Feeding disorders

in infants and children

Deddy S Putra
Definition

The inability or refusal to eat certain

foods because of neuromotor
dysfunction, organic, and/or
psychososial factors
Clinical presentations
Feeding disorder begins in the postnatal
period and is characterized by irregular
, poor feedings and inadequate food
intake.
Food refusal / oral aversion
Failure to thrive
Recurrent pneumonia
Recurrent vomiting
 Diagnosis criteria
The infants feding difficulties start in
the first few month of life and should
be present for at least 2 weeks
The infants has difficulty reaching
and maintaining a calm state of
alertness for feeding ; he or she too
sleepy or too agitated and/or distress
to feed
 Cont
The infants fail to gain age-
appropiate weigh or may show loss
of weight

Teh infants feeding difficulties

cannot be explained by a physical
illness.
Nutritional Management

Nutritional assessment
Dietary history, anthropometry, physical signs of
possible nutritional deficiencies, laboratory tests
Nutritional support
Establishing nutrient needs, choosing feeding
modality, guidelines for nutritional support, goals
for nutrition support, treatment plan
Team work
Evaluation of the child with a feeding
disorders

Feeding history
Current diet
Textures
Route & time of administration
Healthy children >30 min behavioural feeding problem
Children with other disorders ineffective feeding
mechanics
Spesific food aversion metabolic/alergic
disorders
Feeding position
Evaluation of the child with a feeding
disorders (cont)

Medical comorbidities
Recurrent pneumonia chronic aspiration ?
Recurrent vomiting GER ?
Snoring tonsillar and adenoid hypertrophy
Nutritional assessments
Nutrition status
Estimating caloric intake & metabolic needs
Psychological assessments
Behavioural & parental factors
Evaluation of the child with a feeding
disorders (cont)

Observation of feeding
Neuromuscular tone, posture & position
Motivation
Oral structure and function
Efficiency of oral intake
Ability to handle oral secretions
 TABLE 2 -- CAUSES OF FEEDING DISORDERS IN CHILDREN
Depression
Disorders that affect
Deprivation
appetite, food-seeking CNS disease (diencephalic syndrome)
behavior, and ingestion Poverty (inadequate food available)
Hereditary fructose intolerance
Metabolic diseases
Urea cycle disorders
Organic acidemias
Anosmia
Sensory defects
Blindness
Neuromuscular disease (see below)
Oral hypersensitivity or aversion resulting from a
lack of feeding experience during crucial sensitive
periods (long-term parenteral or enteral tube
feeding)
Aspiration
Conditioned dysphagia
Oral inflammation (see below)
Gastroesophageal reflux
Dumping syndrome or gastric bloating after
 TABLE 2 -- CAUSES OF FEEDING DISORDERS IN CHILDREN
(cont)

Anatomic Cleft lip and/or palate

Macroglossia
abnormalities of Ankyloglossia
the oropharynx Pierre Robin sequence
Retropharyngeal mass or abscess
Velopharyngeal insufficiency
Tonsillar hypertrophy
Dental caries

Anatomic/congenit Laryngeal cleft

Laryngomalacia
al abnormalities of Laryngeal cyst
the larynx and Subglottic stenosis
Tracheomalacia
trachea
Tracheoesophageal cleft
 TABLE 2 -- CAUSES OF FEEDING DISORDERS IN CHILDREN
(cont)

Anatomic Tracheoesophageal fistula

Congenital esophageal atresia
abnormalities of
Congenital esophageal stenosis because of
the esophagus tracheobronchial remnants
Esophageal stricture, web, or ring
Esophageal mass or tumor
Foreign body
Vascular rings and dysphagia lusorum

Disorders Choanal atresia

Bronchopulmonary dysplasia
affecting suck-
Cardiac disease
swallow-breathing Tachypnea (respiratory rates > 60
 TABLE 2 -- CAUSES OF FEEDING DISORDERS IN CHILDREN
(cont)
Disorders affecting Cerebral palsy
Bulbar atresia or palsy
neuromuscular Brain stem glioma
coordination of Arnold-Chiari malformation
Myelomeningocele
swallowing Familial dysautonomia
Tardive dyskinesia
Nitrazepam-induced dysphagia
Postdiphtheritic and polio paralysis
Mbius syndrome (cranial nerve
abnormalities)
Myasthenia gravis
Infant botulism
Congenital myotonic dystrophy
Oculopharyngeal dystrophy
Muscular dystrophies and myopathies
Cricopharyngeal achalasia
 TABLE 2 -- CAUSES OF FEEDING DISORDERS IN CHILDREN
(cont)

Mucosal infections Adenotonsillitis

Deep neck space infections
and inflammatory
Epiglottis
disorders causing
Laryngopharyngeal reflux from gastroesophageal reflux
dysphagia Gastroesophageal reflux
Caustic ingestion
Candida pharyngitis or esophagitis
Herpes simplex esophagitis
HIV
Cytomegalovirus esophagitis
Medication-induced esophagitis
Crohn's disease
Behcet disease
 TABLE 2 -- CAUSES OF FEEDING DISORDERS IN CHILDREN
(cont)

Other miscellaneous Xerostomia

Hypothyroidism
disorders associated Idiopathic neonatal hypercalcemia
Trisomy 18 and 21
with feeding and Velocardiofacial syndrome
swallowing difficulties Rett syndrome
Prader-Willi syndrome
Allergies
Lipid and lipoprotein metabolism disorders
Neurofibromatosis
Williams syndrome
Coffin-Siris syndrome
Optiz-G syndrome
Cornelia de Lange syndrome
Interstitial deletion (q21.3q31)
Globus sensation
FEEDING PROBLEM
Implication
EXCESS NUTRITION

FEEDING PROBLEM

SECONDARY
PRIMARY DEFICIENCY

TISSUE DEPLETION

BIOCHEMICAL LESION

CLINICAL SIGNS
EPIDEMIOLOGY
Mild feeding problems: not always
hungry/eating small amounts/picky
eating/strong preferences
Healthy toddlers, early school age
25-40%
Epidemiology
Serious feeding problems: All
children 3-10%/Children
developmental disability 33%
(mental retardation, prematurity,
organic dis)
 DEFINISI
Samsudin : masalah makan adalah bila anak hanya mampu
menghabiskan kurang dari 2/3 dari jumlah makanannya
sehingga kebutuhan nutrien tidak terpenuhi.

Palmer : masalah makan adalah ketidak mampuan untuk

makan atau penolakan terhadap makanan tertentu sebagai
akibat disfungsi neuromotorik, lesi obstruktif, atau faktor
psikososial yang mempengaruhi makan, atau kombinasi dua
atau lebih penyebab tersebut.
Definisi yang lain
Kekurangan dalam semua aspek
mengkonsumsi makanan yang
menyebabkan gizi kurang,
pertumbuhan yang jelek, waktu
makan yang menimbulkan stres baik
untuk anak maupun yang momong
Most common feeding
problems in young children
(Kerwin 1999)
Inappropriate mealtime behaviours (e.g.,
temper tantrums, throwing food)
Lack of self-feeding
Food selectivity (eating only a few foods)
Failure to advance textures from puree to
table food
Food refusal (not accepting any or only
smell quantities of food)
Oral sensorimotor immaturity or
dysfunction
Aspiration or swallowing problems
Frequent gagging or vomiting
 Angka Kejadian
Laporan GUAPCD adalah sbb :

1.Hanya mau makanan lumat/cair 27.3%

2.Kesulitan menghisap, mengunyah, menelan
24.1%
3.Kebiasaan makan yang aneh/ganjil
23.4%
4.Tidak menyukai banyak macam makanan
11.1%
5.Keterlambatan makan mandiri 8.0%
6.Mealtime tantrums 6.1%
Angka Kejadian
Penelitian anak prasekolah usia
4 6 tahun di Jakarta, kesulitan
makan sebesar 33.6%
44.5% diantaranya menderita
malnutrisi ringan- sedang
79.2% telah berlangsung lebih
dari 3 bulan.
Penyebab kesulitan makan
(Samsudin)
Faktor organik
Faktor Nutrisi
Faktor psikologik
Faktor psikiatrik
Faktor organik
Kelainan pada rongga mulut
Kelainan bagian lain saluran cerna
Kelainan organ tubuh lain
Penyakit metabolik
 Faktor Nutrisi :

Bayi konsumer pasif

Anak konsumer semi pasif/ semi aktif

Pemenuhan kebutuhan nutrisi masih

bergantung pada orang lain.
Pada bayi & anak terjadi perubahan pola
makan dari makanan bayi ke makanan
dewasa, seringkali secara sinergis
menimbulkan masalah makan yang dapat
mengakibatkan terjadinya defisiensi nutrien
dan malnutrisi, yang bisa menurunkan nafsu
makan sehingga asupan makanan lebih
berkurang lagi.
 Faktor Psikologik :

Mekanisme beban sosiokultural serta aturan

makan yang ketat/berlebihan

Sikap ibu yang obsesif dan memaksa akibat

overproteksi

Respons infantil terhadap sikap ibu

Faktor psikiatrik
Infancy/early childhood
Pica
Rumination disorder
Infancy/early childhood
Persistent failure to eat
Failure to thrive (> 1 month)
No gastrointestinal/medical cause
No lack of food supply
Before 6 years
Pica
Persistence eating nonnutritive
substances (> 2 months)
Inappropriate for development level
No part of culturally sanctioned
practice
Can be during course of mental
retardation, pervasive,
developmental disorder, but needs
independent attention
Rumination disorder
Repeated regurgitation, rechewing
food (> 1 month)
No gastrointestinal/medical course
Not confined to the course of
anourexia of bulimia
Can be during course of mental
retardation, pervasive developmental
disorder but need independent
attention
Masalah makan tahun pertama
Kurang makan, bayi gelisah, menangis dan
BB kurang

Kelebihan makan baik kualitatif/kuantitatif

Regurgitasi dan muntah, 6 bln pertama

wajar

Diare/tinja lembek. Tinja ASI lebih lembek

Konstipasi, bisa karena cairan/ makanan

kurang
Faktor risiko terjadinya
masalah makan
Bayi/anak dengan GER
Bayi kurang bulan dan berat lahir
rendah terutama dg intubasi lama
Bayi dg komplikasi pada masa
neonatal mis intubasi lama yang
mengakibatkan reflex muntah
berlebihan, bahkan tidak bisa makan
sama sekali
Bayi dengan displasia
brokopulmuner, CHD, nerologik dll
Masalah makan masa anak
Kecepatan tumbuh rata - rata melambat

Nafsu makan bervariasi

Suka/ tidak suka makan cepat berubah

Lambung masih kecil

Anak tidak pernah membuat dirinya kelaparan

Anak tidak boleh dipaksa makan

Suplementasi vitamin/ mineral tak perlu

 Tatalaksana masalah makan
Mencakup 3 aspek yaitu :

1. Identifikasi faktor penyebab

2. Evaluasi tentang dampak yang

telah terjadi

3. Upaya perbaikan : a. nutrisi

b. faktor penyebab
 Upaya yang dilakukan adalah :

1. Atasi faktor penyebab (organik, infeksi,

psikologik, dll)

2. Atasi dampak yang telah terjadi (malnutrisi,

defisiensi nutrien tertentu, dll)

3. Upaya nutrisi : perbaiki/ tingkatkan asupan

makanan

4. Re-edukasi tentang perilaku makan

5. Fisioterapi bagi anak yang mengalami

kesulitan mengunyah/ menelan
Meningkatkan komposisi kalori
pada formula bayi
Formula disajikan dalam konsentrasi
yang lebih tinggi yi dg air kurang dari
yang dianjurkan
Tambahkan glukosa polimer 23
kcal/sendok teh, minyak jagung 8,4
kcal/ml
Pada anak lebih dari 1 tahun
Gunakan formula tinggi kalori yi 1
kcal/ml
Tambahkan suplemen bubuk pada
susu
 SYMPTOMS DIAGNOSIS SELF - CARE
BEGIN
HERE

1. Always NO
Go to Question 5
Hungry?
YES
- Mother drinks enough
YES
Breast milk fluids
2. Breastfed? insufficient or - If sores or white patches
sore mouth in babys mouth, see doctor
NO

3. Bottle fed or YES Bottle nipple

CLOGGED or too small Correct the nipple problem
sore mouth?
or mouth sore See above if mouth sore

4. Fall asleep Common for See doctor to

YES
after feel from younger infants, check babys growth
but must decrease and weight gain
breast or bottle?
as baby grows
NO

Next Page
 SYMPTOMS DIAGNOSIS SELF - CARE
NO

5. Cry after NO
Go to question 9
Feeding?
YES

6. Throwing up with YES

PYLORIC
Contact doctor
forceful vomiting? STENOSIS
NO

7. Lot of gas and YES LACTOSE Switch to a

stomach INTOLERANCE
discomfort? non-cows-milk?

NO

8. Severe crying YES

COLIC? See doctor
after meal?
NO

Next Page
 SYMPTOMS DIAGNOSIS SELF - CARE
NO

9. Little interest
in food YES DEVELOPMENTAL
See your doctor
Or PROBLEM?
slow weight gain?
NO

10. Bowel movements Allergy or more severe

intolerance
YES
loose/ Feel-smelling (LACTOSE INTOL See your doctor
after the feedings or CELIAC DIS)
NO

For more information,

please consult your doctor.
If you think the problem
is serious, call right away
Preventing feeding
problems
Teach to feed him self as early as possible
Provide with healthy choices
Allow experimentation
As long as your child is growing normally,
probably little to worry about
Avoid giving large amount which have
little nutritional value
Meal time should be enjoyable and
pleasant
Childhood Obesity
 Definitions
Obesity
Excessive deposition of adipose tissue

Overweight
Weight in excess of the average for
height
lean body mass or adipose tissue or

both
 Clinical Manifestations
Round face, double chin
Increased truncal fat deposition
Gynecomastia
Pendulous abdomen and white/purple striae
Buried penis
Tall for age & Early menarche
Genu valgum
Clinical manifestations
Clinical manifestations
 Anthropometric Measurement

BMI 95th percentile

% Ideal Body Weight (IBW) 120%
Triceps Skinfold 85th percentile
Fat distribution patterns (waist-hip-
ratio)
< 0.8 gynecoid type (feminine type)
> 0.8 android type (masculine type)
 Causes
Positive energy Medical causes
balance ( 95%)
(<5%)
Excessive caloric
intake Endocrinology
Decreased Cushing syndr.

physical activity Growth hormone

Decreased deficiency, etc
resting metabolic Genetics
rate
Prader Willi, etc
Complications
Endocrine : Insulin resistance, NIDDM
Impaired glucose tolerance, acanthosis nigricans
Cardiovascular: dyslipidemia,hypertension
Altered lipid profiles
Respiratory : obstructive sleep apnea,
Pickwickian syndrome
Snoring and restless sleep, abnormal lung
function tests
Orthopedic : Blount disease, slipped capital
femoral epiphysis, gout
 Complications
Gastrointestinal : Cholelithiasis, NASH
Hepatomegaly, altered serum transaminases

Sexual development & growth : abnormal

growth acceleration, early onset of menarche,
pubertal gynecomastia

Psychiatric : psychosocial dysfunction

Goals of treatment program

Appropriate for the childs age and

developmental status
Result in significant weight reduction
to within 20% of the IBW
Long-term appropriate eating and
physical activity that result in weight
maintenance but do not hinder growth
& development
Principles of treatment

Dietary management
Physical activity (exercise)
Behaviour modification
Family involvement
Alternative therapy
 Dietary management
Hypocaloric balance diet
Reduces caloric intake 200-500 kcal/day of
usual intake
50% carbohydrate, 30% fat, and 20% protein

Protein Sparing Modified Fast Diet

(4-12 weeks)
600-800 kcal/day
1.5-2 g protein/kg ideal body weight/day
No carbohydrate. Low starch vegetables
Water or calorie-free fluid at least 2 L/day
Daily supplements : multivitamins & mineral
 Principle of exercise
Frequency 3-5 x/week
Intensity 50-60% maximal ability
Duration 15 min initially, building to 30-40 min
Mode : use large muscles walking, jogging,
swimming, cycling
Interest : patient dependent tennis, dancing,
martial arts, skating
Enjoyment : important factor
Incorporation into functional activities
walking to school, taking stairs vs elevator,
bicycles vs cars
Reducing passive activities TV watching,
videogames
Behaviour modification
Diet and activity self monitoring
Set weekly goal
Stimulus control
Eat meals and snacks at scheduled times, etc
Cue elimination
Store all food out of sight, leave the table
immediately after eating, etc
Behaviour substitution
Substitute exercise for snacking, etc
Parental support
Alternative (aggressive) therapy
(for morbid obesity)
BMI 95th percentile
Very Low Caloric Diet (PSMF)
Pharmacotherapy
at this time no drugs approved for
use in children
BMI 97th percentile (rarely used)
Bariatric surgery (reduced caloric &
nutrient absorption)
jejunoileal bypass
Roux-en-Y gastric bypass
Recommended Treatment Algorithm

2-7 years of age

BMI BMI
85th 95th > 95th

Complications - Complications + :
mild hypertension,
insulin resistance,
dyslipidemia

Weight
maintenance
Weight loss
Recommended Treatment Algorithm

7 years of age / older

BMI BMI
85th 95th 95th

Complications - Complications +

Weight maintenance Weight loss

 Preventing Obesity:
Tips for Parents
Respect your child's appetite: children do not need to finish every bottle or
meal.
Avoid pre-prepared and sugared foods when possible.
Limit the amount of high-calorie foods kept in the home.
Provide a healthy diet, with 30 percent or fewer calories derived from fat.
Provide ample fiber in the child's diet.
Skim milk may safely replace whole milk at 2 years of age.
Do not provide food for comfort or as a reward.
Do not offer sweets in exchange for a finished meal.
Limit amount of television viewing.
Encourage active play.
Establish regular family activities such as walks, ball games and other
outdoor activities.
 Components of a Successful
Weight Loss Plan
Component Comment
Reasonable weight- Initially, 5 to 10 lb, or a rate of 1 to 4 lb per month.
loss goal
Dietary management Provide dietary prescription specifying total number
of calories per day and recommended percentage of
calories from fat, protein and carbohydrates.
Physical activity Begin according to child's fitness level, with
ultimate goal of 20 to 30 minutes per day (in
addition to any school activity).
Behavior Self-monitoring, nutritional education, stimulus
modification control, modification of eating habits, physical
activity, attitude change, reinforcements and
rewards.
Family involvement Review family activity and television viewing
patterns; involve parents in nutrition counseling.
THANKYOU