Page 44 - Today's Dietitian (February 2020)

Identifying Feeding Disorders: Red Flags such as gastroesophageal reflux disease, food allergies, eosin-
Feeding disorders often have many causes, some of which ophilic esophagitis, or celiac disease may present with food-
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may be related. Causes may be organic, environmental, or averse or -avoidant behaviors. Children with various genetic
behavioral in nature, or a combination of all three factors. diseases such as trisomy 21 (ie, Down syndrome) may be at
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Regardless of the cause, parents and caregivers who voice con- heightened risk of feeding disorders due to the nature of their
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cerns about their children’s feeding behaviors should never diagnoses. These children should be monitored carefully.
be ignored, as these concerns may turn in to a serious condi- Environmental factors that may lead to feeding disorders
tion requiring medical intervention. It’s important to conduct include the home or school environment where the major-
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a thorough feeding and behavioral history and take anthro- ity of meals and the relationship between the child and
pometric measures, and a physical examination may be nec- the adult feeding them (eg, parent, caregiver, teacher) take
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essary to help determine the source of the issue. Even when place. In addition, socioeconomic factors such as income
the problem turns out to be minimal and easily addressed and education levels (of the parents/caregivers) and access
with education or suggestions for behavioral interventions, to food (ie, food security) may affect the feeding environ-
dietitians should provide constructive and practical recom- ment. A thorough history includes a diet history but also an
mendations to parents and caregivers. Some of these rec- environmental scan related to meals and feeding practices.
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ommendations may include a shift in the feeding style of the This should include questions about where meals take place
parents, encouraging them to look for and react to their child’s (eg, at the table? In front of a screen?), how calm or chaotic
hunger and satiety cues, or a change made to the feeding envi- the feeding environment is, and any alarming behaviors,
ronment, such as the removal of distractions. Examples of such as force-feeding, that may be reported by the parents
some common suggested changes can be found in the “Practi- (see table online).
cal Tips for Dietitians” section. Behavioral issues (as outlined in the table) may manifest as
Organic causes of feeding disorders include anatomical a result of undiagnosed organic factors, environmental factors
defects, gastrointestinal (GI) diseases or disorders, and genetic that haven’t been addressed, or, in some cases, traumatic expe-
syndromes. These may affect children’s desire to eat as well as riences from the past (eg, intubation, chemotherapy, resolved
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their mechanical ability to eat or drink. In these cases, devel- GI pathology). Dietitians should be aware that although behav-
opmental readiness, including children’s ability to hold their ioral issues are modifiable, some children who exhibit contin-
trunks and heads up, or the ability to chew and swallow safely, ued behaviors before and after intervention are at risk of poor
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also may need to be considered. Anatomical defects such as growth, failure to thrive, and nutrient deficiencies. Ignor-
cleft palate, abnormal facial structure, or laryngomalacia may ing the behaviors reported by caregivers can lead to a long-
compromise a child’s capacity to eat or drink normally. Chil- lasting unhealthy relationship with food and can be extremely
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dren with hyper- or hypotonicity may be at increased risk of stressful for families and clinicians. Indeed, children whose
reflux, dysphagia, or aspiration and should be carefully assessed picky eating behaviors persist longer than about two years may
for feeding safety. Children with disturbances of the GI tract benefit from additional attention from dietitians and other cli-
nicians to determine the best course of action, whether it be
ongoing support for caregivers, referral to a specialist team,
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or referral to a clinician who provides psychological support.
Children who exhibit behaviors related to feeding without
any medical cause respond best to early intervention and sug-
gestions for behavior modification (both for the child and the
parent/caregiver), as outlined in the section “Practical Tips for
Dietitians.” In more difficult cases, referral to a specialist feed-
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ing team may be required.
Strategies for Managing Picky Eaters
Many dietitians who work with young children and their fami-
lies know that behavioral management of picky eaters is a long
and arduous process. As well as providing direction and help-
ful strategies, dietitians need to support those providing the
food. This may include setting realistic expectations for change
(eg, telling caregivers, “This may take a few weeks”); acknowl-
edging that parents and caregivers may feel guilt or feel they’re
starving their children, even though this isn’t true; and let-
ting parents and caregivers know they should expect pushback
from their children. Reminding parents to be patient is vital
to the success of behavioral management strategies. Coaching
parents and caregivers to create healthy feeding environments
is a necessary part of any behavioral intervention, as the par-
ents’ or caregivers’ feeding styles (eg, controlling feeders who

44 TODAY’S DIETITIAN • FEBRUARY 2020