with height Z-score. Further, intake of some nutrients (e.g., calcium, vitamin D) correlated positively with height Z-score (all P < 0.05). CONCLUSIONS: The cross-sectional relationships reported in this study suggest that in children with ARFID, body weight and consumption of bone-augmenting nutrients such as calcium and vitamin D correlated with height. A thorough understanding of the clinical manifestations of malnutrition and longitudinal effects of restrictive eating in patients with ARFID is critical.

We examined data on growth and height for a sample of 60 children with highly selective eating consistent with an eating/feeding disorder termed avoidant/restrictive food intake disorder (ARFID). These children received treatment in an intensive multidisciplinary intervention program. We found that children had significantly lower weight and body mass index (BMI) compared to same sex and age peers, with a trend toward lower height. Greater body size and intake of specific nutrients was related to taller stature in this sample. Children with ARFID may be at greater risk of impaired growth secondary to highly restricted food intake, a health outcome which should be studied to inform screening and intervention practices.

Preparedness of Speech Language Pathologists and Occupational Therapists to Treat Pediatric Feeding Disorder: A Cross-Sectional Survey.

BACKGROUND: Pediatric feeding disorder (PFD) is increasingly common and is often treated by speech language pathologists (SLPs) and occupational therapists (OTs) in the community setting. However, the preparedness of these disciplines to effectively address PFD is relatively unknown. METHODS: A national (US), online survey was disseminated to providers who assess and treat PFD. For the present analysis, the responses of SLPs (N = 418) and OTs (N = 195) related to their clinical background, educational background, post-graduate training, and self-rated clinical effectiveness were statistically analyzed and compared across the two disciplines. RESULTS: Both SLPs and OTs report feeling underprepared to work with PFD clients immediately following their academic training, but time spent in post-graduate training and years of clinical practice both significantly (p < 0.0001) increased feelings of effectiveness in assessing and treating PFD. Most SLPs and OTs pursued self-directed learning activities to increase competence, with the most common activities being article review, podcasts, and peer case review, although SLPs were significantly more likely to use podcasts (p < 0.0001) and peer review (p = 0.0004) than OTs. The most common barriers for providers were financial, time, travel, and institutional support barriers. CONCLUSIONS: While PFD is a key practice area of both SLPs and OTs, both provider groups feel unprepared and under-supported in providing competent care to these patients upon graduation. Future research and policy should support advancements in training for current SLPs and OTs related to PFD and address current barriers to a specialized educational pathway.

Clinical Correlates and Prevalence of Food Selectivity in Children with Autism Spectrum Disorder.

OBJECTIVE: To examine clinical correlates and prevalence of food selectivity (FS) - ie, self-restricted diet, reluctance to try new foods - in children with autism spectrum disorder (ASD) ascertained from a general outpatient autism clinic. STUDY DESIGN: A multidisciplinary team (pediatric nurse practitioner, psychologist and dietitian) assessed medical and psychosocial histories and dietary habits in 103 children with ASD (mean age = 5.8 ± 2.2 years; range 2-10). Parents rated child mealtime behavior on the Brief Autism Mealtime Behavior Inventory (BAMBI) and disruptive behavior on the Aberrant Behavior Checklist (ABC). Height and weight measurements were collected. Children were classified as FS or no FS based on parent reported intake and mealtime behavior. A 24-hour dietary recall was used to record intake percentages < 80%. Logistic regression and multivariable modeling were used to evaluate clinical correlates with FS. RESULTS: Of 103 children, 45.6% (n = 47) were classified as FS; 54.4% (n = 56) no FS. After adjusting for potential confounders, the odds of FS increased by 1.91 (95% CI: 1.38, 2.64, P < .001) for every half-SD increase in BAMBI total score and by 1.35 (95% CI: 1.05, 1.74, P = .020) for every half-SD increase in ABC Hyperactivity/Noncompliance. No group differences in anthropometrics or nutritional intake were identified. CONCLUSIONS: Food selectivity (FS) in children with ASD was strongly associated with greater severity of disruptive mealtime and hyperactivity/noncompliance behaviors. FS was not associated with anthropometrics or nutritional intake.

Assessing the US treatment landscape for paediatric feeding disorder: A survey of multidisciplinary providers.

BACKGROUND: Paediatric feeding disorder (PFD) is a common childhood condition, estimated to impact one in 37 American children under the age of five. Such high prevalence occurs against a backdrop of limited understanding of the community treatment landscape in the United States. METHOD: To better understand the community treatment landscape for PFD in the United States and identify provider and treatment delivery characteristics, we collected primary data through a web-based survey targeting providers from all four PFD domains (i.e., medical, nutritional, feeding skill, and/or psychosocial) between January 2022 and March 2022. The 71-item cross sectional survey focussed on patient, provider and treatment characteristics. We distributed the survey using an electronic survey tool through Feeding Matters listserv followed by solicitation to discipline specific listservs and professional networks. The analytic approach involved descriptive statistics compared across settings and provider types, focussing on respondents within the United States. RESULTS: Eighty-three percent of respondents reported practicing in the United States. Most of the US sample (74.3%) involved providers from the feeding skill domain (speech-language pathologist - SLP, occupational therapist - OT) who reported delivering care through early intervention or outpatient settings using responsive and sensory based approaches. These approaches lack rigorous empirical evaluation. CONCLUSIONS: Survey results suggest a need to support community providers in engagement with research activity to promote a better understanding of treatment approaches and outcomes associated with a large cohort of providers delivering care (i.e. SLPs, OTs) to patients with PFD.

Feeding after congenital heart surgery: a mixed-methods study of the caregiver experience.

OBJECTIVES: Feeding difficulties after congenital heart surgery are a common concern for caregivers of children with CHD. Insight into the intricacies of their experience is lacking. With a better understanding, healthcare providers can continue to optimize the approach and support mechanisms for these families. This study will explore the psychosocial impacts on caregivers, define barriers to care, and identify areas to improve their care. STUDY DESIGN: This mixed-methods study combined semi-structured interviews with surveys. Purposive sampling targeted caregivers of a child who underwent heart surgery and was discharged with alternative enteral feeding access. A hybrid inductive-deductive methodology was used to analyse interview transcripts. Survey scores were compared to interview content for concordance. RESULTS: Fifteen interviews were conducted with socio-demographically diverse caregivers. Feeding difficulties were often identified as their greatest challenge, with the laborious feeding schedule, sleep deprivation, and tube management being common contributors. Most caregivers described feeling overwhelmed and worried. Time-intensive feeding schedules and lack of appropriate childcare options precluded caregivers' ability to work. Barriers to care included imperfect feeding education, proximity of specialist clinics, and issues with medical supply companies. Caregiver proposals for improved care addressed easing the transition home, improving emotional support mechanisms, and intensifying feeding therapy for expedited tube removal. CONCLUSION: This study describes the psychosocial toll on the caregiver, typical barriers to care, and ideas for improved provision of care. These themes and ideas can be used to advance the family-centered approach to feeding difficulties after heart surgery.

Quantitative impact of frenotomy on breastfeeding: a systematic review and meta-analysis.

BACKGROUND: Symptoms related to infant ankyloglossia/tongue-tie may deter mothers from breastfeeding, yet frenotomy is controversial. METHODS: Databases included PubMed, Embase, CINAHL, PsycINFO, Web of Science, and Google Scholar from 1961-2023. Controlled trials and cohort studies with validated measures of surgical efficacy for breastfeeding outcomes were eligible. Meta-analyses synthesized data with inverse-variance weighting to determine standardized mean differences (SMD) between pre-/postoperative scores. RESULTS: Twenty-one of 1568 screened studies were included. Breastfeeding self-efficacy improved significantly post-frenotomy: medium effect after 5-10 days (SMD 0.60 [95% CI: 0.48, 0.71; P < 0.001]), large effect after 1 month (SMD 0.91 [CI: 0.79, 1.04; P < 0.001]). Nipple pain decreased significantly post-frenotomy: large effect after 5-15 days (SMD -1.10 [CI: -1.49, -0.70; P < 0.001]) and 1 month (SMD -1.23 [CI: -1.79, -0.67; P = 0.002]). Frenotomy had a medium effect on infant gastroesophageal reflux severity at 1-week follow-up (SMD -0.63 [CI: -0.95, -0.31; P = 0.008]), with continued improvement at 1 month (SMD -0.41 [CI: -0.78, -0.05; P = 0.04]). From LATCH scores, breastfeeding quality improved after 5-7 days by a large SMD of 1.28 (CI: 0.56, 2.00; P = 0.01). CONCLUSIONS: Providers should offer frenotomy to improve outcomes in dyads with ankyloglossia-associated breastfeeding difficulties. PROTOCOL REGISTRATION: PROSPERO identifier CRD42022303838 . IMPACT: This systematic review and meta-analysis showed that breastfeeding self-efficacy, maternal pain, infant latch, and infant gastroesophageal reflux significantly improve after frenotomy in mother-infant dyads with breastfeeding difficulties and ankyloglossia. Providers should offer frenotomy to improve breastfeeding outcomes in symptomatic mother-infant dyads who face challenges associated with ankyloglossia.

Systematic review of pharmacological treatments that reduce conditioned taste aversions in rodents: A potential animal model of pediatric feeding disorder and avoidant/restrictive food intake disorder (ARFID).

Avoidant/restrictive food intake disorder (ARFID) is diagnosed when food avoidance leads to clinically significant nutritional, weight/growth, or psychosocial impairment. As many as 81.5% of children and adolescents diagnosed with ARFID have a history of a medical condition associated with pain, fatigue, or malaise. ARFID is diagnosed and treatment begins after the medical condition is resolved but food avoidance remains. Effective treatment involves repeated exposure to eating food and related stimuli aimed at creating inhibitory learning to counteract learned fears and aversions. Treatment usually involves positive reinforcement of food approach behavior and escape extinction/response prevention to eliminate food avoidant behavior. To shed light on the neural mechanisms that may maintain ARFID and to identify candidate pharmacological treatments for adjuncts to behavioral interventions, this paper systematically reviews research on drug treatments that successfully reduce conditioned taste aversions (CTA) in animal models by disrupting reconsolidation or promoting extinction. The mechanism of action of these treatments, brain areas involved, and whether these CTA findings have been used to understand human eating behavior are assessed. Collectively, the results provide insight into possible neural mechanisms associated with resuming oral intake following CTA akin to the therapeutic goals of ARFID treatment and suggest that CTA animal models hold promise to facilitate the development of interventions to prevent feeding problems. The findings also reveal the need to investigate CTA reduction in juvenile and female animals and show that CTA is rarely studied to understand disordered human feeding even though CTA has been observed in humans and parallels many of the characteristics of rodent CTA.

Screening for Caregiver-Reported Feeding Concerns in Children with Autism Spectrum Disorder in a Tertiary-Care Clinic.

OBJECTIVE: Feeding concerns, primarily food selectivity, are commonly observed in children with autism spectrum disorder (ASD). Prevalence rates suggest that at least half of autistic youth have feeding difficulties. METHODS: A retrospective chart review examining records of a large cohort of autistic children (N = 746) referred for ASD evaluation was conducted. Families completed a survey regarding feeding concerns in their children before a diagnostic evaluation. RESULTS: Post hoc analyses based on retrospective chart review revealed approximately 30% of caregivers reported significant difficulty feeding their child. Young age, food selectivity, and concerns about weight were associated with increased likelihood of reported feeding difficulties. There was clear overlap between overall feeding difficulties and specific food selectivity; however, 1 in 5 children whose caregivers did not report feeding difficulties endorsed food selectivity. CONCLUSION: Findings highlight the need for multipronged approaches to screening to facilitate service prioritization by pediatric providers.

Quantifying the Healthcare Burden of Pediatric Feeding Disorder after Congenital Heart Surgery.

OBJECTIVE: To determine the healthcare costs and use burden of pediatric feeding disorder after congenital heart surgery. STUDY DESIGN: A retrospective, population-based cohort study using claims data (2009-2018) was performed. Participants include patients aged 0-18 years who had undergone congenital heart surgery and were included in the insurance database ≥1 year after surgery. The main exposure variable was the presence of a pediatric feeding disorder, defined as a need for a feeding tube at discharge or diagnosis of dysphagia or feeding-related difficulty within the study timeframe. Main outcomes include overall and feeding-related medical care use, defined as readmissions and outpatient use, and feeding-related cost of care within 1 year of surgery. RESULTS: A total of 10 849 pediatric patients were identified, with 3347 (30.9%) presenting with pediatric feeding disorder within 1 year of surgery. Patients with pediatric feeding disorder spent a median of 12 days (IQR, 6-33 days) in the hospital, compared with 5 days (IQR, 3-8 days) in patients without (P < .001). Rate ratios for overall readmissions, feeding-related readmissions, feeding-related outpatient use, and cost of care over the first year after surgery were significantly increased at 2.9 (95% CI, 2.5-3.4), 5.1 (95% CI, 4.6-5.7), 7.7 (95% CI, 6.5-9.1), and 2.2 (95% CI, 2.0-2.3) among patients with pediatric feeding disorder as compared with those without. CONCLUSIONS: Pediatric feeding disorder after congenital heart surgery is associated with a significant healthcare burden. Multidisciplinary care for and research on this health condition is needed to identify optimal management strategies to reduce this burden and improve outcomes.

A Survey of Community Providers on Feeding Problems in Autism Spectrum Disorder.

PURPOSE: Feeding problems, ranging from mild to severe, are common in children with autism spectrum disorder. We conducted a 15-item online survey of community providers to gather information on service demand and current treatment approaches for this clinical population. METHODS: Respondents, speech-language pathologists, occupational therapists, registered dietitians, and Board-Certified Behavior Analysts, were recruited via e-mail listservs, professional conferences, continuing education programs, social media and electronic newsletters. The survey included questions about professional discipline, years in practice, patient population served, feeding problem types, therapeutic approaches, and level of interest in parent-mediated interventions. RESULTS: A total of 541 community practitioners responded to the survey; 419 provided usable data. Across all providers, 97% (n = 406) reported seeing children with ASD and feeding problems. Of these, 90% (n = 367) offered treatment. Providers (n = 23) who did not treat feeding problems cited "insufficient training." Most common presenting problems included limited dietary variety, texture sensitivity, and disruptive mealtime behavior. Although treatment approaches varied across disciplines, 89.3% indicated openness to parent-mediated treatment. CONCLUSIONS: These results indicate a high demand for treatment of children with ASD and feeding problems across disciplines. Food selectivity was the most common problem. Treatment approaches varied across disciplines. Dissemination and implementation of evidence-based, parent-mediated intervention is warranted.

Brief Report: Decreased Bone Health in Children with Autism Spectrum Disorder and Avoidant Restrictive Food Intake Disorder.

PURPOSE: Children with autism spectrum disorder (ASD) and food selectivity are at increased risk for nutritional deficiencies which could affect bone health. METHODS: We report on four male patients with ASD and avoidant restrictive food intake disorder (ARFID) with significant bone conditions including rickets, vertebral compression fractures, osteopenia, and slipped capital femoral epiphyses. RESULTS: Each patient was at risk for at least one nutritional deficiency. Two out of four patients had deficiencies in Vitamins A, B12, E, and zinc. Calcium and Vitamin D deficiency were noted in all four. Two out of four patients with Vitamin D deficiency developed rickets. CONCLUSION: Provisional evidence suggests that children with ASD and ARFID are at elevated risk for serious adverse bone health outcomes.

Intensive Multidisciplinary Feeding Intervention for High-Risk Infants.

Infants born premature or other medical complex infants are at high risk for developing long-term feeding problems that extends beyond infancy. Intensive multidisciplinary feeding intervention (IMFI) represents the standard of care for children with chronic and severe feeding issues, with a profession team that should involve, at a minimum, psychology, medicine, nutrition, and feeding skill expertise. IMFI seems to hold benefit for preterm and medically complex infants; however, there remains a need to develop and investigate new therapeutic pathways to reduce the number of patients who likely require this level of care.

Bone health in avoidant/restrictive food intake disorder: a narrative review.

BACKGROUND: Avoidant/restrictive food intake disorder (ARFID) is an eating/feeding disturbance characterized by severe food avoidance or restriction that results in faltering growth, nutritional deficiencies, dependence on formula supplementation, and/or significant psychosocial impairment. Compared to other eating disorders, ARFID is observed to have an earlier childhood onset and chronic course without intervention. Childhood represents a sensitive period for longitudinal growth and bone accrual, setting the stage for long-term health outcomes associated with longevity and quality of life, including risk for fracture and osteoporosis. RESULTS: This narrative review discusses published scientific literature on bone health in individuals with ARFID by describing the current understanding of ARFID's effect on bone health, how common dietary constraints characteristic of ARFID may present unique risks to bone health, and the current clinical recommendations for bone health assessment. Reviewing what is known of clinical data from anorexia nervosa (AN) and similar cohorts, the chronicity and etiology of dietary restriction observed in ARFID are hypothesized to compromise bone health significantly. Although limited, examination of bone health in ARFID patients suggests children with ARFID tend to have shorter stature compared to healthy reference datasets and have lower bone density compared to healthy individuals, similar to those with AN. There remains a substantial knowledge gap in how ARFID may interrupt bone accrual during childhood and adolescence, and subsequent impact on attainment of peak bone mass and peak bone strength. The longitudinal effects of ARFID may be subtle and overlooked clinically in the absence of severe weight loss or growth stunting. Early identification and remediation of threats to bone mass accrual have significant personal and population-level implications. CONCLUSION: For patients with ARFID, delayed identification and intervention to address feeding disturbances may have a long-lasting impact on various body systems and processes, including those relating to longitudinal growth and bone mass accrual. Further research employing rigorous prospective observational and/or randomized study designs are required to clearly define effects of ARFID, as well as clinical interventions aimed at addressing ARFID-related feeding disturbances, on bone accrual.

Changes in Medical Charges Following Intensive Multidisciplinary Intervention for Pediatric Gastrostomy Tube Dependence.

OBJECTIVE: Intensive multidisciplinary intervention (IMI) is the most evidence-based approach to treat pediatric feeding disorders. The goal of this exploratory study was to assess changes in health care charges for patients with gastrostomy tube dependence following participation in IMI compared to a waitlist control. METHODS: Medical charges were assessed for 9 families who participated in IMI compared to 6 control families on a multi-year waitlist for IMI. The IMI and control groups were compared on raw charges submitted as well as individual year-over-year changes in medical charges. RESULTS: The IMI group decreased health care charges by 71% on average in the year following IMI compared to the control group increasing charges by 22% over the same period. CONCLUSIONS: IMI also holds potential cost-savings in the year following treatment compared to children who do not receive treatment and adds to previous research focusing on long-term cost effectiveness of IMI.

A Retrospective Consecutive Controlled Case Series of Underspoon: A Modified-Bolus Placement to Address Behavior That Interfere With Swallowing.

Children diagnosed with pediatric feeding disorder (PFD) or avoidant/restrictive food intake disorder (ARFID) may present with comorbid oral-motor delays that often contribute to their failure to consume an adequate volume and/or variety of foods. Once the food enters the mouth, these children may exhibit additional problematic behavior such as expulsion and packing that further averts oral intake. Previous research has evaluated the impact of modified-bolus placement methods, including flipped spoon and NUK® brush, in comparison to upright spoon on expulsion and packing. Whether responses are due to performance or skill deficits, researchers hypothesize that modified-bolus placement may assist with reducing the response effort associated with swallowing. This retrospective consecutive controlled case series assessed the clinical application of an additional modified-bolus placement method, underspoon, to increase food consumption and decrease problematic behavior that interfere with mouth clean for children with PFD or ARFID.

Treatment of Feeding Concerns in Children With Autism Spectrum Disorder: A Systematic Review of Behavioral Interventions With Caregiver Training.

Successful feeding intervention ultimately requires generalization and adoption of treatment into the home. Treatment models, however, differ regarding how and when caregivers are integrated into care delivery process. Some treatments involve a primary model of parent training with caregivers serving as co-therapist at the onset of intervention, while others involve a complimentary model where a therapist delivers the intervention and caregiver training occurs once the child's behavior is stable. This review systematically evaluates the evidence-base regarding behavioral feeding intervention for children with autism spectrum disorder (ASD), with a specific focus on interventions involving parent training. Results provide further evidence regarding the potential benefits of behavioral intervention to improve feeding concerns in ASD, while also highlighting growing attention to documenting and/or evaluating parent training within the treatment literature. Important questions remain regarding factors guiding the use of a primary or complimentary model of parent training.