feeding clinic: a multidisciplinary approach to pediatric ... · feeding disorders • pediatric...
TRANSCRIPT
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© The Children's Mercy Hospital, 2017
Brenda Sitzmann, MA, CCC-SLP Sarah Edwards, DO Laura Slosky, PhD
Jamie Wilkins, RD, LD, CNSC Elizabeth Schroeder, OTR/L
Feeding Clinic: A Multidisciplinary Approach to Pediatric Feeding Disorders
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© The Children's Mercy Hospital, 2014. 03/142
Feeding Services at Children’s Mercy
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© The Children's Mercy Hospital, 2014. 03/143
Feeding Services at Children’s Mercy
Interdisciplinary Pediatric Feeding & Swallowing Program
• Multidisciplinary Feeding Clinic at Adele Hall • Focus of today’s presentation • GI, psychology, nutrition, speech and OT
• Multidisciplinary Feeding Clinic at CMK • GI NP, pediatrician, psychology, nutrition, OT • Similar to MDFC but no SLP services
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Multidisciplinary Feeding Clinic (MDFC)• Adele Hall Team Members
• Gastroenterologist: Sarah Edwards, DO
• Psychology: Laura Slosky, PhD • Nutrition: Jamie Wilkins, RD, LD, CNSC & April Escobar, MS,
RD, CSP, LD
• Speech: Brenda Sitzmann, MA, CCC-SLP, CLC
• OT: Elizabeth Schroeder, MOT, OTR/L & Rebecca Pearson, MOT, OTR/L
• Social work is available as needed
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Patient Population• Birth to 18 years of age
• Oral feeders or potential to be oral feeders
• Children with g-tubes who are unable to be oral feeders are followed by g-tube clinic
• Benefit from at least 3 of the 5 disciplines5
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Feeding Disorders• Pediatric Feeding Disorders are Common
– 25% of children
• 3-10% of children have severe feeding problems
– 80% in developmentally delayed population
• Feeding difficulties are often multifactorial
• Combination of medical, psychosocial, nutrition and skills/ability factors
6Manikam R and Perman JA. Pediatric Feeding Disorders. Journal of Clinical Gastroenterology. 2000. 30;1, 34-46.
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Common Diagnoses/Reason for Referrals• Oral aversion
• Aspiration
• Extremely selective eaters
• Limited oral intake
• Difficulty gaining weight
• Non-oral feedings
• Behaviors are impacting oral intake
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• EoE
• Sensory concerns
• Reflux
• Constipation Vomiting/feeding intolerance
• Using liquids to meet nutritional needs
• Weaning from g-tube feedings
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Typical Team Visit• Family completes a packet before they are scheduled
• Birth history, medical history, development, current medications, current therapy services, food log
• 1 1/2 to 2 hour visit
• Height and weight
• Caregiver interview with the entire team
• Feeding assessment
• May use the observation window
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Typical Team Visit• Physical exam
• Team meeting
• Team leaves the exam room to formulate a plan
• Recommendations
• Personalized written recommendations/home program “Depart Summary”
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Gastroenterology
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Sarah Edwards, DO
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History• Illness
• Prematurity
• Development and acquisition of oral motor skills
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History• Medications
• Bowel Habits
• Detailed diet and feeding history
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Feeding History• Choking or Gagging
• Changes in respiration
• Regurgitation or Vomiting
13Cohen SA and Navathe AS. Nutrition and Feeding For Children with Developmental Disabilities. In: Wyllie R and Hyams JS, ed. Pediatric Gastrointestinal and Liver Disease. Philadelphia: Saunders; 2011: Ch. 92.
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Reflux or Vomiting?• Is it reflux or vomiting
– Reflux is the EFFORTLESS return of gastric contents into the esophagus and/or out of the mouth
– Vomiting is the forceful return of gastric contents out of the mouth, often accompanied by nausea and retching
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Feeding History• Feeding refusal
• Meal duration
• Current Diet, textures
15Cohen SA and Navathe AS. Nutrition and Feeding For Children with Developmental Disabilities. In: Wyllie R and Hyams JS, ed. Pediatric Gastrointestinal and Liver Disease. Philadelphia: Saunders; 2011: Ch. 92.
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Feeding History• Stage at which choking/gagging,
regurgitation occurs is important • Later in feeding: greater correlation with
medical issues
16Cohen SA and Navathe AS. Nutrition and Feeding For Children with Developmental Disabilities. In: Wyllie R and Hyams JS, ed. Pediatric Gastrointestinal and Liver Disease. Philadelphia: Saunders; 2011: Ch. 92.
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Feeding History• Problems early in feeding:
• may relate to positioning
• parent-child interaction
• oral defensiveness
17Cohen SA and Navathe AS. Nutrition and Feeding For Children with Developmental Disabilities. In: Wyllie R and Hyams JS, ed. Pediatric Gastrointestinal and Liver Disease. Philadelphia: Saunders; 2011: Ch. 92.
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Feeding History• Meal duration beyond 30 min
– Healthy child: behavioral feeding problem
– Medical disorder: ineffective mechanics
18Cohen SA and Navathe AS. Nutrition and Feeding For Children with Developmental Disabilities. In: Wyllie R and Hyams JS, ed. Pediatric Gastrointestinal and Liver Disease. Philadelphia: Saunders; 2011: Ch. 92.
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Physical Exam• Assessment of Growth
• Abdomen for constipation
• Spine for kyphoscoliosis, sacral anomalies
19Cohen SA and Navathe AS. Nutrition and Feeding For Children with Developmental Disabilities. In: Wyllie R and Hyams JS, ed. Pediatric Gastrointestinal and Liver Disease. Philadelphia: Saunders; 2011: Ch. 92.
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Physical Exam• Neurologic for tone and level of function
• Oral for gag, swallow, seal, drooling, mucosal problems
20Cohen SA and Navathe AS. Nutrition and Feeding For Children with Developmental Disabilities. In: Wyllie R and Hyams JS, ed. Pediatric Gastrointestinal and Liver Disease. Philadelphia: Saunders; 2011: Ch. 92.
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Physical ExamSigns of deficiency or chronic illness
21Cohen SA and Navathe AS. Nutrition and Feeding For Children with Developmental Disabilities. In: Wyllie R and Hyams JS, ed. Pediatric Gastrointestinal and Liver Disease. Philadelphia: Saunders; 2011: Ch. 92.
http://en.wikipedia.org/wiki/Nail_clubbing
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Assessing Growth• Account for prematurity
– Correct until age 2 years
• Adequate growth is the most important goal.
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Oral Motor Competency
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Oral Motor Competency
24McSweeney ME, Kerr J, Amirault J, et al. Oral Feeding Reduces Hospitalizations Compared with Gastrostomy Feeding in Infants and Children who Aspirate. The Journal of Pediatrics. 2016;170:79-84.
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Further Investigation• Labs
• Imaging
• Procedures
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Laboratory• CBC
• Electrolytes
• Vitamin and Mineral levels
• Metabolic
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Imaging• Bone age
• MRI of the head
• Upper GI x-ray
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Imaging• Videofluoroscopic Swallow
Study
• Gastric emptying study
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Procedures• pH study with impedance
• Esophagogastroduodenoscopy (EGD)
• Fiberoptic Endoscopic Evaluation of Swallowing (FEES)
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Findings• 86% medical disorder
• 61% oropharyngeal dysfunction
• 18.1% behavioral problem
Conditions occurred both alone and in combination.
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Findings
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© The Children's Mercy Hospital, 2014. 03/1433
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Findings: Medical Conditions• Prematurity significant risk factor for developing
feeding problems – Medical feeding problems were related to birth weight
for GA but not to GA alone – GI pathology related to GA <34 weeks – Medical interventions strongly related to GA
34Rommel N, Meyer AMD, Feenstra L, et al. The complexity of Feeding Problems in 700 Infants and Young Children Presenting to a Tertiary Care Institution. Journal of Pediatric Gastroenterology and Nutrition. 2003; 37:75-84.
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Summary• Multidisciplinary approach
• Thorough history and physical
• Diagnostic testing is sometimes needed
• Many different causes for feeding problems
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Psychology
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Laura Slosky, PhD
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• Approximately ½ to ⅔ of children with feeding disorders present with mixed etiology that includes behavioral, physiological, and developmental factors (Budd, et al., 1992; Rommel, et al., 2003).
• A psychologist is uniquely equipped to evaluate and treat these contributory factors.
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The Pediatric Psychologist:– provides a behavioral perspective on the feeding problem – assesses for comorbid behavioral or psychiatric conditions impacting the
child or the broader family system – provides referrals as appropriate – Addressing feeding behavior
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Behavioral Perspective• Missed or delayed stages of feeding development
• Learned avoidance secondary to aversive conditioning
• Frequency and severity of challenging mealtime interactions
• Behavioral refusals that have been inadvertently reinforced by caregivers
• Inappropriate family or cultural expectations for feeding
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Comorbidities• Child:
– Inattention – Hyperactivity – Anxiety – Developmental Complexities – Oppositionality – Many others as feeding is a highly heterogeneous population
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Comorbidities• Caregivers:
–Caregiver stress! –Parent mental health
***These all impact caregiver ability to adhere to treatment plans and to follow through with their child on a consistent basis.***
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Referrals• Often need to build basic behavioral skills
– Hard time getting child to do something that is hard for them when a basic request results in a tantrum!
• Outpatient behavioral therapy
• Psychiatry
• Parent Supports – This is stressful!
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Behavioral Feeding Interventions• Implementation of mealtime structure!!
• Structured feeding schedule
• Appetite Manipulation
• Behavior Management – Differential Attention – Reinforcement Strategies – Extinction of negative feeding behaviors – Consistent Contingency Management
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Behavioral Feeding Interventions• Parent Training
– Train the parent to become the child’s therapist – Changing Parent-Child Interaction Pattern – Changing the Feeding Behaviors of both parent and child – Consistency!!!
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Nutrition
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Jamie Wilkins, RD
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Speech-Language Pathology
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Brenda Sitzmann, MA, CCC-SLP, CLC
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Speech-Language Pathology• Assess for oral and pharyngeal dysphagia
• Overlap with OT
• Collect history as a team
• Current and past therapy services
• Clinical signs of aspiration
• Preferred and non-preferred foods
• Helpful strategies53
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Speech-Language Pathology• Complete feeding assessment
• Observe a typical feeding with caregivers
• Ideally with preferred and non-preferred foods
• Evaluating oral motor feeding skills
• Assessing for aspiration
• Trial therapy techniques
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Speech-Language Pathology• Recommendations
• Work with team members
• Feeding therapy • Home programming
• Mealtime structure • Therapy techniques
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Speech-Language Pathology• Recommendations (continued)
• Additional evaluations
• Videofluoroscopic swallow study
• FEES
• Nutritional needs
• Prioritize foods to add
• Safe for chewable vitamin?56
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Occupational Therapy
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Feeding Skills: Posture & Tone, Sensory-motor, Oral-motor
Elizabeth Schroeder, MOT, OTR/L
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Observation prior to feeding• Motor milestones
– Are they developmentally appropriate? Why not?
• Tone driven posturing
– Do they have spasticity or hypotonia negatively effecting self-feeding and posture
– Asymmetry – torticollis • Breathing differences
– Do they have mobility in chest and shoulders for breathing
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Posture & Tone• Fine movements of the jaw and tongue needed for
feeding are dependent on…
– Head control, which is influenced by… • Trunk alignment, which depends upon…
– The stability of the pelvic area.
• All that to say: seating is so important!
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Postural Goal• Neutral pelvis with slight anterior
tilt
• Thighs should be parallel and hips bent to 90 degrees
• Knees should be bent to 90 degrees with toes pointing forward
• Feet in contact with surface
• Symmetrical elongated trunk -not leaning
• Symmetry through shoulders -not elevated or rotated
• Placement of tray at nipple height
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Sensory Processing
“The ability to take in information from all of the senses, process that information and then produce an adaptive response”
- Jean Ayres
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Sensory ProcessingLike it Dislike it
Active Seeker -prefer big flavors -over filling
Avoider -gag/vomit -push away from table
Passive Bystander -pockets food -loses food in mouth
Sensor -difficult to engage -inconsistent preferences
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External Sensations• Sight
– looks away from food; tray is overwhelming • Sound
– Covers ears; startles to noise; distractible • Smell
– Covers nose; prefer bland food • Touch
– Frequent hand wiping; finger splaying
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Oral-Sensory• Texture
– Gagging, scraping off tongue, predictable pattern
• Taste – Grimacing, shuddering
• Proprioception – Over filling, looses food in mouth, swallows food whole
• Praxis – Difficulty learning oral movements, unpredictable motor skills
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References• Cohen SA and Navathe AS. Nutrition and Feeding For Children with Developmental Disabilities. In: Wyllie R
and Hyams JS, ed. Pediatric Gastrointestinal and Liver Disease. Philadelphia: Saunders; 2011: Ch. 92.
• Grossman AB Liacouras CA. Gastroesophageal Reflux. In: Bell LM, ed. Pediatric Gastroenterology: The Requisites in Pediatrics.. Philadelphia: Mosby; 2008:74-85.
• Harding C, Faiman A, Wright J. Evaluation of an intensive desensitisation, oral tolerance therapy and hunger provocation program for children who have had prolonged periods of tube feeds. Int J Evid Based Healthc 2010;8(4):268-276.
• Ishizaki A, Hironaka S, Tatsuno M, et al. Characteristics of and weaning strategies in tube-dependent children. Pediatr Int 2013;55(2):208-213.
• Markowitz JE and Liacouras CA. Allergic and Eosinophilic Gastrointestinal Disease. In: Wyllie R and Hyams JS, ed. Pediatric Gastrointestinal and Liver Disease. Philadelphia: Saunders; 2011: Ch. 38.
• Manikam R and Perman JA. Pediatric Feeding Disorders. Journal of Clinical Gastroenterology. 2000. 30;1, 34-46.
• Mukkada VA, Haas A, Maune NC, et al. Feeding Dysfunction in Children with Eosinophilic Gastrointestinal Diseases. Pediatrics. 2010; 126:e672-677.
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References• McSweeney ME, Kerr J, Amirault J, et al. Oral Feeding Reduces Hospitalizations
Compared with Gastrostomy Feeding in Infants and Children who Aspirate. The Journal of Pediatrics. 2016;170:79-84.
• Pentiuk S, O'Flaherty T, Santoro K, et al. Pureed by gastrostomy tube diet improves gagging and retching in children with fundoplication. JPEN J Parenter Enteral Nutr 2011;35(3):375-379.
• Rommel N, Meyer AMD, Feenstra L, et al. The complexity of Feeding Problems in 700 Infants and Young Children Presenting to a Tertiary Care Institution. Journal of Pediatric Gastroenterology and Nutrition. 2003; 37:75-84.
• Sherman PM, Hassall E, Fagundes-Neto U, et al. A Global, Evidence-based Consensus on the Definition of Gastroesophageal Reflux Disease in the Pediatric Population. The American Journal of Gastroenterology. 2009; 104:1278-1295.
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THANK YOU
GI Multidisciplinary Feeding Clinic (816) 302-8037
* All numbers Fiscal 2016
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