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EVIDENCE-BASED FEEDING STRATEGIES FOR CHILDREN WITH
SPECIAL NEEDSSandee Dunbar DPA, OTR/L, FAOTA
Professor – Occupational Therapy
Assistant Dean of Professional Development
Nova Southeastern University – Ft. Lauderdale, Florida
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Objectives
■ Identify key evidence that supports therapeutic feeding intervention
■ Apply evidence-based literature to case examples
■ Examine various strategies for improved feeding among children
■ Recognize the significance of family-centered care
approaches for feeding intervention
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Is Feeding an Issue?
■ At least 5% of infants and young children have feeding issues
■ Children with developmental disabilities have an increased risk (40-70%)
■ Feeding, eating and swallowing difficulties are caused by multiple underlying factors.
■ Represents one of the most frequent concerns in pediatric settings
Sharp et al (2017)
Definitions
■ Feeding – process of setting up, arranging, and bringing food from a plate or mouth
■ Eating – ability to keep and manipulate food in mouth, then swallow
■ Swallow – food or fluid moving through mouth, then pharynx, then esophagus, then stomach
OT Practice Framework, 2014
Oral Motor Structures
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Stages of the Swallow
1. Oral Preparatory Phase2. Oral Transit Phase3. Pharyngeal Phase4. Esophageal Phase
Oral Motor Structures
Anatomy and Swallowing Process
Swallowing Phases
Swallowing Phases
Reference: https://www.youtube.com/watch?v=YQm5RCz9Pxc
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Oral Motor Development Overview
■ Birth – 3 months – predominance or oral reflexes (suck, rooting, gag), suck/swallow/breathe coordination
■ 4-6 months – bringing hands to midline to help with bottle, starting spoon feeding
■ 6-9 months – increasing textures, cleans spoon, holding bottle, increased tongue mobility
■ 10-12 months – sippy cup, finger feeding, some solids, attempts at utensil use
Video - 10-12 month feeding skills
Reference: https://www.youtube.com/watch?v=hkN-PUXCHw0
Are you evidence-based?
■ Process of questioning
■ Reading the available literature in the
related areas
■ Evaluating available information
from the literature (evidence)
■ Applying the information to practice
■ Evaluating your own clinical outcomes
(Law, 2008; Brown, 2017)
Levels of Evidence
1. Randomized studies
2. Comparison Group
3. Single Subject
4. Case Study
5. Clinical Data (Your treatment notes are evidence!)
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The Cycle of Evidence Based Practice
Brown, 2017
1. Formulate a question
2. Identify relevant evidence
3. Evaluate the evidence
4. Implement and apply
5. Evaluate the outcomes
The Cycle of Evidence-Based Practice
Feeding Project Example■ My own question – How can we move children from tube to
oral feeding successfully? What are the outcomes of a multidisciplinary feeding program?
■ Relevant evidence – Articles related to tube to oral feeding programs (Blackmon and Nelson) – Specific steps (introduce/prepare, compliance, cooperation, parent ed)
■ Evaluation – compare/contrast to others, what fit with OT philosophy
■ Implement – intense inpatient program for 2-3 weeks with MD, Dietician, OTs
■ Evaluate – 3/4 children had significant improvements in oral intake
Dunbar, Jarvis and Breyer, ‘91
Treatment Notes into Graphs -
Single Subject Research
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Outline
■ Autism
■ Developmental Delays
■ Prematurity
■ Sensory Processing Issues
■ Models for Eval and Treatment
Family Centered Care
Person Environment Occupation
■ Advancing the Evidence Approach
Autism
■ Complex disorder with varying levels of severity of symptoms
■ Characterized by impairments in social interaction, communication and activity participation (APA, 2013)
■ Diagnosis typically in the preschool years (CDC, 2014), but behaviors may indicate differences much earlier
■ Children with autism often display issues related to feeding (Smith, 2016)
Autism and Feeding
Challenges■ Up to 89% with feeding difficulties
■ Restricted variety in diets
■ Strong food preferences
■ Aversion to certain textures
■ Excessive mouthing of objects
■ Extreme attachment to routines with resistance to change in routines
■ Repetitive movements
■ Food neophobia
■ Restrictive interests
■ Difficulty with sensory processing
(Smith, 2016; Marshall, 2014)
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Feeding Video – Child with Autism and Oral Aversion
■ Feeding Issues - 18 month old
Reference: https://www.youtube.com/watch?v=iVUbVcKrmGI
How many identifiable issues or questions?
1.
2.
3.
Other
Developmental Delays
■ Cognitive delays – Difficult to understand mealtime concepts, instructions etc.
■ Motor delays and differences – CP, exaggerated reflexes, limited use of UEs to assist with feeding, poor postural control, poor lip closure, low or high tone
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Intervention for Various Developmental Needs – Jaw
Control
Jaw Control with Tongue Pressure
Positioning
■ Midline
■ Body symmetry as much as possible
■ Hips at 90 degrees as able for older child
■ Neurodevelopmental treatment to prepare for feeding
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NDT as Preparation for Feeding
■ NDT for poor trunk control
Reference: https://www.youtube.com/watch?v=fLm9MaTELZA&list=PLuzKn45IjydlccuJ21wVuuH-M1rSrzQJM
The Necessary Nuk
Nuk Use
■ Increase oral tone
■ Facilitate tongue lateralization
■ Tactile input
■ Decrease tongue thrusting
■ Work on decreasing gag response
■ Facilitate lateral and rotary chew
■ Oral desensitization
■ Systematic desensitization (term - Marshall et al, 2014)
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Transitioning to Cup
■ Prolonged bottle use past 18 months (keep in mind cultural differences) tooth decay, higher risk for obesity
■ Sippy cup by 7-9 months typically
■ Try different kinds of sippy cups
■ Put milk on tip for tasting
■ Encourage fine motor engagement
■ With transition to cup, initial jaw control
Grading the Transition to Cup-Pre-requisite Skill Development
Pre-requisite skill development and management PRIOR to cup drinking.
Examples -
■ Fine motor
grasp refinement
■ Sensory
tactile acceptance
■ Oral motor
tongue mobility
THE EVIDENCE
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Interventions to Improve Feeding Difficulties for Children
with Autism
THE EVIDENCE
Marshall et al (2014)
23 studies –low samples
Behavioral approaches
Increased volume, but not variety
Managing Behaviors in Feeding with Developmental
Delays
Howe & Wang (2013) Systematic Review
■ Behavioral Intervention – 7 studies
■ Attention, positive reinforcement, physical guidance, and shaping
■ Evidence supports that behavioral interventions can improve acceptance of a variety of foods.
Feeding Video – Child with Autism and Oral Aversion
What strategies can you now incorporate?■ Feeding Issues - 18 month old
Reference: https://www.youtube.com/watch?v=iVUbVcKrmGI
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Feeding and Prematurity
Common Concerns
■ Synactive Theory – Autonomic, Motor, State, Attention, Self-Regulation differences
■ Suck/swallow/breathe coordination – 34 weeks plus
■ Low tone
■ Sensory issues
■ Prolonged intubation and other negative experiences
■ Need for adaptive devices
■ Need for parental collaboration and understanding
Synactive Theory of Neurobehavioral Development
H. Als■ Autonomic - respiration, heart rate, skin color
■ Motor - tone, posture, movement
■ State - level of arousal
■ Attention-interaction – efforts at engaging
■ Self regulation - ability to achieve, maintain, or regain balance in each subsystem.
Feeding the Premature Infant
■ Take breaks for babies who do not have an established suck-swallow-breathe pattern yet. You can help to develop with strategic breaks.
■ Be intentional about integrating the family
■ Listen/collaborate with the nurses, dieticians
■ Posture is essential
■ Monitor the influence of the environment
■ Jaw control, cheek stroking
■ Tongue stroking
■ Massage for high tone, tap lightly for low tone
■ Supplemental oxygen as needed for those how have respiratory issues
■ Caution – Aspiration – Swallow studies will assist for ensuring safest feeding
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Feeding the Premature Infant
Intervention continued■ Non-nutritive sucking
■ Tactile input around face
■ Nuk brush for older, more regulated babies, to stimulate tongue mobility
■ Try various nipples, based on suck strength and mouth size
■ Watch for signs of previous subsystems to assess readiness for feeding. If still in autonomic, then not ready.
So many choices
The Feeding Evidence -Prematurity
Chorna et al Pediatrics, 2014
■ Vanderbilt Children’s Hospital in Tennessee
■ 94 premature infants at 34-36 weeks, randomly selected in experimental and control group
■ Experimental group – 5 days for 15 minutes
■ Sucking on pacifier (non-nutritive sucking)- resulted in hearing recorded mothers voice
■ Tubes out one week earlier, increased intake and faster feeding rate
■ Way to engage families for family centered developmental care
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Oral Readiness in Premature Babies
Harding et al (2016)
Assessed 15 nurses on their ability to assess oral readiness in their study. None of the nurses indicated parental teaching regarding states or use of formal assessments.
Signs of readiness
■ Stability in motor sub-system
■ Stability of suck-swallow-breathe pattern
■ Ability to demonstrate hunger cues
■ Evidence or oral reflexes
■ Practitioner competence
■ Quiet alert state
■ State control and variability
LESS PREPARED TO
■ Understand impact on parent-interaction
■ Use formal checklists
Feeding the Premature Infant
Sidelying FeedingReference: https://www.youtube.com/watch?v=Bl_hNk3NoC4&list=PLDLTp_qK_bIX6BsLcWFXmJ8nN5SJOPIQh&index=2
Feeding Resource
http://nomasinternational.org/
Sidelying Feeding
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Key LiteratureEVIDENCE-BASED PRACTITIONER QUESTIONS
DOES ORAL MOTOR THERAPY WORK?
DOES PARENTAL TRAINING WORK?
Howe & Wang (2013) – Systematic Review with positive results – 1. Behavioral, 2. Parental training, 3. Physiological interventions.
Sigan et al; (2013) – Parental training- 81 children randomized into training and non-training groups. Training group significantly improved on feeding scores.
Other studies have moderate to strong support. No consensus on best form of parental training. Combined with tx seems more effective.
Key Literature
Howe & Wang (2013) Systematic Review – 21 studies
■ Physiological interventions
■ Breathing, sucking, swallowing
■ Physical and sensory aspects
Results – Prep Activities (non nutritive sucking) decreases hospital stays, improves breastfeeding, but not weight gain.
Feeding Skill Training – shortens tube feeding time, improves quality of oral feeding, increases oral intake
Sensory Aspects of Feeding
■ Tactile Defensiveness – observable aversive or negative behavioral responses to certain types of touch stimuli that most people find to be non-painful. Inability to interpret/process touch in a meaningful way
■ Think of skin as a receptive organ with multiple receptors
(Murray, Fisher and Bundy, 1991 – based on Jean Ayres original work in Sensory Integration)
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Case Example - Sensory
■ Sensory Feeding Issues
Reference: https://www.youtube.com/watch?v=4AF0fpvqRko
Family Centered Care
Core Principles of Family Centered Care
1. Listening
2. Flexibility
3. Sharing of information
4. Formal and informal support systems
5. Collaboration at all levels
6. Building on strengths of families
Heffernan et al, 2014
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Why Family Centered Care?
■ Decreased hospital length of stay
■ More efficient utilization of resources
■ Reduced litigation risk
Clay and Parsh, 2016
Family Centered Care in Feeding
■ Ask parents about typical mealtimes
■ Recognize and respect differences in culture based food selections
■ Create goals collaboratively that reflect parental preferences
■ Be aware of your own implicit biases
■ Discuss appropriate options with the family during intervention
■ Include the family in decision-making for mealtimes, food etc.
Family Centered Care (Con’t)
Definitions
■ https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4201206/
■ https://medicalhomes.aap.org/Pages/Providing-Family-Centered-Care.aspx
Survey
■ http://www.fv-ncfpp.org/files/4113/0626/9064/fcca_ProviderTool.pdf
Institute for Patient and Family Centered Care
■ http://www.ipfcc.org/
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Case Example – Family Centered Care
Marsha Dunn Klein - OT
■ Transition to Oral and Jaw Control
Reference: https://www.youtube.com/watch?v=oF2ZE5YTq4o
Triad of Feeding for Assessment and Intervention
■ Person
Physical
Sensory
Cognitive
■ Environment
Family
Physical space
Culture
■ Occupation
Self-feeding with a spoon
Social participation at mealtime
Cup-drinking
Feeding Assessment Tool Samples
■ Feeding Assessment – Centra
■ Feeding Assessment – CHOC
■ Huntington Speech - Feeding Form
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Be aware of your own “EVIDENCE”
■ Excellent documentation
■ Parent report
■ Video
■ Pre-post data from standardized assessments
■ Observations
■ Experience
Designing your own
How effective are preschool feeding groups for increasing oral intake? Or mealtime socialization? Or utensil use?
1. P-E-O considerations
2. Review of the literature (evidence)
3. Baseline data – Formal feeding evaluations
4. Case study or single subject
5. Collect data
6. Analyze data
7. Adjust approaches based on the evidence
AOTA Evidence-Based Resources
■ http://www.aota.org/Practice/Children-Youth/Evidence-based.aspx
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What can you commit to for evidence-based feeding
intervention?■ Read, read, read
■ Critically appraise
■ Journal clubs
■ Use of strategies for simple
research projects
■ Question
■ Professional involvement (membership, conferences etc.)
■ Dialogue with peers
■ Learn something new every day!
Case
Matthew is a 5 year old with a diagnosis of developmental delay, functioning around a 2-3 year old level for many skills. You receive a feeding referral, due to his very limited food diet. During your general assessment, you observe that he is tactilely defensive when you present different toys for him to play with. He withdraws when objects aren’t smooth. You also observe with his snacks that he barely wants to touch them on the tray. When you observe his general play, while talking to his parents, Matthew has poor postural control and doesn’t maintain anti-gravity postures for more than a couple seconds on the gym swing. What are three areas of intervention that you would prioritize for Matthew?
1.
2.
3.
Case continued
Describe 3 specific treatment strategies that you would use with Matthew during the first month of therapy. Be specific for your area (PT, OT, ST etc.)
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Summary
Creating intentionality for being an evidence-based practitioner is essential. As therapists, we are obligated to engage in best practices for optimal therapeutic gains. Stay updated, have conversations, record your success and read, read, read. Feeding is a very critical area of need among so many children with and without specific disabilities. Use the very available opportunities to get involved and make a difference for increased participation in what can be one of life’s most enjoyable occupations!
Questions
ReferencesBrown, C. (2017). The evidence based practitioner. Philadelphia, PA: F.A. Davis
Bundy, A.C., Lane, S J., & Murray. (2002). Sensory Integration: Theory and Practice (2nd
ed). Philadelphia, PA: F.A. Davis
Chorna, O. D., Slaughter, J. C. & Wang, L. et al. (2014). A pacifier-activated music player with
mother’s voice improves oral feeding in preterm infants. Pediatrics. 133:462-68.
Clay, A.M. & Parsh, B. (2016). Patient and family centered care: It’s not just for pediatric
anymore. American Medical Association Journal of Ethics, 18, 40-44. doi: 10.1001/journalofethics.2016.18.01.medu3-1601.
Dunbar, S.B., Jarvis, A.H., Breyer, M. (1991). The transition from nonoral to oral feeding
in children, American Journal of Occupational Therapy, 45, 402-408.
Harding, C., Frank, L., Botting, N., & Hilari, K. (2015). Assessment and management of infant feeding.
Infant, 11, 85-89.
Heffernan, J., Gustafson, K., Packard, S. & Toole, C. (2014). What works: All in the family –
How a family advisory council promotes family-centered care in the NICU. American
Nurse Today, 9.
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References Cont.Howe, T., & Wang, T. (2013). Children with feeding difficulties ages birth- 5 years.
American Journal Occupational Therapy, 67, 405-412.
Law, M. & MacDermid, J. (2002). Evidence-based rehabilitation. Thorofare, New Jersey: Slack Inc.
Marshall, J., Ware, R., Ziviani, J., Hill, R.J., & Dodrill, P. (2014). Efficacy of interventions to improve feeding difficulties in children with autism spectrum disorders: A systematic review and meta-analysis. Child: Care, Health and Development, 41, 278-302 doi:10.1111/cch.12157.
Sharp, W.G., Volkert, V.M., Scahil, L., McCracken, C.E., McElhanon, B. (2017). A systematic review and meta-analysis of intensive multidisciplinary intervention for pediatric feeding disorder: How standard is the standard of care? Journal of Pediatrics, 181, 116-124.
Smith, J.A. (2016). Sensory processing as a predictor of feeding: Eating behaviors in children with autism spectrum disorder. The Open Journal of Occupational Therapy, 4 dx.doi.org/10.15453/2168-6408.1197.