อ.จันท์ทิตา dbp-feeding difficulties-imfed (21july2011) · anorexia,fever,...
TRANSCRIPT
![Page 1: อ.จันท์ทิตา DBP-feeding difficulties-IMFeD (21July2011) · Anorexia,fever, weight loss, apthus ulcer, vomiting, diarrhea Illnesses FTT Developmental anomalies](https://reader034.vdocuments.us/reader034/viewer/2022042320/5f0a32877e708231d42a7b75/html5/thumbnails/1.jpg)
Chandhita PruksananondaChulalongkorn University
July21,2011DBP short course at Pramongkut
![Page 2: อ.จันท์ทิตา DBP-feeding difficulties-IMFeD (21July2011) · Anorexia,fever, weight loss, apthus ulcer, vomiting, diarrhea Illnesses FTT Developmental anomalies](https://reader034.vdocuments.us/reader034/viewer/2022042320/5f0a32877e708231d42a7b75/html5/thumbnails/2.jpg)
Feeding- mutual interactions between child & caregiver
![Page 3: อ.จันท์ทิตา DBP-feeding difficulties-IMFeD (21July2011) · Anorexia,fever, weight loss, apthus ulcer, vomiting, diarrhea Illnesses FTT Developmental anomalies](https://reader034.vdocuments.us/reader034/viewer/2022042320/5f0a32877e708231d42a7b75/html5/thumbnails/3.jpg)
Child’s temperamentState regulationPhysiologic variablesBehavioral organization
Mom’s temperamentPsychological healthCharacteristic of momPerspective on parentingSocial support
Child- parent dyad nurturing encounter
![Page 4: อ.จันท์ทิตา DBP-feeding difficulties-IMFeD (21July2011) · Anorexia,fever, weight loss, apthus ulcer, vomiting, diarrhea Illnesses FTT Developmental anomalies](https://reader034.vdocuments.us/reader034/viewer/2022042320/5f0a32877e708231d42a7b75/html5/thumbnails/4.jpg)
20-60% reported - not eating optimally-too selective or “picky “-eat too little-fail to advance to more complex food-eat “ junk food”-unusual food habits-poor meal time behavior
force negative consequences compromise parent-child interactionsuboptimal development
![Page 5: อ.จันท์ทิตา DBP-feeding difficulties-IMFeD (21July2011) · Anorexia,fever, weight loss, apthus ulcer, vomiting, diarrhea Illnesses FTT Developmental anomalies](https://reader034.vdocuments.us/reader034/viewer/2022042320/5f0a32877e708231d42a7b75/html5/thumbnails/5.jpg)
Normal development of feedingMilk smooth textures lumpy foods
finger food adult food
Normal development ofHead & neck controlOral- motor skillsFine motor skills of hands & fingersCommunication skills
![Page 6: อ.จันท์ทิตา DBP-feeding difficulties-IMFeD (21July2011) · Anorexia,fever, weight loss, apthus ulcer, vomiting, diarrhea Illnesses FTT Developmental anomalies](https://reader034.vdocuments.us/reader034/viewer/2022042320/5f0a32877e708231d42a7b75/html5/thumbnails/6.jpg)
Introduction of solid food 4-6 moHead & trunk control - to sit uprightReach for & grasp object ( pincer grasp )(hand-eye coordination skill )
![Page 7: อ.จันท์ทิตา DBP-feeding difficulties-IMFeD (21July2011) · Anorexia,fever, weight loss, apthus ulcer, vomiting, diarrhea Illnesses FTT Developmental anomalies](https://reader034.vdocuments.us/reader034/viewer/2022042320/5f0a32877e708231d42a7b75/html5/thumbnails/7.jpg)
explore new textures, tastes, smells, colors
![Page 8: อ.จันท์ทิตา DBP-feeding difficulties-IMFeD (21July2011) · Anorexia,fever, weight loss, apthus ulcer, vomiting, diarrhea Illnesses FTT Developmental anomalies](https://reader034.vdocuments.us/reader034/viewer/2022042320/5f0a32877e708231d42a7b75/html5/thumbnails/8.jpg)
Self discovery & masteryExploration& experimentation messy table, messy kids
![Page 9: อ.จันท์ทิตา DBP-feeding difficulties-IMFeD (21July2011) · Anorexia,fever, weight loss, apthus ulcer, vomiting, diarrhea Illnesses FTT Developmental anomalies](https://reader034.vdocuments.us/reader034/viewer/2022042320/5f0a32877e708231d42a7b75/html5/thumbnails/9.jpg)
Feeding-Development of autonomyMotor skillLanguage skillPsychological development
![Page 10: อ.จันท์ทิตา DBP-feeding difficulties-IMFeD (21July2011) · Anorexia,fever, weight loss, apthus ulcer, vomiting, diarrhea Illnesses FTT Developmental anomalies](https://reader034.vdocuments.us/reader034/viewer/2022042320/5f0a32877e708231d42a7b75/html5/thumbnails/10.jpg)
Independent feedingSelf regulationSelf determinationPsychosocial separationOccurs at different rates
![Page 11: อ.จันท์ทิตา DBP-feeding difficulties-IMFeD (21July2011) · Anorexia,fever, weight loss, apthus ulcer, vomiting, diarrhea Illnesses FTT Developmental anomalies](https://reader034.vdocuments.us/reader034/viewer/2022042320/5f0a32877e708231d42a7b75/html5/thumbnails/11.jpg)
Opportunities for preventing of feeding problems
Anticipatory guidance :respond to a child’s cues & needsat a particular developmental age
![Page 12: อ.จันท์ทิตา DBP-feeding difficulties-IMFeD (21July2011) · Anorexia,fever, weight loss, apthus ulcer, vomiting, diarrhea Illnesses FTT Developmental anomalies](https://reader034.vdocuments.us/reader034/viewer/2022042320/5f0a32877e708231d42a7b75/html5/thumbnails/12.jpg)
Parental concerns about feeding
![Page 13: อ.จันท์ทิตา DBP-feeding difficulties-IMFeD (21July2011) · Anorexia,fever, weight loss, apthus ulcer, vomiting, diarrhea Illnesses FTT Developmental anomalies](https://reader034.vdocuments.us/reader034/viewer/2022042320/5f0a32877e708231d42a7b75/html5/thumbnails/13.jpg)
Kerzner B. Clin Pediatr. 2009;48:960-965.
![Page 14: อ.จันท์ทิตา DBP-feeding difficulties-IMFeD (21July2011) · Anorexia,fever, weight loss, apthus ulcer, vomiting, diarrhea Illnesses FTT Developmental anomalies](https://reader034.vdocuments.us/reader034/viewer/2022042320/5f0a32877e708231d42a7b75/html5/thumbnails/14.jpg)
Diagnose and treat underlying pathologyRed flags include:
Taking a few sips, rearing back in pain, crying, discontinuing feedingDysphagia, odynophagia – esophgitis due to GER,
infection, toxic injury
Chronic cough, choking, recurrent pneumoniaPoorly coordinated swallowing – CP
Anorexia,fever, weight loss, apthus ulcer, vomiting, diarrheaIllnesses
FTT
Developmental anomalies – prematurity, congenital abnormalities, autism
![Page 15: อ.จันท์ทิตา DBP-feeding difficulties-IMFeD (21July2011) · Anorexia,fever, weight loss, apthus ulcer, vomiting, diarrhea Illnesses FTT Developmental anomalies](https://reader034.vdocuments.us/reader034/viewer/2022042320/5f0a32877e708231d42a7b75/html5/thumbnails/15.jpg)
Kerzner B. Clin Pediatr. 2009;48:960-965.
![Page 16: อ.จันท์ทิตา DBP-feeding difficulties-IMFeD (21July2011) · Anorexia,fever, weight loss, apthus ulcer, vomiting, diarrhea Illnesses FTT Developmental anomalies](https://reader034.vdocuments.us/reader034/viewer/2022042320/5f0a32877e708231d42a7b75/html5/thumbnails/16.jpg)
![Page 17: อ.จันท์ทิตา DBP-feeding difficulties-IMFeD (21July2011) · Anorexia,fever, weight loss, apthus ulcer, vomiting, diarrhea Illnesses FTT Developmental anomalies](https://reader034.vdocuments.us/reader034/viewer/2022042320/5f0a32877e708231d42a7b75/html5/thumbnails/17.jpg)
Parental concern about feeding
“My child is not gaining enough weight”Obtain additional details on feeding practices
Weight, height growth curve normal, mid-parental height
Educate about appropriate expectations forfeeding, growth, nutrition
Promote healthy eating habitsFeeding principles
![Page 18: อ.จันท์ทิตา DBP-feeding difficulties-IMFeD (21July2011) · Anorexia,fever, weight loss, apthus ulcer, vomiting, diarrhea Illnesses FTT Developmental anomalies](https://reader034.vdocuments.us/reader034/viewer/2022042320/5f0a32877e708231d42a7b75/html5/thumbnails/18.jpg)
Underfeeding + milder form of weight loss evaluationInfections- sick, fever, irritable, sore mouth, anorexia
Observe- parent-child interaction2 days nutrition diary
Clear explanation of the effect of illness on appetite & temporary weight loss
If parent’s fear of malnutrition or impaired growth& devforceful feeding nutritional supplement
FTT : cross > 2 major percentile, <-2 SD
![Page 19: อ.จันท์ทิตา DBP-feeding difficulties-IMFeD (21July2011) · Anorexia,fever, weight loss, apthus ulcer, vomiting, diarrhea Illnesses FTT Developmental anomalies](https://reader034.vdocuments.us/reader034/viewer/2022042320/5f0a32877e708231d42a7b75/html5/thumbnails/19.jpg)
“My baby is spitting up all the time.”spitting up ( regurgitation )- common during infancyNo projectile vomiting & poor weight gain
Gastroesophageal reflux(transient lower esophageal relaxation, common maturational process )Occurs at least once dairy in50% < 3 mo67% 4 mo20% 6 mo<5% 12 moSpitting every meal + irritableNormal growth & PE GER
![Page 20: อ.จันท์ทิตา DBP-feeding difficulties-IMFeD (21July2011) · Anorexia,fever, weight loss, apthus ulcer, vomiting, diarrhea Illnesses FTT Developmental anomalies](https://reader034.vdocuments.us/reader034/viewer/2022042320/5f0a32877e708231d42a7b75/html5/thumbnails/20.jpg)
Treatment: show diagram
Meal modification: Smaller, more frequent feeds, Proper positioning :upright positioningThickening a formula with rice cerealMedications, surgery
formula change not indicated , unless allergic HxSevere esophagitis, “ heartburn”
dramatic arching of trunk & neck
![Page 21: อ.จันท์ทิตา DBP-feeding difficulties-IMFeD (21July2011) · Anorexia,fever, weight loss, apthus ulcer, vomiting, diarrhea Illnesses FTT Developmental anomalies](https://reader034.vdocuments.us/reader034/viewer/2022042320/5f0a32877e708231d42a7b75/html5/thumbnails/21.jpg)
“My baby is spitting up all the time”
Aerophagia
Over feeding :weight> 1 oz/dayMilk > 35 oz/day
![Page 22: อ.จันท์ทิตา DBP-feeding difficulties-IMFeD (21July2011) · Anorexia,fever, weight loss, apthus ulcer, vomiting, diarrhea Illnesses FTT Developmental anomalies](https://reader034.vdocuments.us/reader034/viewer/2022042320/5f0a32877e708231d42a7b75/html5/thumbnails/22.jpg)
“My baby is so fussy. The formula isn’t satisfying him.”
![Page 23: อ.จันท์ทิตา DBP-feeding difficulties-IMFeD (21July2011) · Anorexia,fever, weight loss, apthus ulcer, vomiting, diarrhea Illnesses FTT Developmental anomalies](https://reader034.vdocuments.us/reader034/viewer/2022042320/5f0a32877e708231d42a7b75/html5/thumbnails/23.jpg)
“I know she’s growing, you ’ve shown me her growth chart. But she only eats a few preferred foods and refuses most of the food we serve. It’s very frustrating.”
Food fussinessPicky eating ( limited food preference)-developmental expectation-parent-child interaction
![Page 24: อ.จันท์ทิตา DBP-feeding difficulties-IMFeD (21July2011) · Anorexia,fever, weight loss, apthus ulcer, vomiting, diarrhea Illnesses FTT Developmental anomalies](https://reader034.vdocuments.us/reader034/viewer/2022042320/5f0a32877e708231d42a7b75/html5/thumbnails/24.jpg)
No parent has ever won “ a battle ” over food intake or preferences.
By encourage choice in the diet,parents promote autonomy, mastery and self esteem.
Keeping health food in the home for meal & snack.
- eat with other family member- eat with friends
no TV no forcing
Promote healthy eating habits
![Page 25: อ.จันท์ทิตา DBP-feeding difficulties-IMFeD (21July2011) · Anorexia,fever, weight loss, apthus ulcer, vomiting, diarrhea Illnesses FTT Developmental anomalies](https://reader034.vdocuments.us/reader034/viewer/2022042320/5f0a32877e708231d42a7b75/html5/thumbnails/25.jpg)
1. Maintain appropriate boundariesparent decides where, when, & what the child eatschild decides how much is eaten
2.Avoid distractionfree of noise & distractionuse high chairsit at the tablemay offer a toy to get the child settled removed once the meal starts
3.Feed to encourage appetiteallow 3-4 hours intervals between mealsavoid snack, juice, milk ( only water for thirst)time the meal to coincide with parent’s meal ( 3 meals+ 1snack )
Feeding principles
![Page 26: อ.จันท์ทิตา DBP-feeding difficulties-IMFeD (21July2011) · Anorexia,fever, weight loss, apthus ulcer, vomiting, diarrhea Illnesses FTT Developmental anomalies](https://reader034.vdocuments.us/reader034/viewer/2022042320/5f0a32877e708231d42a7b75/html5/thumbnails/26.jpg)
Feeding principles4.Maintain neutral attitude
not get overly excited or animatednever angry
5.Limit durationeating begin within 15 minutes of the start of the meal< 30-35 minutesnot become a short-order cook
6.Serve age-appropriate food7.Systematically introduce new food
offer repetitively 10-15 timesreward with praise or stickersnot use food as reward
![Page 27: อ.จันท์ทิตา DBP-feeding difficulties-IMFeD (21July2011) · Anorexia,fever, weight loss, apthus ulcer, vomiting, diarrhea Illnesses FTT Developmental anomalies](https://reader034.vdocuments.us/reader034/viewer/2022042320/5f0a32877e708231d42a7b75/html5/thumbnails/27.jpg)
Feeding principles
8. Encourage independent feeding9. Tolerate age- appropriate mess
use a bib, sheetnot irritate the child by wiping the mouth each mouthful
![Page 28: อ.จันท์ทิตา DBP-feeding difficulties-IMFeD (21July2011) · Anorexia,fever, weight loss, apthus ulcer, vomiting, diarrhea Illnesses FTT Developmental anomalies](https://reader034.vdocuments.us/reader034/viewer/2022042320/5f0a32877e708231d42a7b75/html5/thumbnails/28.jpg)
“My child will always choose junk foods over good foods”
Food preference is a learned behavior.Food advertising
Educate parentsRole modelNo TV
![Page 29: อ.จันท์ทิตา DBP-feeding difficulties-IMFeD (21July2011) · Anorexia,fever, weight loss, apthus ulcer, vomiting, diarrhea Illnesses FTT Developmental anomalies](https://reader034.vdocuments.us/reader034/viewer/2022042320/5f0a32877e708231d42a7b75/html5/thumbnails/29.jpg)
![Page 30: อ.จันท์ทิตา DBP-feeding difficulties-IMFeD (21July2011) · Anorexia,fever, weight loss, apthus ulcer, vomiting, diarrhea Illnesses FTT Developmental anomalies](https://reader034.vdocuments.us/reader034/viewer/2022042320/5f0a32877e708231d42a7b75/html5/thumbnails/30.jpg)
Vigorous child with little interest in feeding
Child- alert, active, inquisitive, more interest in environment than foodParent- anxious & encourage “ grazing ”
further inhibits appetitecoercive with feeding power struggle
Minimal appetiteReadily satiatedEasily distracted from eating
Infantile anorexia
![Page 31: อ.จันท์ทิตา DBP-feeding difficulties-IMFeD (21July2011) · Anorexia,fever, weight loss, apthus ulcer, vomiting, diarrhea Illnesses FTT Developmental anomalies](https://reader034.vdocuments.us/reader034/viewer/2022042320/5f0a32877e708231d42a7b75/html5/thumbnails/31.jpg)
Treatment – increase appetite by promoting hunger-Ensure 3 meals & afternoon snack-Begin eating within 15 minutes of presenting food,meal should end 20 minutes later-Not start or finish within that time remove meal-Do not be tempted to encourage “grazing” or offer juices ;allow only water between meals
Minimize distractions during feedingTime-out to discourage disruptive behavior
Select high-calorie food, nutritional balanced, 30-calories-per-ounce supplementCyproheptadine +--
Parents & family members are in agreement & mutually supportConsistent
![Page 32: อ.จันท์ทิตา DBP-feeding difficulties-IMFeD (21July2011) · Anorexia,fever, weight loss, apthus ulcer, vomiting, diarrhea Illnesses FTT Developmental anomalies](https://reader034.vdocuments.us/reader034/viewer/2022042320/5f0a32877e708231d42a7b75/html5/thumbnails/32.jpg)
Depressed child with little interest in feedingflat affect, show little interest in eatingwithdrawn, loss appetite
“disorder of reciprocity”break-down in the communication between mother & childNeglected
![Page 33: อ.จันท์ทิตา DBP-feeding difficulties-IMFeD (21July2011) · Anorexia,fever, weight loss, apthus ulcer, vomiting, diarrhea Illnesses FTT Developmental anomalies](https://reader034.vdocuments.us/reader034/viewer/2022042320/5f0a32877e708231d42a7b75/html5/thumbnails/33.jpg)
Depressed child with little interest in feeding
Treatment:-response positively to an enthusiastic & experienced feeder-admission to induce a positive feeding environment
![Page 34: อ.จันท์ทิตา DBP-feeding difficulties-IMFeD (21July2011) · Anorexia,fever, weight loss, apthus ulcer, vomiting, diarrhea Illnesses FTT Developmental anomalies](https://reader034.vdocuments.us/reader034/viewer/2022042320/5f0a32877e708231d42a7b75/html5/thumbnails/34.jpg)
Child with poor appetite due to organic disease
Treat any underlying pathology
![Page 35: อ.จันท์ทิตา DBP-feeding difficulties-IMFeD (21July2011) · Anorexia,fever, weight loss, apthus ulcer, vomiting, diarrhea Illnesses FTT Developmental anomalies](https://reader034.vdocuments.us/reader034/viewer/2022042320/5f0a32877e708231d42a7b75/html5/thumbnails/35.jpg)
![Page 36: อ.จันท์ทิตา DBP-feeding difficulties-IMFeD (21July2011) · Anorexia,fever, weight loss, apthus ulcer, vomiting, diarrhea Illnesses FTT Developmental anomalies](https://reader034.vdocuments.us/reader034/viewer/2022042320/5f0a32877e708231d42a7b75/html5/thumbnails/36.jpg)
![Page 37: อ.จันท์ทิตา DBP-feeding difficulties-IMFeD (21July2011) · Anorexia,fever, weight loss, apthus ulcer, vomiting, diarrhea Illnesses FTT Developmental anomalies](https://reader034.vdocuments.us/reader034/viewer/2022042320/5f0a32877e708231d42a7b75/html5/thumbnails/37.jpg)
Highly selective eating limit essential nutrients– vitamins. Iron, zinc
May lack some developmentally acquired feeding skillsDifficulty socially“ sensory food aversions”
![Page 38: อ.จันท์ทิตา DBP-feeding difficulties-IMFeD (21July2011) · Anorexia,fever, weight loss, apthus ulcer, vomiting, diarrhea Illnesses FTT Developmental anomalies](https://reader034.vdocuments.us/reader034/viewer/2022042320/5f0a32877e708231d42a7b75/html5/thumbnails/38.jpg)
Treatment: systematic introduction of new food items, one at a time-Serve minimal quantities -Expose repeatedly (10-15 times)-Leave food within reach without offering it (in control)-Parent model eating with pleasure, not offer food until he expresses interest
-Mix very small amounts of new food with accepted food & gradual shift the ratio-If gagging or vomiting withdraw the food& try something more resemble a preferred food-Remain neutral & relaxed about his intake
![Page 39: อ.จันท์ทิตา DBP-feeding difficulties-IMFeD (21July2011) · Anorexia,fever, weight loss, apthus ulcer, vomiting, diarrhea Illnesses FTT Developmental anomalies](https://reader034.vdocuments.us/reader034/viewer/2022042320/5f0a32877e708231d42a7b75/html5/thumbnails/39.jpg)
Excessive or irrational fear of feeding“ Post traumatic feeding disorder”
Hx of noxious oral experiences
Treatment:Desensitize feed when half asleep & relaxedNot threatening
![Page 40: อ.จันท์ทิตา DBP-feeding difficulties-IMFeD (21July2011) · Anorexia,fever, weight loss, apthus ulcer, vomiting, diarrhea Illnesses FTT Developmental anomalies](https://reader034.vdocuments.us/reader034/viewer/2022042320/5f0a32877e708231d42a7b75/html5/thumbnails/40.jpg)
Feeding difficulties in disabled children1/3The direct effect of impairment on feeding-Oral motor impairment- muscle spasticity or hypotonia
- delayed maturation of skill- retention of primitive reflexes
-Anatomical abnormality-Medical & psychological dysfunction
![Page 41: อ.จันท์ทิตา DBP-feeding difficulties-IMFeD (21July2011) · Anorexia,fever, weight loss, apthus ulcer, vomiting, diarrhea Illnesses FTT Developmental anomalies](https://reader034.vdocuments.us/reader034/viewer/2022042320/5f0a32877e708231d42a7b75/html5/thumbnails/41.jpg)
Hypotonia & delayed maturation of feeding skill
May improve with time & feeding experience
![Page 42: อ.จันท์ทิตา DBP-feeding difficulties-IMFeD (21July2011) · Anorexia,fever, weight loss, apthus ulcer, vomiting, diarrhea Illnesses FTT Developmental anomalies](https://reader034.vdocuments.us/reader034/viewer/2022042320/5f0a32877e708231d42a7b75/html5/thumbnails/42.jpg)
![Page 43: อ.จันท์ทิตา DBP-feeding difficulties-IMFeD (21July2011) · Anorexia,fever, weight loss, apthus ulcer, vomiting, diarrhea Illnesses FTT Developmental anomalies](https://reader034.vdocuments.us/reader034/viewer/2022042320/5f0a32877e708231d42a7b75/html5/thumbnails/43.jpg)
Prader Willi
![Page 44: อ.จันท์ทิตา DBP-feeding difficulties-IMFeD (21July2011) · Anorexia,fever, weight loss, apthus ulcer, vomiting, diarrhea Illnesses FTT Developmental anomalies](https://reader034.vdocuments.us/reader034/viewer/2022042320/5f0a32877e708231d42a7b75/html5/thumbnails/44.jpg)
The child’s fine motor & adaptivechoice of utensils & level of independence at meal time
Effective caregiver-child communication during mealtime is crucial.
![Page 45: อ.จันท์ทิตา DBP-feeding difficulties-IMFeD (21July2011) · Anorexia,fever, weight loss, apthus ulcer, vomiting, diarrhea Illnesses FTT Developmental anomalies](https://reader034.vdocuments.us/reader034/viewer/2022042320/5f0a32877e708231d42a7b75/html5/thumbnails/45.jpg)
Co-existing medical condition
CHD - gut dysmotility- increased energy requirement- early fatigability
Chronic lung disease – raised work of feeding & increased oxygen requirement
Cleft lip& palate - cannot develop sufficient negativeintra-oral pressure to suck well
- may have oral hypersensitivity & GER
Medication – anticonvulsantInfection
![Page 46: อ.จันท์ทิตา DBP-feeding difficulties-IMFeD (21July2011) · Anorexia,fever, weight loss, apthus ulcer, vomiting, diarrhea Illnesses FTT Developmental anomalies](https://reader034.vdocuments.us/reader034/viewer/2022042320/5f0a32877e708231d42a7b75/html5/thumbnails/46.jpg)
The indirect effects of disability on feeding & attitude to meal times
Social function – reluctant to eat out( eat slowly, messy, vomit, drool)Behavioral problems – poor attention& concentration
- frustration, chronic high stress
![Page 47: อ.จันท์ทิตา DBP-feeding difficulties-IMFeD (21July2011) · Anorexia,fever, weight loss, apthus ulcer, vomiting, diarrhea Illnesses FTT Developmental anomalies](https://reader034.vdocuments.us/reader034/viewer/2022042320/5f0a32877e708231d42a7b75/html5/thumbnails/47.jpg)
Pica: eat non-food substances< 2 yearsNormal hand- to- mouth exploratory behavior
>2 yr, toxic substanceMR , Autistic, Psychological problem, sensory impaired , lack of stimulation
![Page 48: อ.จันท์ทิตา DBP-feeding difficulties-IMFeD (21July2011) · Anorexia,fever, weight loss, apthus ulcer, vomiting, diarrhea Illnesses FTT Developmental anomalies](https://reader034.vdocuments.us/reader034/viewer/2022042320/5f0a32877e708231d42a7b75/html5/thumbnails/48.jpg)
![Page 49: อ.จันท์ทิตา DBP-feeding difficulties-IMFeD (21July2011) · Anorexia,fever, weight loss, apthus ulcer, vomiting, diarrhea Illnesses FTT Developmental anomalies](https://reader034.vdocuments.us/reader034/viewer/2022042320/5f0a32877e708231d42a7b75/html5/thumbnails/49.jpg)
MaterialsFlipchart Questionnaire
Brochure
![Page 50: อ.จันท์ทิตา DBP-feeding difficulties-IMFeD (21July2011) · Anorexia,fever, weight loss, apthus ulcer, vomiting, diarrhea Illnesses FTT Developmental anomalies](https://reader034.vdocuments.us/reader034/viewer/2022042320/5f0a32877e708231d42a7b75/html5/thumbnails/50.jpg)
Procedures
![Page 51: อ.จันท์ทิตา DBP-feeding difficulties-IMFeD (21July2011) · Anorexia,fever, weight loss, apthus ulcer, vomiting, diarrhea Illnesses FTT Developmental anomalies](https://reader034.vdocuments.us/reader034/viewer/2022042320/5f0a32877e708231d42a7b75/html5/thumbnails/51.jpg)
Questionnaire 1/2
![Page 52: อ.จันท์ทิตา DBP-feeding difficulties-IMFeD (21July2011) · Anorexia,fever, weight loss, apthus ulcer, vomiting, diarrhea Illnesses FTT Developmental anomalies](https://reader034.vdocuments.us/reader034/viewer/2022042320/5f0a32877e708231d42a7b75/html5/thumbnails/52.jpg)
Questionnaire 2/2
![Page 53: อ.จันท์ทิตา DBP-feeding difficulties-IMFeD (21July2011) · Anorexia,fever, weight loss, apthus ulcer, vomiting, diarrhea Illnesses FTT Developmental anomalies](https://reader034.vdocuments.us/reader034/viewer/2022042320/5f0a32877e708231d42a7b75/html5/thumbnails/53.jpg)
Flipchart
![Page 54: อ.จันท์ทิตา DBP-feeding difficulties-IMFeD (21July2011) · Anorexia,fever, weight loss, apthus ulcer, vomiting, diarrhea Illnesses FTT Developmental anomalies](https://reader034.vdocuments.us/reader034/viewer/2022042320/5f0a32877e708231d42a7b75/html5/thumbnails/54.jpg)
Flipchart
![Page 55: อ.จันท์ทิตา DBP-feeding difficulties-IMFeD (21July2011) · Anorexia,fever, weight loss, apthus ulcer, vomiting, diarrhea Illnesses FTT Developmental anomalies](https://reader034.vdocuments.us/reader034/viewer/2022042320/5f0a32877e708231d42a7b75/html5/thumbnails/55.jpg)
Questionnaire 1/2
![Page 56: อ.จันท์ทิตา DBP-feeding difficulties-IMFeD (21July2011) · Anorexia,fever, weight loss, apthus ulcer, vomiting, diarrhea Illnesses FTT Developmental anomalies](https://reader034.vdocuments.us/reader034/viewer/2022042320/5f0a32877e708231d42a7b75/html5/thumbnails/56.jpg)
Questionnaire 2/2
กล้วยผกัใบเขยีว
ปลา
นมเปรียว
ข้าว
158 cm170 cm
![Page 57: อ.จันท์ทิตา DBP-feeding difficulties-IMFeD (21July2011) · Anorexia,fever, weight loss, apthus ulcer, vomiting, diarrhea Illnesses FTT Developmental anomalies](https://reader034.vdocuments.us/reader034/viewer/2022042320/5f0a32877e708231d42a7b75/html5/thumbnails/57.jpg)
Flipchart
![Page 58: อ.จันท์ทิตา DBP-feeding difficulties-IMFeD (21July2011) · Anorexia,fever, weight loss, apthus ulcer, vomiting, diarrhea Illnesses FTT Developmental anomalies](https://reader034.vdocuments.us/reader034/viewer/2022042320/5f0a32877e708231d42a7b75/html5/thumbnails/58.jpg)
Flipchart
![Page 59: อ.จันท์ทิตา DBP-feeding difficulties-IMFeD (21July2011) · Anorexia,fever, weight loss, apthus ulcer, vomiting, diarrhea Illnesses FTT Developmental anomalies](https://reader034.vdocuments.us/reader034/viewer/2022042320/5f0a32877e708231d42a7b75/html5/thumbnails/59.jpg)
Brochure1 2 3 4 5 6
![Page 60: อ.จันท์ทิตา DBP-feeding difficulties-IMFeD (21July2011) · Anorexia,fever, weight loss, apthus ulcer, vomiting, diarrhea Illnesses FTT Developmental anomalies](https://reader034.vdocuments.us/reader034/viewer/2022042320/5f0a32877e708231d42a7b75/html5/thumbnails/60.jpg)
Prevention is more important
ANTICIPATORY GUIDANCE
![Page 61: อ.จันท์ทิตา DBP-feeding difficulties-IMFeD (21July2011) · Anorexia,fever, weight loss, apthus ulcer, vomiting, diarrhea Illnesses FTT Developmental anomalies](https://reader034.vdocuments.us/reader034/viewer/2022042320/5f0a32877e708231d42a7b75/html5/thumbnails/61.jpg)