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Summary of Clinical Practice Guideline 

Feeding Problems of Infants and Toddlers
Bernard-Bonnin, A. C. (2006).
Canadian Family Physician, 52(10), 1247-51.  
AGREE Rating: Recommended with Provisos
Description:
This guideline provides recommendations regarding the diagnosis and management of feeding problems in young children. Populations included, but were not limited to, children with behavioral feeding disorders, craniofacial anomalies and neurodevelopmental disabilities. Levels of evidence are provided for recommendations throughout the text. Level I evidence requires at least one well done randomized controlled trial, systematic review, or meta-analysis. Level II evidence requires at least one (preferably more than one) comparison trial, non-randomized cohort, case-control, or epidemiologic study. Level III evidence is based on expert opinion or consensus statements.

Recommendations:

  • Assessment/Diagnosis

Assessment Areas

Swallowing/Feeding
  • When evaluating feeding disorders the following key elements should be considered:
    • “How is the problem manifested?
    • Is the child suffering from any disease?
    • Have the child’s weight and development been affected?
    • What is the emotional climate like during the child’s meals?
    • Are there any great stress factors in the family?” (p. 1248).
  • Medical history should include investigation of development, e.g., “antenatal and perinatal history” (p. 1248), family history, diet and dietary changes, feeding characteristics, e.g., “route and time of administration” (p. 1248) and “feeding position” (p. 1248), strategies previously used, and environments and behaviors at mealtimes.
  • “Anatomic abnormalities should be suspected when children have problems swallowing” (p. 1249).
  • “A history of recurrent pneumonia should alert physicians to chronic aspiration…” (p. 1249).
  • “Stridor in relation to feeding could be due to glottic or subglottic abnormalities. Suck-swallow-breathing coordination can be affected by choanal atresia” (p. 1249).
  • An assessment of parent-child interaction should be completed during feeding. “Positive interactions, such as eye contact, reciprocal vocalizations, praise and touch, and negative interactions, such as forced feeding, coaxing, threatening, and children’s disruptive behavior (turning the head away from food, throwing food) should be noted” (p. 1249).
  • Additionally, assessment should document behavior prior to the presentation of food. Specifically, behaviors such as prompting, reinforcement and consequences should be noted.
  • Treatment

Swallowing/Feeding

Behavioral Interventions 

  • Mothers of children with "state regulation" feeding disorders should "modulate the amount of stimulation during feeding” (p. 1250) (Level III Evidence). Feeding should occur promptly before prolonged crying (not more than 30 minutes) and mothers should avoid arousing, burping, or wiping during feeding.
  • Parents of children with "reciprocity" feeding disorders should be trained to be sensitive and responsive to infants' feeding cues (Level III Evidence). "Complicated cases need a multidisciplinary approach where family physicians can play a key role in coordinating services" (p. 1250).
  • Therapy for children with "infantile anorexia" consists of "helping parents understand their children’s special temperaments, set limits, and structure mealtimes to facilitate the internal regulation of eating and to counteract the external regulation produced by emotional interactions within the caregiving environment" (p. 1250). "Food rules" are encouraged, and "time out" may be an appropriate response to inapporpriate behavior (Level II Evidence) (p. 1250).
  • Food aversions can be treated by increasing appropriate behavior with positive reinforcement and decreasing maladaptive behavior with extinction. "Time out" may also be used (p. 1250).
  • Parents of children with feeding problems associated with concurrent medical conditions should be taught management skills to motivate children to improve food intake (Level I Evidence) (p. 1250).
  • Treatment should focus on the elimination of tube feeding and increased acceptance of oral feeding. Treatment should incorporate the "behavioural technique of extinction" (Level I Evidence), or "gradual desensitization" (Level II Evidence) (p. 1250).

Tube Feeding - Treatment should focus on the elimination of tube feeding and increased acceptance of oral feeding. Treatment should incorporate the "behavioural technique of extinction" (Level I Evidence), or "gradual desensitization" (Level II Evidence) (p. 1250). 

Keywords: Cerebral Palsy, Congenital Disorders, Developmental Disorders, Swallowing Disorders, Tube Feeding