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Pediatric Dysphagia Evidence Map
Treatment

Behavioral Interventions

 

 

 

External Scientific Evidence

  

Evidence-Based Practice Guidelines

Feeding Problems of Infants and Toddlers
Bernard-Bonnin, A. C. (2006).
Canadian Family Physician, 52, 1247-1251
.
Added: July 2011
 
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
  • 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).
 
 
 
New York State Department of Health, Early Intervention Program; U.S. Department of Education
 
Clinical Practice Guideline: Report of the Recommendations. Down Syndrome, Assessment and Intervention for Young Children (Age 0-3 Years)
New York State Department of Health, Early Intervention Program. (2006).
Albany (NY): NYS Department of Health, Publication No. 4959, 292 pages.
 
 
Added: July 2011
 
Description
This guideline provides recommendations pertaining to the assessment and intervention of young children with Down syndrome. The intended audiences for this guideline include families and professionals. Of particular importance to speech-language pathologists and audiologists are recommendations regarding assessment and management of communication, cognition, social relationships, oral-motor feeding, and hearing. The recommendations are classified A, B, C, D1 or D2, based on the strength and quality of evidence. Level A recommendations are considered “strong evidence” based on high quality evidence from two or more efficacy studies. Level B recommendations are considered “moderate evidence" and based on evidence from at least one high quality efficacy study. Level C recommendations are "limited evidence" and based on evidence from at least one efficacy study with moderate quality or applicability to the topic.  Level D1 and D2 are consensus recommendations. Level D1 recommendations are consensus panel opinion based on information not meeting criteria for evidence in systematic reviews and Level D2 recommendations are based on information where a systematic review has not been done. 
 
Recommendations
  • Interventions for oral motor and feeding problems may include behavioral interventions "to improve tongue posture and encourage appropriate development of jaw, lip, and tongue movements used in eating, drinking, and speaking" (Level C).
  • Parent-child groups and parent-parent training to facilitate feeding (Level D2).
 
 
 
Royal College of Speech & Language Therapists; Department of Health (UK); National Institute for Clinical Excellence (NICE)
 
Royal College of Speech and Language Therapists Clinical Guidelines: 5.8 Disorders of Feeding, Eating, Drinking & Swallowing (Dysphagia)
Taylor-Goh, S., ed. (2005).
RCSLT Clinical Guidelines. Bicester, Speechmark Publishing Ltd.
 
Added: July 2011
 
Description
This guideline provides recommendations for the assessment and management of swallowing disorders in children and adults. This guideline is intended for speech-language pathologists. Populations included, but were not limited to, stroke, traumatic brain injury, autism spectrum disorder, cerebral palsy, Parkinson’s disease and head and neck cancer. Each recommendation is graded A (requires at least one randomized controlled trial), B (requires at least one well-conducted clinical study), or C (requires evidence from expert committee reports). 
 
Recommendations

“The Speech & Language Therapist will identify which behavioural strategies facilitate the eating and drinking process and communicate these to the relevant carers. These may include:

  • Situational strategies prior to, during and after mealtime
  • Verbal cues
  • Written cues and/or symbols
  • Physical cues
  • Visual cues” (Level A Evidence) (p. 68).
 
 
 
Evidence-Based Systematic Reviews
Behavioral Treatment of Drooling: A Methodological Critique of the Literature with Clinical Guidelines and Suggestions for Future Research
Van der Burg, J. J. W., Didden, R., et al. (2007).
Behavior Modification, 31(5), 573-594.
Added: April 2013

Description
This is a review of the literature investigating behavioral treatments to address drooling or the self-management of drooling in children with developmental disabilities.

Conclusions
This review investigated various behavioral treatments such as instruction, prompting, and positive reinforcement; negative social reinforcement and decelarative procedures; cueing techniques; and self-management procedures. Although the studies found positive results, methodological shortcomings were noted. Many behavioral approaches did not produce lasting effect because they were not consistently or systematically implemented. The authors concluded that behavioral procedures "need both elaboration and evaluation in future studies" (p. 85).

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Interventions for Drooling in Children with Cerebral Palsy
Walshe, M., Smith, M., et al. (2012).
Cochrane Database of Systematic Reviews, 2, CD008624.

This review meets the criteria for a high-quality evidence-based systematic review.
Added: April 2013

Description
This is a systematic review of randomized controlled trials examining various interventions for drooling in children with cerebral palsy (CP). Treatments investigated in the review include: surgery, pharmacological interventions, botulin toxin, oro-motor/oro-sensory therapies, behavioral interventions, intra-oral appliances, and acupuncture.

Conclusions
No studies were found on surgery, physical/oro-motor-oro-sensory therapies, behavioral treatments, intra-oral appliances, or acupuncture. "There is insufficient evidence to evaluate the effectiveness and safety of interventions aimed at reducing or eliminating drooling in children with cerebral palsy or to provide the best available evidence to inform clinical practice" (p. 30).

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Feeding Problems in Children with Autism Spectrum Disorders: A Review
Ledford, J. R., & Gast, D. L. (2006).
Focus on Autism & Other Developmental Disabilities, 21(3), 153-166
.
 
Added: March 2012
 
Description
This is a review of experimental, peer-reviewed research studies evaluating the effectiveness of feeding interventions for children with autism spectrum disorders (ASD). 
 
Conclusions
“Of the nine intervention studies reviewed, all reported successful treatment of feeding problems in children with ASD. A variety of approaches, including simultaneous presentation, sequential presentation, differential reinforcement of acceptance, stimulus fading, escape extinction, and appetite manipulation, were studied in isolation or in combination. Research designs also varied across studies. Overall, the results of these studies demonstrate the availability of a wide range of effective intervention strategies for treating feeding acceptance and consumption problems exhibited by children with ASD” (p. 162).
 
 
 
 
 
Food Refusal in Children: A Review of the Literature
Williams, K. E., Field, D. G., et al. (2010).
Research in Developmental Disabilities, 31(3), 625-633.
Added: July 2011
 
Description
This is a review of the literature investigating the etiology and interventions pertaining to children with behavioral feeding problems. 
 
Conclusions
  • "It is not yet possible to directly compare the effectiveness of the various intervention packages... " due to the heterogeneity of the populations and interventions studied  (p. 629).
  • Some promising aspects of behavioral intervention programs were noted (e.g. stimulus fading, bolus manipulation, escape prevention) with further research recommended.

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Pediatric Feeding Disorders: A Quantitative Synthesis of Treatment Outcomes
Sharp, W. G., Jaquess, D. L., et al. (2010).
Clinical Child & Family Psychology Review, 13(4), 348-365.
 
 
This review meets the criteria for a high-quality evidence-based systematic review.
Added: July 2011
 
Description
This is a meta-analysis of single-subject experimental design studies investigating feeding interventions in children with severe feeding disorders. Participant diagnoses included global developmental delay, autism spectrum disorders, intellectual disabilities, speech/language delay, as well as children who were considered typically developing. 
 
Conclusions
  • Behavioral interventions were "associated with significant improvements in feeding behavior" (p. 348).
  • "...[N]o well-controlled studies evaluating feeding interventions by other theoretical perspectives or clinical disciplines met inclusion criteria" (p. 348).

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Clinical Expertise/Expert Opinion

 
Consensus Guidelines  
American Speech-Language-Hearing Association
 
Guidelines for Speech-Language Pathologists Providing Swallowing and Feeding Services in Schools
American Speech-Language-Hearing Association. (2007).
Retrieved from: http://www.asha.org/docs/html/GL2007-00276.html
 
Added: July 2011
 
Description
This ASHA guideline addresses the issues, models, and procedures for management of students with swallowing and feeding disorders in the school setting. 
 
Recommendations
“A swallowing and feeding plan typically includes recommendations/guidelines on the following: positioning, equipment, diet/food preparation, feeding plan techniques and precautions (which may include behavioral considerations), and the name and contact information for the dysphagia case manager” (p. 16).
 
 
 

Client/Patient/Caregiver Perspectives

 
Treatment Outcomes for Severe Feeding Problems in Children with Autism Spectrum Disorder
Laud, R. B., Girolami, P. A., et al. (2009).
Behavior Modification, 33(5), 520-536.
Added: April 2013

Description

This is a study of 46 children with autism spectrum disorders (ASD). This study examines the impact of intensive behavioral treatment on feeding skills, negative behaviors, oral intake, and caregiver satisfaction.

Conclusions
Caregivers reported a significant decrease in the Total Eating Problem score on the Children's Eating Behavior Inventory (CEBI) from admission to discharge. Additionally average caregiver satisfaction scores at discharge were reported to range from very satisfied to extremely satisfied.

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Treatment of Food Selectivity in a Young Child With Autism
Wood, B. K., Wolery, M., et al. (2009).
Focus on Autism & Other Developmental Disabilities, 24(3), 169-77.
Added: September 2012

Description
This is a case-study of a treatment for food selectivity in a young child with autism. The child was provided a gluten-free/casein-free diet and treatment included task direction, contingent reinforcement, physical prompts, and gradual food introduction. Outcome included the number and variety of food consumed and parent satisfaction.

Conclusions
The child’s mother indicated that the study “made a positive difference in her child’s eating habits,” “that the intervention seemed to benefit her child” and “that she would recommend the intervention” (p. 175).

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A Retrospective Chart Review of Dietary Diversity and Feeding Behavior of Children With Autism Spectrum Disorder Before and After Admission to a Day-Treatment Program
Sharp, W. G., Jaquess, D. L., et al. (2011).
Focus on Autism & Other Developmental Disabilities, 26(1), 37-48
.
 
Added: July 2011
 
Description
This is a study of 13 children with autism spectrum disorders (ASD) and severe food selectivity. This study examines the impact of a behavioral approach implemented in an intensive day-treatment program. 
 
Conclusions
  • Upon completion of the program, caregivers completed a questionnaire assessing program satisfaction, treatment gains, and social acceptance. Items were rated from 1-5 with higher scores reflecting greater satisfaction, improvement, and acceptance of treatment.
  • "All respondents indicated that they were extremely satisfied with treatment, with an average rating of 4.9 (range, 4-5). Caregivers also reported positive change in their child's mealtime behaviors (M=4.4; range, 3.8-5) and indicated that they viewed the treatment approach as acceptable for addressing their child's feeding difficulties (M= 4.9; range, 4.3-5)" (p. 9).

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Utilizing a Home-Based Parent Training Approach in the Treatment of Food Selectivity
Najdowski, A. C., Wallace, M. D., et al. (2010).
Behavioral Interventions, 25(2), 89-107.
 
Added: July 2011
 
Description
This is a single-subject design study of 3 children (two with autism spectrum disorders and one typically developing) with significant feeding difficulties characterized by severe food selectivity. This study examines the the effectiveness of professionals acting as consultants to train parents to implement a behavioral in-home feeding program. 
 
Conclusions
"The results of the parent satisfaction questionnaire used in the study suggested that parents were highly satisfied with their treatments and the outcomes they produced. It should be noted that the questionnaire used is an unvalidated measure and caution should therefore be exercised when interpreting its results" (p. 106). 
 
 




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