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Serious feeding disorders call for intensive therapy. (Beyond the 'Picky Eater').

MIAMI BEACH -- Intensive therapy is needed for the small subset of young children with feeding disorders that extend beyond that of the "picky eater," Dr. Jay Perman said at a pediatric meeting sponsored by Miami Children's Hospital.

Children who simply won't eat at all or who have extremely bizarre eating habits--such as only eating round, white food or eating just the corners off saltine crackers--often confound even the most experienced child health experts.

An interdisciplinary team-including the physician, nurse, behavioral psychologist, nutritionist, occupational therapist, and other professionals--may be required to help these children learn to eat normally, said Dr. Perman, professor and chairman of pediatrics at the University of Maryland, Baltimore.

Such behaviors may arise in children with organic problems such as cleft palate, dysphagia, or esophagitis. Patients learn to associate swallowing with pain and subsequently refuse to eat even after the physical problem has been corrected. Similarly, children who are tube-dependent during the first 1-2 years of life also may have trouble eating because they were never exposed to developmentally appropriate textures.

Behavioral mismanagement by often well-meaning parents also may lead children to develop bad associations with eating and food refusal, he said.

An estimated 25% of all children have some degree of feeding disorders (including the less severe "picky eater" category), but more severely disordered eating patterns occur in up to 80% of children with developmental disabilities and more than half of autistic children.

"My impression is that these problems are much more common than we've appreciated. Some are clearly iatrogenic, [as with] the tube-fed child," Dr. Perman commented.

Among the many specific disordered eating behaviors seen in these children are avoidance of drinking, bottle dependency, total food refusal, food refusal by volume, food selectivity by texture and/or type, recurrent emesis, and various chewing! feeding skill deficits.

In one of the most common scenarios, a child with gastroesophageal reflux develops both esophagitis and food avoidance: Fighting, crying, gagging, vomiting, pushing food away and! or throwing a temper tantrum becomes a nightly dinnertime ordeal. Parents, in turn, will either try to force-feed the child, or will simply allow the child to escape the meal to avoid further fighting.

"I get a lot of referrals for this scenario," said Dr. Perman, who has a special interest in child nutrition and feeding.

Over time, feeding difficulties may permanently adversely affect growth, psychosocial development, and family harmony. Malnourished children also tend to be more vulnerable to a variety of illnesses.

Intensive stepwise treatment--outpatient, inpatient, or day patient-is necessary. All programs involve family training and continuing reinforcement after the active treatment phase, which typically lasts an average of 6-9 weeks.

Treatment includes positive reinforcement for accepting, chewing, and ultimately swallowing food. Meal volume, duration, and variety are slowly increased until the child learns to eat normally. Aversive tactics are not used. "It's a painstaking process, but it's what these children require," Dr. Perman noted.

When referring children for such therapy, be prepared to discuss the child's individual circumstance with the payer, and explain your assessment and treatment plan.

"In my experience, payers will individualize decision making. You must be willing to talk with them," he said.
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Author:Tucker, Miriam E.
Publication:Pediatric News
Geographic Code:1USA
Date:Oct 1, 2002
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