Transcript Why Won*t My Child Eat? Therapeutic Interventions for the

Annie Sylvester, MOT, OTR
What is occupational therapy?
Within the Framework, occupational therapy is defined as:
The therapeutic use of everyday life activities (occupations) with individuals or groups for
the purpose of enhancing or enabling participation in roles, habits, and routines in home,
school, workplace, community, and other settings.
Occupational therapy practitioners use their knowledge of the transactional relationship
among the person, his or her engagement in valuable occupations, and the context to design
occupation-based intervention plans that facilitate change or growth in client factors (body
functions, body structures, values, beliefs, and spirituality) and skills (motor, process, and
social interaction) needed for successful participation.
Occupational therapy practitioners are concerned with the end result of participation and
thus enable engagement through adaptations and modifications to the environment or
objects within the environment when needed.
Occupational therapy services are provided for habilitation, rehabilitation, and promotion
of health and wellness for clients with disability- and non–disability-related needs. These
services include acquisition and preservation of occupational identity for those who have or
are at risk for developing an illness, injury, disease, disorder, condition, impairment,
disability, activity limitation, or participation restriction.
American Occupational Therapy Association.(2014).Occupational therapy practice framework: Domain and process (3rd
ed.).American Journal of Occupational Therapy, 68(Suppl.1), S1–S48.http://dx.doi.org/10.5014/ajot.2014.682006
What does occupation mean?
 “In occupational therapy, occupations refer to the everyday activities
that people do as individuals, in families and with communities to
occupy time and bring meaning and purpose to life. Occupations
include things people need to, want to and are expected to do” (World
Federation of Occupational Therapists, 2012).
 “Occupation is used to mean all the things people want, need, or have
to do, whether of physical, mental, social, sexual, political, or spiritual
nature and is inclusive of sleep and rest. It refers to all aspects of actual
human doing, being, becoming, and belonging. The practical, everyday
medium of self-expression or of making or experiencing meaning,
occupation is the activist element of human existence whether
occupations are contemplative, reflective, and meditative or action
based” (Wilcock & Townsend, 2014, p. 542).
American Occupational Therapy Association.(2014).Occupational therapy practice framework: Domain and
process (3rd ed.).American Journal of Occupational Therapy, 68(Suppl.1), S1–
S48.http://dx.doi.org/10.5014/ajot.2014.682006
Occupations
…Various kinds of life activities in which individuals, groups, or populations engage, including activities of daily living, instrumental activities of daily living, rest and
sleep, education, work, play, leisure, and social participation.
 ADLs
 Bathing, showering
 Toileting and toilet hygiene
 Dressing
 Swallowing/eating
 Feeding
 Functional mobility
 Personal device care
 Personal hygiene and grooming
 Sexual activity
http://sleepcenterlcmc.com/the-role-of-occupational-therapy-inachieving-healthy-sleep-patterns
 IADLs
 Care of others
 Care of pets
 Child rearing
 Communication management
 Driving and community mobility
 Financial management
 Health management and
maintenance
 Home establishment and
management
 Meal preparation and cleanup
 Religious and spiritual activities and
expression
 Safety and emergency maintenance
 Shopping
Occupations (cont.)
 Work
 Employment interests and
pursuits
 Employment seeking acquisition
 Job performance
 Retirement preparation and
adjustment
 Volunteer exploration
 Volunteer participation
 Education
 Play
 Play exploration
 Play participation
 Leisure
 Leisure exploration
 Leisure participation
 Social participation
 Community
 Family
 Peer, friend
http://sleepcenterlcmc.com/the-role-of-occupational-therapyAmerican
Occupational Therapy Association.(2014).Occupational therapy practice framework: Domain and process (3rd ed.).American Journal of Occupational Therapy,
in-achieving-healthy-sleep-patterns
68(Suppl.1),
S1–S48.http://dx.doi.org/10.5014/ajot.2014.682006
OT’s Role in: Feeding/Eating/Swallowing
Feeding, eating, and swallowing are interdependent activities, and definitions
of each term overlap in literature sources. For purposes of this paper, broad
definitions are noted.
 Feeding is “the process of setting up, arranging, and bringing food [or fluid]
from the plate or cup to the mouth; sometimes called self-feeding” (AOTA,
2006a).
 Eating is “the ability to keep and manipulate food or fluid in the mouth and
swallow it; eating and swallowing are often used interchangeably” (AOTA,
2006a).
 Feeding and eating, essential to human functioning for nourishment of the
body, is a form of social interaction and is involved in many facets of a
person’s culture—from leisure to professional activities.
 Swallowing involves a complicated act in which food, fluid, medication, or
saliva is moved from the mouth through the pharynx and esophagus into
the stomach (AOTA, 2006a).
American Occupational Therapy Association. (2007). Feeding, Eating and Swallow Knowledge and Skills Paper. American
Journal of Occupational Therapy, 61
Fetal Oral Development
Week of
Gestation
Relevant developmental milestones
Weeks 1-8
Development of primitive structures required for
sucking and swallowing
Weeks 11–13
Taste buds develop
Beginning of pharyngeal swallow
Weeks 12-40
Sex-related differences in oral and upper airway
development
Weeks 22-24
Consistent swallowing develops, suckling motion
present
Weeks 36-38
Fetus swallows 0.5 to 1 liter of amniotic fluid per
day!
(Delaney & Arvedson, 2008)
Sensory Function of Cranial Nerves
CN V (Trigeminal nerve)- tactile, proprioceptive, and nociceptive
sensation from the mouth/face
CN VII (Facial nerve)- taste sensation from anterior 2/3 of tongue
CN IX (Glossopharyngeal nerve)- general sensation and taste of posterior
tongue, tonsils, and pharyngeal walls (responsible for gag reflex)
CN X (Vagus nerve)-parasympathetic sensory innervation of all
abdominal viscera, taste from epiglottis (Miller, 1999)
Are They Ready to Eat?
 Readiness to eat based
on:





Medical stability
RN/MD approval
Parental Agreement
OT Assessment
Patient signs
 Precautions/Contraindications:
Current Medications
 Respiratory Status and O2 requirements (HFNC,
BiPAP, CPAP, intubated)
 Current diet orders (continuous feeds, TPN)
 Cognition (ability to follow commands, verbalize
discomfort)

http://www.sagecreekorganics.com/blog/healthier-meand-you/getting-kids-to-eat-their-veggies/
Reasons to not eat













Infant feeding in NICU
Cardiology
Dental sensivities
Gastrointestinal diseases
 Reflux
 Short gut
Liver disease
Long term tube feeding
Neurological insult
Oral aversion
Post-op cleft/reconstruction/repair
Pulmonary
Renal disease
Tracheostomies
Failure to Thrive
 Concern for aspiration
 Decreased oral motor skills
 Need for parent education
Incidence of Feeding Disorders
Descriptive study of 700 patients seen at
multidisciplinary feeding program in Belgium
86% medical
61% oral
16% behavioral
Oral sensory-based disorders occurred in 21% of
patients.
(Rommel et al, 2003)
Refusal to foods in toddlers
Hunger is due to the integration of (taste, smell, and vision),
limbic and cortical modulators (mood or affect), and
visceral feedback (nociceptive stimuli, gastric volume and
distention, substrates, and hormonal effects. (Staiano,
2003)
Gut motor function is coordinated by contractions of smooth
muscle cells, controlled by the CNS (central nervous
system), but more immediately by the ENS (enteric
nervous system). (Staiano, 2003)
May be due to overall pain, unpleasant to eat or fear it will be
a dysphoric experience. (Zangen et al, 2003)
Nociception and Feeding
Intraoral and perioral area have the highest density
of nociceptive sensory receptors of any part of the
human body (Miller, 1999).
Visceral sensory dysfunction such as visceral
hyperalgesia may be an underlying cause of food
refusal in some children (Staiano, 2003)
Visceral sensation and food refusal
In 14 patients with persistent oral aversion and continued
retching/vomiting after surgery and behavioral treatment, Zangen et al
(2003) found:
 decreased esophageal motility
 decreased gastric threshold for retching
 decreased visceral pain threshold
Effective treatment resulted in improved oral intake and emotional
health and included:
 temporary continuous drip feedings
 pharmacological intervention (increase motility, reduce pain)
 cognitive, family, behavioral therapy
Physiological responses to
sensory stimulation by food
Cephalic phase responses to presentation of food include:
 increased thermogenesis
 increased salivary flow and altered salivary composition
 decreased cardiac output and increased heart rate
 compensatory changes to diuresis
 increased digestive enzyme secretion
 increased acid and digestive enzyme secretion, gut hormone
release, motility, and gut pressure
(Mattes, 1997)
What is oral aversion?
 Definition: Reluctance, avoidance, or fear of eating, drinking, or accepting
sensation in or around the mouth.
http://www.medterms.com/script/main/art.asp?articlekey=23918
 Causes
 There are many reasons that children have or develop oral aversion
 Treatment
 No universal accepted treatment/management
 All treatments are based in the child and what his/her are
Types of oral sensation
Oral sensation occurs via a range of modalities that
include:
 taste
 somesthetic sensitivity
 two-point discrimination
 oral stereognosis
 vibrotactile detection
 proprioception
 nociception
 chemical and thermal sensitivity
(Delaney & Arvedson, 2008)
Taste Selectivity
Infants who are breastfed may have less prominent food selectivity due to
exposure to more flavors (Mennella et al, 2007)
Difficulties in introducing protein hydrolysate formula (ie Nutramigen)
in older infants may be due to limited experience of multiple flavors
(Mennella et al., 2004)
Preferences for food tastes are developed by repeated exposure in early
critical period. Increased intake is observed with increased exposure
(Sullivan & Birch, 1994)
“…Experiences with novel tastes that are not followed by negative
gastrointestinal consequences can produce enhanced taste preference
.” (Birch et al., 1987)
“Contrary to some recommendations that infants should be weaned early
to develop a liking for foods, infants do not need solid food-they can
learn from mother’s milk.” (Mennella & Castor, 2012)
Early Taste Development
Certain strong flavors (garlic, anise seed) are transmitted via
amniotic fluid and ingested by the fetus. Newborn
infants can recognize and will turn to smells that their
mothers ate during pregnancy. (Menella et al, 1995,
Schaal et al, 2000)
Newborn infants demonstrate a preference for sweet tastes
and reject bitter tastes. They become able to detect salt
water vs. plain water by 4 months of age (Mennella and
Beauchamp, 1998)
Sensory Input for Swallowing
Temporarily decreased
oropharyngeal sensory input has
been shown to impede cortical
control for swallowing in healthy
adults (Teismann et al., 2007).
When pharyngeal and
laryngotracheal sensation is
reduced, silent aspiration is
more likely to occur.
Signs of Aspiration









Coughing/choking/gagging/throat clearing
Oxygen desaturations/apnea/bradycardia
Congestion/gurgling/wet breath sounds/wet vocal quality
Watery eyes
Gulping
Stridor or wheezing
Increased work of breathing
Unexplained spike in temperatures
Difficulty weaning oxygen or need for increased oxygen
Other Risk Factors:
 Infrequent swallows
 Multiple swallows per bolus
 Silent aspiration
 The patient is aspirating with no signs noted.
 Vocal cord damage
 Neurologically impaired
When to consult OT?
 Decreased oral motor skills
 Swallowing difficulties
 Feeding difficulty
 Poor PO intake
 FTT; difficulty gaining weight
 Concern for aversion
 Concern for aspiration
 Delayed developmental milestones affecting
progression of PO
Non-nutritive Oral Motor Assessment
 Jaw
 Tongue
Position, shape, mobility and
stability
Mobility, stability, resting
position, tone, symmetry
 Lips and cheeks
 Teeth
Tone, position, mobility, strength,
cleft
Present, intact
 Palate
Shape, arch, cleft
http://mun-h-center.se/en/Mun-H-Center/Mun-H-Center-E/Oral-Motor-Treatment/
Progression after evaluation/bedside
assessment
 When to refer a Swallow
Function Study in Radiology
with Speech Therapy:
 (+) signs aspiration
 Concern for silent aspiration
 Diagnosis
 Vocal cord dysfunction
 Difficulty advancing with
feeding
 Progressive diagnosis
 When SFS not recommended:
 Advance to regular diet
 Recommend diet based on
assessment
 PO with OT only
Conclusions
Feeding is the most complex motor and sensory task that children engage in.
Feeding problems are complex and multifactorial, including the influence of:
 Descriptive study of 700 patients seen at multidisciplinary feeding program in
Belgium
- 86% medical
- 61% oral
- 16% behavioral
- Oral sensory-based disorders occurred in 21% of patients.
(Rommel et al, 2003)
 physiological stability
 general sensory and pain sensitivity
 level of exposure
 age
 neurological status
References
Birch LL, McPhee L, Shoba BC, Pirok E, Steinberg L. What kind of exposure reduces children’s food neophobia? Looking vs tasting.
Appetite 1987; 9: 171-8.
Cermak SA, Curtin C, Bandini LG. Food Selectivity and Sensory Sensitivity in Children with Autism Spectrum Disorders. J Am
Diet Assoc. 2010;110:238-246.
Delaney A, Arvedson J. Development of swallowing and feeding: prenatal through first year of life. Dev Disabil Res Rev 2008; 14:
105-17.
Mattes, R. D. Physiologic Responses to Sensory Stimulation by Food: Nutritional Implications. Journal of the American Dietetic
Association, XCVII (1997), 406-413.
Mennella JA, Beauchamp GK. 1998. Development and bad taste. Pediatr Asthma Allergy Immunol 12:161-164.
Mennella JA, Griffin CE, Beauchamp GK. 2004. Flavor programming during infancy. Pediatrics 113:840-845.
Mennella JA, Forestell CA, Morgan LK, Beauchamp GK. Early milk feeding influences taste acceptance and liking during infancy.
Am J Clin Nutr2009; 90(suppl):780S-8S.
Miller AJ. 1999. The neuroscientific principles of swallowing and dysphagia. San Diego: Singular Publishing Group.
Rommel N, De Meyer AM, Feenstra L, Veereman-Wauters G. The complexity of feeding problems in 700 infants and young
children presenting to a tertiary care institution. J Pediatr Gastroenterol Nutr 2003;37:75-84.
Staiano, A. Food refusal in toddlers with chronic diseases. J. Pediatr. Gastroenterol. Nutr., Philadelphia, v. 37, n. 3, p. 225-227, sep.
2003.
Sullivan SA, Birch LL. Infant dietary experience and acceptance of solid foods. Pediatrics 1994; 93(2): 271-7.
Teismann IK, Steinstraeter O, Stoeckigt K, et al. 2007. Functional oropharyngeal sensory disruption interferes with the cortical
control of swallowing. BMC Neurosci 8:62.
Thach BT. 2001. Maturation and transformation of reflexes that protect the laryngeal airway from liquid aspiration from fetal to
adult life. Am J Med 111(Suppl 8A):69S-77S.
Thach BT. 2007. Maturation of cough and other reflexes that protect the fetal and neonatal airway. Pulm Pharmacol Ther 20:365370.
Zangen T, Ciarla C, Zangen S, et al. Gastrointestinal motility and sensory abnormalities may contribute to food refusal in medically
fragile toddlers. J Pediatr Gastroenterol Nutr.2003;37 :287-293