Feeding Problems:

Pediatrician’s Role

Titis Prawitasari
UKK Nutrisi & Penyakit Metabolik IDAI
 Eating is not feeding

Eating - child actions

Feeding - interaction
 Chief Complain
• Food refusal • Inappropriate
• Aspiration or mealtime behavior
swallowing problems • Lack of self feeding
• Frequent vomiting • Food selectivity
• Oral-motor immaturity • Failure to advance
• Gastro-intestinal texture
reflux
 Physically normal children

50-60% of parents
report feeding difficulty

20-30% of children
are implicated

1-2% have severe

Kerzner B. Clin Pediatr. 2009;48:960-5.
& prolonged problems
Manikam R, Perman J. Clin Gastroenterol.
2000;30:34-46.
A wide array of feeding difficulties
Normal but “Picky eaters” Severe feeding or
Small appetites eating disorders

• Parental • Mild-to- • Chronic, severe

misperception moderate medical or
of feeding behavioral behavioral issues
problem
• Normal small
conditions
stature, low Increasing severity
metabolic
needs

Krugman SD, Dubowitz H. 2003. Am Fam Physician. 68:879-884.

Chatoor I. 2002. Child Adolesc Psychiatr Clin N Am. 11:163-183
 Who resolves the feeding
difficulties?
Nutritionist

Feeding team

Family
Mild-Picky Severe-Disorders and phobias
physician
Pediatrician Mild

Oro-motor specialist
and/or Gastroenterologist
 Etiology
• Structural abnormalities
– Abnormalities of the naso-oropharynx, larynx trachea,
and the esophagus
• Neurodevelopmental disabilities
– Disrupt the process of “learning to eat”, result in oral
hypersensitivity or oral-motor dysfunction
• Behavioral disorders
– Defined by DSM-IV-TR, defined by Chatoor
• Overlap between categories

Bonnin AC. Can Fam Physician. 2006;52:1247-1251

Classification Category
Behavioral
Feeding disorder
Newborns
of state regulation
Feeding disorder of poor
mother-infant reciprocity 2 to 6 months

Infantile anorexia 6 months to 3 years

Sensory aversions
Not linked to stage
Post-traumatic feeding disorder

Chatoor I. Pediatrics. 2004;113:e440-447.

 Infantile anorexia
• Infantile anorexia ≠ anorexia nervosa
• Onset: < 3 years of age, mostly 9-18 mo
• Description:
– Rarely show any signals of hunger
– Take only few bites for experience, never reach
fullness
– More interested in their surroundings
– Parents: often distract, threaten and entertain to
get their children to eat
 Child
Temperament Component of Infantile Anorexia

Parent-child Infantile
interaction Anorexia

Parents’ Relationship
&
Eating history

•Explain toddler’s temperament characteristics

•Address parents background
•Provide specific guideline to remove parents-child conflict
•Facilitate child’s recognition of hunger and fullness
Chatoor I. 2nd International Summit on Identification and
management of children with feeding difficulties. 2010
 Sensory food aversions
• Description:
– Refuse foods that related to the taste, texture, smell,
temperature, and/or appearance of the food
– Some children tend to generalize and refuse the same
look/smell, so sensitive
– Reaction: grimacing, gagging, vomiting or spitting out
the food
– Eat well if given the foods they prefer
– Reluctant to try new foods
 Post-traumatic feeding disorder
• Description:
– Resistance to eating solid or drinking from bottle
– Usually after an incidence of choking, gagging, vomiting
or force feeding
– Traumatic events → distress → fearful reactions →
sometimes lead to gagging, vomiting
– Reactions: crying, arching and refusing to open their
mouths or spit out or store in their cheeks and then spit
out later
Pediatrician’s role (1)
• Prevention
–Provide a positive and
supportive environment
–Anticipatory guidance
 Anticipatory guidance
 Advance education
 Well-child visits to include:
 Growth parameters
 Age-appropriate nutrition guidance
 Solids, texture, quantity
 Discussion of normal childhood feeding behavior
 neophobia, self-regulation & autonomy, appropriate
mess
 Support parents with their difficult feeders
 Video 1
• Link
Pediatrician’s role (2)
• Assessment
–Identify feeding problems
–Identify red flags
 History taking
• Medical history
– Antenatal and perinatal history; atopy, previous
illnesses/hospitalizations; oropharynx manipulation,
such as tube feeding

• The chronology of feeding and dietary history

– Breastfeeding or formulas, introduction of solids,
current diet, textures, route and time of
administration, feeding position and pattern

Krugman SD, Dubowitz H. Am Fam Physician. 2003;68:879-884.

Bonnin AC. Can Fam Physician. 2006;52:1247-1251
 History taking
• Environment and behavior
– Food aversions; quantities eaten, length of meals
and associated routines, strategies already used
• when, where, with whom does child eat?
• Any feeding battles or punishment?
– Social and family history
• Socioeconomic, household problems, child &
caregivers temperament and mental conditions

Krugman SD, Dubowitz H. Am Fam Physician. 2003;68:879-884

Bonnin AC. Can Fam Physician. 2006;52:1247-1251
 Physical examination
• Start with anthropometric measurements
– Plotting on growth curve
• Looking for structural (craniofacial) abnormalities
and signs of systemic disease
– Stridor → glottic/subglottic abnormalities?
– Suck-swallow-breathing coordination
– Vomiting, diarrhea, constipation, colic, abdominal pain
→ GERD? Cow’s milk allergy?
– Recurrent aspiration? pneumonia?
• Complete neurologic examination as well as
psychomotor development
Bonnin AC. Can Fam Physician. 2006;52:1247-1251
Screening tool (anthropometry)

WHO Child Growth Standards. 2006. Available at: http://www.who.int/childgrowth/standards/en/.

CDC. 2000. National Center for Health Statistics. Available at: http://www.cdc.gov/growthcharts
Growth Indicator
 RED
FLAGS
 Video 2a & 2b
• Link2a
• Link2b
Pediatrician’s role (3)
• Decision
–Observe or treat
–Refer
–Feeding principles and rules
 Management
For infants who are growing and developing
normally:
• Correct misperceptions
• Advise to follow general feeding
recommendations
• Reassure parents if their child’s growth
and development is within the normal
range
 Management
• If a child’s growth appears to be wasted/stunted,
caloric intake should be increased
– Human milk can be fortified
– Infant formula can be concentrated up to 0.8-1
kcal/mL, by either lessening dilution or adding
glucose polymers or vegetable oil
– Solid foods can be fortified with butter, vegetable oil,
cream, sauces, glucose polymers & powdered milk
 Management
• Neurologically disabled children, however,
need nasogastric or gastrostomy feedings
• Good medical management does not
always alleviate feeding problems
adequately → considered behavioral
interventions
 Behavioral interventions
• A typical behavioral treatment plan may include:

– Improving the feeding setting and routine

– Ensuring the child is hungry

– Managing the reinforcement of desired eating behaviors

– Moving step-by-step to the desired behaviors

– Training parents to manage the child’s eating behaviors

Nurture & Nutrition
Child

Environment Parent / Family

 Parenting Styles

• Permissive = “nutritional
neglect”
Effects
of • Authoritarian =
restriction and control
Feeding
• Authoritative =
Style encourage healthy foods
while giving choices
 Feeding Young Children:
The Food Rules
Advise parents to:
• Establish regular mealtimes
• Encourage self-feeding
• Support appropriate food choices
• Encourage appropriate mealtime behavior

Arvedson JC. 1997. Semin Speech Lang. 18:51-69.

Allen RE, Myers AL. 2006. Am Fam Physician. 74:1527-1532.
AFP. http://www.aafp.org/afp/20061101/1533ph.html. Accessed June 20, 2008.
Birch LL. 1998. Proc Nutr Soc. 57:617-624.
 Food Rules
1. Scheduling
• Regular mealtimes;
• Only planned snacks added
• Mealtimes no longer than
30 min
• Nothing offered between
meals except water

Bonnin AC. Can Fam Physician. 2006;52:1247-1251

 Food Rules
2. Environment
• Neutral atmosphere
(no forcing of food)
• Sheet under chair to catch
mess
• No game playing
• Food never given as
reward or present

Bonnin AC. Can Fam Physician. 2006;52:1247-1251

 Food Rules
3. Procedures
• Small portions
• Solids first, fluids last
• Self-feeding
• Food removed after 10-15 min if
child plays without eating
• Meal terminated if child throws
food in anger
• Wiping child’s mouth and
cleaning up occurs only after
meal is completed

Bonnin AC. Can Fam Physician. 2006;52:1247-1251

 Algoritma Masalah Makan
(Rekomendasi UKK NPM th 2014)
Keluhan masalah Elaborasi dan tata
makan laksana red flags

Gizi Kurang Gizi Baik

Feeding Rules Benar Feeding Rules Salah Feeding Rules Salah Feeding Rules Benar

Small Eaters Inappropriate Feeding Practice Parental

Mispersepsion

Feeding Rules Reassurance

High Calorie Food of Feeding
include ONS Rules

Keterangan: ↓ Alur Diagnosis; ↑ Tata Laksana

Lanjutan…
(Rekomendasi UKK NPM th 2014)
Inappropriate Feeding Practice

Edukasi feeding rules dan penerapan asuhan

nutrisi pediatrik, lakukan pemantauan 1-2 minggu

Penerapan feeding rules benar Penerapan feeding rules salah

Berat badan naik Berat badan turun/tetap

Penyebab Primer:
kurangnya pengetahuan Penyebab Sekunder

Jumlah/volume - Kuantitatif Pilihan - Kualitatif

(Small eater) (Food preference)

Picky eater Selective eater

Edukasi Feeding rules
Feeding Rules High calorie
food include Pengenalan secara
ONS sistematis makanan baru
 TAKE HOME MESSAGE
• Sebagian besar masalah makan pada anak
bersumber dari praktik pemberian makan yang
salah
• Masalah makan yang berat dan memerlukan tata
laksana komprehensif  1-2%
• Tugas dokter spesialis anak dalam tata laksana
masalah makan pada anak meliputi:
– Upaya preventif
– Melakukan penilaian dengan seksama
– Menetapkan dan melaksanakan keputusan yang tepat
dan adekuat
 Need more on nutrition problem?
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THANK YOU