Feeding disorders affect children with normal development as well as those with difficulties attributable to medical or developmental factors(1,2). The estimated prevalence of feeding problems in the pediatric population ranges from 25% to 35% in normally developing children (3-5) to 33% to 80% in children with developmental delay (6,7). Children present for the evaluation and treatment of feeding problems for a variety of reasons, including physical defects, global developmental delay, neurological problems, and behavioral difficulties (8). A review of the literature on pediatric feeding disorders reveals several attempts to classify feeding problems. The most frequently cited distinction is the organic-nonorganic dichotomy (9,10). Organic feeding disorders include problems related to structural abnormalities involved with feeding (e.g., anatomical defects of the palate, tongue, and esophagus), neuromuscular problems (e.g., cerebral palsy, paralysis), or other know physiologic reasons (e.g., esophagitis, gastroesophageal reflux[GER]) in which feeding can be disrupted (11,12). In contrast, feeding disorders which are classified as having nonorganic origins reflect disruptive social and environmental antecedents and consequences for feeding (3-4,11-13). The organic-nonorganic dichotomy is rigid and fails to account for feeding problems which may have a combination of physiological and environmental or emotional causes. Rarely can one reason or cause for feeding disorders be isolated or identified (11,14,15).
Classification attempts which try to account for both organic and nonorganic features of feeding problems have included factors related to medical conditions, oral-motor delays, and behavioral mismanagement(3,5). Similar to the organic-nonorganic dichotomy, however, feeding problems categorized in this manner are described in terms of exclusive categories and do not adequately capture mixed etiologies of pediatric feeding problems. A comprehensive classification system which conceptualizes the assessment and treatment of feeding difficulties in a multilevel, yet systematic, manner may help to describe mixed feeding etiologies.
In the current study, a classification system was developed and implemented with a large sample of children who presented for an evaluation of complex feeding problems. The classification categories used in this study were derived from previous descriptions and classification attempts (e.g.3,5,10,13,15-28) with further elaboration based on clinical experience. Given that previous attempts to classify feeding problems in a mutually exclusive, categorical fashion have failed to capture mixed etiologies of feeding problems, the purpose of this study was to describe the combinations of features associated with complex feeding problems using a nonmutually exclusive classification system.
METHOD
Subjects
Subjects in this study were 103 children (64 males and 39 females) ranging in age from 4 months to 17 years. The majority of subjects (67%) were under the age of 3 years. All children were referred to the Interdisciplinary Feeding Team (IFT) at Children's Hospital Medical Center in Cincinnati, Ohio. Children were referred to the IFT for concerns related to poor oral intake and problems with sustaining growth. Physician referrals consisted of children with feeding problems from local, regional, national and international sources. Disciplines represented on the team include Pediatric Gastroenterology, Nursing, Nutrition, Occupational Therapy, Psychology, and Speech Pathology. The initial team evaluations from each consecutive child from September, 1992 to September, 1995 were reviewed.
Categories
The following five categories were identified by the Interdisciplinary Feeding Team as reflecting the nature of the complex pediatric feeding disorders.
- Structural Abnormalities-anatomic abnormalities of the structures associated with eating and feeding. For example: defects associated with Pierre-Robin syndrome such as retrognathic jaw, cleft palate and posterior tongue placement, macroglossia, tracheotomy, esophageal strictures or stenosis.
- Neurological Conditions-feeding problems associated with central nervous system insult or musculoskeletal disorders. For example: cerebral palsy, muscular dystrophies, cranial nerve dysfunction, mental retardation/developmental disabilities, brain stem injury, Pervasive Developmental Disorder.
- Behavioral Issues-feeding difficulties resulting from psychosocial difficulties (poor environmental stimulation, dysfunctional feeder-child interaction), negative feeding behaviors shaped and maintained by internal and/or external reinforcement (selective food refusal, rumination), and/or emotionally based difficulties (phobias, conditioned emotional reactions, depression).
- Cardiorespiratory Problems-feeding difficulties associated with diseases and symptoms which compromise the cardiovascular and respiratory systems, complicating the coordination of sucking, swallowing and breathing during feeding. For example: tachypnea associated with bronchopulmonary dysplasia.
- Metabolic Dysfunction-feeding difficulties associated with metabolic diseases and syndromes which interfere with the development and/or maintenance of normal feeding patterns. For example: hereditary fructose intolerance, dumping syndrome.
Procedure
Team reports from the interdisciplinary feeding evaluation include medical and developmental history, summary of the child's feeding status, diagnosis and recommendations. Team reports also include a "problem list" generated by all Team members following an evaluation. This list identifies the factors related to and affecting the child's current feeding problems. The "problem lists" from the 103 first-time evaluations were retrospectively reviewed and coded by the authors in order to identify which classification categories were reflected in the child's current feeding problems. Each "problem" was usually worded clearly and only pertained to one category. Independent coders were instructed to review the descriptive assessment portion of the report if necessary, such as when a problem was too vague to code.
Interrater reliability for the classification coding was conducted on a random sample of approximately 20% of the cases for a total of 57 codes. Percent agreement was calculated by dividing the number of coding agreements by the number of total codes identified. Total reliability was 88% for the two primary coders, and 94% on a smaller sample between each primary coder and a third independent coder. Twenty-two reports were coded to obtain reliability data. Any coder disparities were resolved by consensus prior to inclusion in the data set for the study.
To assess the concordance of prematurity and/or presence of developmental delay with pediatric feeding problems, the frequency of these factors was examined. Prematurity was coded when the team report indicated gestational age of 36 weeks or less. Developmental delay or mental retardation was coded when either of these diagnoses were reported to the team.
Data were analyzed using the Statistical Analysis System for personal computers (29). Frequencies were conducted to determine the representation of each feeding classification group. Correlational analyses were conducted to assess the association of age and prematurity with categorization of feeding problems. Chi-square analyses were conducted to assess gender differences for prematurity, developmental delay and categorization of feeding problems.
RESULTS
Thirty-eight percent (n = 39) of the subjects were born prematurely (range 24 to 36 weeks). Developmental delay or mental retardation was reported for 74% (n = 76) of all subjects. Age and prematurity were not related to categorization of feeding problems. There were no significant gender differences for prematurity, developmental delay or categorization of feeding problems.
The percent occurrence of categories and clusters of categories was identified and is listed in Table 1. The combination of Structural-Neurological-Behavioral codes identified as components of the current feeding problem occurred most frequently (n = 31; 30%), followed by Neurological-Behavioral (n = 28; 27%), Behavioral (n = 12; 12%), Structural-Behavioral (n= 9; 9%), and Structural-Neurological (n = 8; 8%). The remaining categories/clusters occurred in less than 5% of the sample and are also listed in Table 1.
;)
TABLE 1: Percent occurrence of categories and clusters (n = 103)
The overall percentage of subjects assigned to each of the five general categories, whether exclusively representing a single category (e.g., Behavioral) or serving as a component of a combination of categories (e.g., Structural-Neurological-Behavioral), was also examined. These results are shown in Figure 1. Eighty-five percent of subjects were categorized as having a behavioral component to their feeding disorder. Neurological Conditions were identified in 73% of the sample, Structural Abnormalities in 57% of the sample, Cardiorespiratory Problems in 7% and Metabolic Dysfunction in 5% of the sample.
FIG. 1: Percent of subjects assigned to each category (alone or in combination). Bar 1: Behavioral Issues, n = 88 (85%); Bar 2: Neurological Conditions, n = 75 (73%);Bar 3: Structural Abnormalities, n = 59 (57%); Bar 4: Cardiorespiratory Problems, n = 7 (7%); Bar 5: Metabolic Dysfunction, n = 5 (5%).
DISCUSSION
Children referred to the Feeding Team presented with a variety of physical and behavioral problems. When examining the characteristics of feeding problems in this population which were categorized in a nonmutually exclusive fashion, about 15% of the feeding team patients were assigned only one classification of problems. The largest group with one prioritized problem category were the 12% of the children described as having only behavioral issues with another 4% having only structural abnormalities. The other 85% of the population presented with prioritized problems in two to four categories. When combinations of categories are considered, 80% of the children were seen as having a significant behavioral component to their feeding disorder; neurological conditions (including major developmental delays) were identified in over 70%. Structural abnormalities were noted in 60% of the referred patients. Budd, et al. (12) using a classification of organic/non-organic/mixed etiology found a similar distribution in their feeding disordered population. Only 10% of their patients were seen as having only non-organic feeding problems but 26% were seen as having only organic problems. Sixty-four percent were seen as displaying some combination of problems.
If a majority of feeding disorder patients are seen as showing a combination of organic and non-organic problems, a dichotomous classification system cannot be adequately discriminating the differences among these children. Rather, it is suggested that no attempt be made to force a choice between organic and non-organic characterization of feeding problems in children. Instead, a more descriptive, multi-dimensional classification system such as the one described in this paper may be more representative. It allows further discrimination among those who might have been categorized as"combination of organic and non-organic factors." The fact that interrater agreement in using this system was high suggests that this system may be clear enough to allow it to be applied to children being treated for feeding disorders in a variety of settings. Multidimensional descriptive classifications may be used to drive treatment planning. The development of empirically validated treatment protocols specific to the constellation of problems present would both increase effectiveness and reduce costs. The authors and other members of the feeding team are currently conducting this pilot project.
The multiplicity of the problems bearing on the process of eating and the substantial role of behavior suggests that feeding disorders represent biobehavioral conditions. Congenital malformations or neurologic disorders may disrupt the typical development of eating and provide opportunities for a child and his or her caregivers to acquire maladaptive behavioral patterns. Caregiver responses are often influenced by the importance attached to feeding (15). The presence of physical problems may increase the importance attributed to feeding by concerned parents(28). The biological and behavioral aspects are mutually interactive. Both often need to be addressed to reach normal feeding. That several disciplines may need to be involved in the care of these children is not surprising (30).
The finding that neurological conditions were noted in a large majority of the feeding cases was related to the inclusion of major developmental disorders in this category. The data indicating that over 75% of the children were reported to show some signs of developmental delay are consistent with earlier reports that the disabled population is particularly at risk for feeding problems (6). Possible contributions of developmental delay to the development of feeding disorders include the disruption of the communication that synchronizes the feeder/child interactions and motor delays involved in the coordination of sucking, chewing, and swallowing.
Given the relationship between complications of premature birth and neurologic disorders, it was somewhat surprising that less than 25% of the children evaluated by this feeding team were born before 36 weeks gestation. There was a much higher proportion of children with either structural abnormalities or neurologic disorders not associated with prematurity. This finding suggests that research focusing on the early development of feeding disorders in the at risk populations could be particularly informative with regard to formulating prevention strategies.
A limitation of this data is that it describes 103 children seen by one feeding team. The feeding team is, however, part of a large pediatric facility that provides primary, tertiary and quaternary care for an 8 county region and often beyond. More than 50% of the children seen by the team in the three year report period were from outside that region. The children referred to this team represent those with the most complex cases of feeding disorders, including structural anomalies, who have been unresponsive to initial treatment efforts by a single discipline such as Occupational Therapy or Speech Pathology in a community setting. This probability however, only serves to make more striking the role that behavior plays even in children with substantive medical problems impacting on feeding.
Acknowledgment: The authors thank the members of the Children's Hospital Medical Center Interdisciplinary Feeding Team, whose expertise and dedication have improved the management and care of the children described in this report, and to the children and families for allowing us to be touched by their lives.
Funded in part by the Association of Volunteers, Convalescent Hospital for Children, Cincinnati, Ohio.
REFERENCES
1. Rudolph C. Feeding disorders in infants and children.
J Pediatr 1994;125:116-24.
2. Stevenson RD. Feeding and nutrition in children with developmental disabilities.
Pediatr Ann 1995;24(5):255-60.
3. Beautrais AL, Fergusson DM, Shannon FT. Family life events and behavioral problems in preschool-aged children.
Pediatrics 1982;70:774-9.
4. Forsyth BW, Leventhal JM, McCarthy PJ. Mothers' perceptions of feeding and crying behaviors.
Am J Dis Child 1985;139:269-72.
5. Linscheid T. Eating problems in children. In: Walker CE, Roberts MC, editors.
Handbook of Clinical Child Psychology. New York: John Wiley & Sons, 1992;451-73.
6. Palmer S, Horn S. Feeding problems in children. In: Palmer S, Ekvall S, eds.
Pediatric Nutrition in Developmental Disorders. Springfield, IL: Thomas, 1978:95-100.
7. Perske R, Clifton A, McClean BM, Stein JI, eds.
Mealtimes for Severely and Profoundly Handicapped Persons: New Concepts and Attitudes. Baltimore: University Park Press, 1977.
8. Palmer S, Thompson RJ, Linscheid TR. Applied behavior analysis in the treatment of childhood feeding problems.
Dev Med Child Neurol 1975;17:333-9.
9. Woolston JL. Eating and Growth Disorders in Infants and Children.
Dev Clin Psychol Psychiatry 1991;24:1-85.
10. Frank DA, Zeisel SA. Failure to thrive.
Pediatr Clin North Am 1988;35:1187-206.
11. Babbitt RL, Hoch TA, Coe DA, et al. Behavioral assessment and treatment of
pediatric feeding disorders: A review and program description.
J Dev Behav Pediatr 1994;15:278-91.
12. Budd KS, McGraw TE, Farbisz R, et al. Psychosocial concomitants of children's feeding disorders.
J Pediatr Psychol 1992;17:81-94.
13. Iwata BA, Riordan MM, Wohl MG, Finney JW.
Pediatric feeding disorders. Behavioral analysis and treatment. In: Accardo PJ, ed.
Failure to Thrive in Infants and Early Childhood: A Multidisciplinary Team Approach. Baltimore: University Park Press, 1982:297-325.
14. Bithoney WG, Dubowitz H. Organic concomitants of nonorganic failure to thrive: Implications for research. In: Drotar D, ed.
New directions in failure to thrive: Implications for research and practice. New York: Plenum, 1985:47-68.
15. Linscheid TR, Budd KS, Rasnake LK.
Pediatric feeding disorders. In: Roberts MC, ed.
Handbook of Pediatric Psychology. 2nd ed. New York: Guilford Press, 1995:501-15.
16. Homer C, Ludwig S. Categorization of etiology of failure to thrive.
Am J Dis Child 1981;135:848-51.
17. Woolston JL. Eating disorders in infancy and early childhood.
J Am Acad Child Psychiatry 1983;22:114-21.
18. Woolston JL, Forsyth B. Obesity of infancy and early childhood: a diagnostic schema. In: Lahey BB, Kazdin AE, eds.
Advances in Clinical Child Psychology. New York: Plenum, 1989;12:179-92.
19. Willbarger P, Willbarger JL.
Sensory Defensiveness in Children Aged 2-12: An Intervention Guide for Parents and Other Caretakers. Santa Barbara, CA: Avanti Educational Programs, 1991:1-21.
20. Wolf L, Glass R.
Feeding and Swallowing Disorders in Infancy. Tucson, Arizona: Therapy Skill Builders 1992:1-475.
21. Agras WS, Berkowitz RI, Hammer LC, Kraemer HC. Relationships between the eating behaviors of parents and their 18-month old children: A laboratory study.
J Eating Disorders 1988;7:461-8.
22. Chatoor I, Conley C, Dickson L. Food refusal after an incident of choking: A posttraumatic eating disorder.
J Am Acad Child Adolesc Psychiatry 1988;27(1):105-10.
23. Drotar D, Eckerle D. The family environment in nonorganic failure to thrive.
J Pediatr Psychol 1989;14:245-57.
24. Ginsberg A. Feeding disorders in the developmentally disabled population. In: Russo DC, Kedesdy JH, eds.
Behavioral Medicine With The Developmentally Disabled. New York: Plenum Press, 1988:21-41.
25. Illingworth R, Lister J. The critical or sensitive period with reference to certain feeding problems in infants and children.
J Pediatr 1964;65:839-848.
26. Pugliese MT, Weyman-Daum M, Moses N, Lifshitz F. Parental health beliefs as a cause of nonorganic failure to thrive. Pediatrics 1987;80:175-82.
27. Sanders MR, Patel RK, LeGrice B, Shepherd RW. Children with persistent feeding difficulties: An observational analysis of the feeding interactions of problem and nonproblem eaters.
Health Psychol 1993;12:64-73.
28. Singer L. When a sick child won't-or can't-eat.
Contemp Pediatr 1990:60-76.
29.
SAS/STAT User's Guide. Cary, NC: SAS Institute, Inc. Ver. 6, vol. 1, 1990.
30. O'Brien S, Repp AC, Williams GE, Christophersen ER.
Pediatric feeding disorders.
Behav Modif 1991;15:394-418.
