Trastornos Conducta Alimentaria

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  • The learning objectives for this presentation are: Define the term feeding difficulty and distinguish it from related terms such as feeding disorder and picky eating Examine data on the prevalence and persistence of feeding difficulties in young children Describe growth, nutritional, and behavioral outcomes associated with feeding difficulties Present a systematic approach to the identification of 7 types of feeding difficulties that are commonly encountered in young children Discuss management strategies that are tailored to each type of feeding difficulty
  • The presentation comprises 3 main sections: Introduction to types of feeding difficulties that pediatricians commonly encounter in young children, clarification of terminology, and review of available data on prevalence and associated outcomes Description of a systematic approach to the identification and treatment of 7 common types of feeding difficulties in young children Discussion of management strategies that are tailored to each type of feeding difficulty
  • Feeding difficulties occur commonly in young children; however, the prevalence is greater in children with neurological impairments and developmental disorders than in normally developing children. Precise estimates of the prevalence of feeding difficulties in children without neurological or developmental impairments are difficult to ascertain in part because of the use of varying terminology and/or definitions across studies. Widely quoted prevalence estimates include 50% to 60% for any parent-reported feeding difficulty, 25% to 35% for specific feeding difficulties such as food refusal or selectivity, and 1% to 2% for severe and prolonged feeding difficulties.
  • These data from a survey of parents/caregivers of infants and toddlers demonstrated an increasing prevalence of picky eating (no definition provided to parents) increasing with age up to 2 years. Half of all surveyed caregivers of toddlers 19 to 24 months perceived their child to be a picky eater Picky eaters were reported at all ages for both sexes, all ethnicities, and all ranges of household incomes Background information on study population and methods: This study was a cross-sectional survey of a nationally representative sample of US households with infants and toddlers aged 4 to 24 months; N=3022 infants and toddlers Data were collected by telephone interviews with the primary caregiver residing in an identified household. Caregivers were asked whether they considered their child a very picky eater, a somewhat picky eater, or not a picky eater. Responses were coded as yes, no, don’t know, or refusal. The telephone interviewer did not define the term picky eater. Therefore, the data represent the caregivers’ definitions of picky eater Data for infants and toddlers perceived as very picky and somewhat picky were combined to form a picky eater data set for each of the 6 age groups
  • This slide summarizes the prevalence of specific difficult mealtime behaviors in toddlers considered to be problem eaters and compares these results to the prevalence of these same behaviors in the entire study population. With the exception of “will not take solids,” the prevalence of each difficult mealtime behavior was significantly higher in the subset of problem eaters as compared with all of the children in the study. Background information on study population and methods: These data are from a UK population-based birth cohort known as the Gateshead Millennium Baby Study. The cohort includes 1029 children recruited at birth between June 1999 and May 2000 Data for the results shown in this slide were collected by questionnaires completed by parents when their children were between 29 and 33 months of age (mean age, 30 months) Of the 455 children whose parents completed the questionnaire for this study, 89 (20%) were classified as “problem eaters” on the basis of one or more of the following criteria: Parents answered yes to the question “Do you see your child as having eating problems at present?” Parents said their child “definitely” had at least 1 of 3 specific problems—was a poor eater, was faddy, or behaved badly at mealtimes Parents stated they had sought professional help for an eating problem
  • Feeding difficulties in young children occur in many different countries and cultures. For example, a survey of child behavior problems conducted in the Yunnan Province of China found that 17% of children aged 2 to 6 years were perceived by their mothers to be picky eaters. Background information on survey population and methods: Structured interviews were conducted in subjects’ homes by trained interviewers. Subjects included 652 mother-boy pairs (53.4%) and 570 mother-girl pairs (46.6%). All sampled mothers were married. No definition for picky eating was provided Similarly, a population-based study of preschool children in Quebec found that prevalence rates for picky eating ranged from 14% in 2.5-year-old children to 17% in 4.5-year-old children. Background information on study population and methods: Analyses included 1498 children from the Longitudinal Study of Child Development in Québec, a representative sample of children born in 1998 in the Canadian province of Québec. Picky eating was assessed by questionnaires completed by parents when their children were 2.5, 3.5, and 4.5 years of age. Children met the criteria for picky eating if they “always” ate a different meal from that eaten by other members of the family, “often” refused to eat the right food, “often” refused to eat. Picky eating was assessed separately for each time point (at 2.5, 3.5, and 4.5 years) and for the entire 3-year study period.
  • Although feeding difficulties are often thought of as transient, these data underscore the potential for feeding difficulties to persist for a number of years in some children. The data shown in this slide are from a follow-up study that looked at the prevalence of eating problems in a group of 9-year-old children (n=18) who were first identified at between 3 and 12 months of age with episodes of refusal to eat with no medical explanation. The researchers found a significantly higher rate of parent- and teacher-reported eating problems in the children with early refusal to eat as compared with a control group (n=240) of their classmates. Background information on study population and methods: The original study enrolled 25 children with early refusal to eat (RTE) who had been identified through 10 child health care units in Uppsala, Sweden. This study was a follow-up investigation of all 18 children with early RTE who at the time of the study were still resident in or around Uppsala. The follow-up RTE group included 7 boys and 11 girls. The parents of all 287 classmates of the 18 early RTE children were asked to participate in the control group Definition of “eating problem” Parents and teachers were asked to report on the occurrence and frequency of 6 problematic eating behaviors: eats small amounts, refuses food, prolonged meals, irritated during meals, uninterested in food, stomach pains An eating problem was defined as 2 or more problem behaviors occurring 3 to 4 times per week
  • The literature does, however, point to issues of concern that pediatricians must keep in mind about the child with feeding difficulties. For example, at the extreme of the spectrum of feeding difficulties, phobia can lead to socially stigmatizing meal behavior and intensive multidisciplinary treatment may be required to overcome the difficulty.
  • A cross-sectional study of children in the United Kingdom reported that children identified by their parents as having an eating problem were significantly lighter and shorter than the other children in the study. Moreover, 11% of the children with eating problems met the conventional criteria for weight faltering (5th percentile for weight gain from birth to 2 years); this figure was 3 times the proportion in those without ( P =0.01) eating problems Background information on study population and methods: The investigators conducted a cross-sectional analysis of data from a UK population-based birth cohort, the Gateshead Millennium Baby Study. This analysis included 455 questionnaires completed by parents when their children were aged 30 months Eating was perceived to be a problem by 89 (20%) parents. Eating a limited variety of foods and preferring drinks to food were the most prevalent problem behaviors Assessment of growth outcomes: Parents were asked to supply an up-to-date clinic weight and height on their child; routine weights from infancy and height measurements at 13 months of age had already been collected
  • Some children with feeding difficulties may have suboptimal consumption of nutrients. For example, a study in 9-year-old girls found that while a ll girls consumed low amounts of vitamin E, calcium, and magnesium, more girls who were picky were at risk for not meeting recommendations for vitamins E and C. Picky eaters also consumed significantly less fiber. Background information on study population: Participants were 173 9-year-old non-Hispanic white girls and their mothers. All were from central Pennsylvania and were part of a longitudinal study of the health and development of young girls Similarly, a study in 4.5-year-old children found that p icky eaters consumed fewer total fats, less energy, and less protein than children never reported as picky eaters. Picky eaters were also more likely to consume less than the dietary recommendations for fruit and vegetables and for meat and meat alternatives. Background information on study population: P opulation-based cohort study of 1,498 preschool children enrolled in the Longitudinal Study of Child Development in Quebec. This study followed a representative sample (n=2103) of children born in 1998 in the Canadian province of Quebec
  • This case-control study found significantly lower intakes of calcium, zinc, and vitamin B6 in toddlers with feeding problems as compared with controls. The study also found that the intake of protein and kilocalories was significantly lower in toddlers with feeding problems as compared with controls (data not shown). Background information on study population and methods: Cases: 15 children (9 girls, 6 boys), each with a parent-identified feeding problem without any identified medical cause, were recruited prospectively from the Specialist Child Health Care Unit serving the county of Uppsala in Sweden. All children had a birth weight of >2500 g. Six of the children never demonstrated any hunger or interest in food; 4 demonstrated problems with the introduction of solid foods, accepting only breast milk; 5 accepted only soft foods. Mean age at inclusion in the study (time 1) was 14.5 months; follow-up (time 2) was performed at mean age 25.1 months Controls: 15 children with no history of feeding problems were recruited as a control group from the central child health register for the county of Uppsala; controls were closely matched to cases with respect to age and sex. Birth weight was >2500 g for all children. Mean age at enrollment (time 1) was 15.2 months; follow-up (time 2) was conducted at mean age 26.3 months Data on dietary intake were collected at times 1 and 2 using 4-day dietary records; comparisons of age between cases and controls at times 1 and 2 did not reveal any significant differences Background information on recommended levels of nutrients used in this study: The investigators compared mean nutrient intakes in this study to the 1996 Recommended Dietary Allowance (RDA) for children 1 to 3 years old. The 1996 RDA for each of the nutrients included in the figure is listed below along with the current US Dietary Reference Intake (DRI) for that nutrient: Calcium: 1996 RDA=600 mg; DRI=500 mg Iron: 1996 RDA=8 mg; DRI=7 mg Zinc: 1996 RDA=5 mg; DRI=3 mg Vitamin A: 1996 RDA=400 mcg; DRI=300 mcg Vitamin B6: 1996 RDA=0.8 mcg; DRI= 0.5 mg
  • This picture of a cricopharyngeal achalasia is a reminder that feeding problems may be the manifestation of underlying organic disease. The most common underlying organic conditions are gastroesophageal reflux and allergies. Celiac disease should also be considered, as well as subtle lesions such as esophageal webs.
  • This picture of a cricopharyngeal achalasia is a reminder that feeding problems may be the manifestation of underlying organic disease. The most common underlying organic conditions are gastroesophageal reflux and allergies. Celiac disease should also be considered, as well as subtle lesions such as esophageal webs.
  • A number of studies conducted in young children have reported a significant inverse correlation between parental pressure to eat and child weight and/or body mass index (BMI). For example, this inverse relationship has been demonstrated in preschool children attending full-day care programs at a large state university, 7-year-old children with a predisposition for obesity based on mother’s weight before the child’s birth, and Mexican American fifth-grade students enrolled in an obesity prevention program. However, it is difficult to discern from these studies whether parental pressure to eat causes lower body weight and/or BMI in children or, conversely, whether a child’s lower body weight leads parents to exert greater pressure on the child to eat more. A longitudinal study showed that maternal pressure to eat in children 1 year of age prospectively predicted child weight at 2 years, even after controlling for child weight at 1 year. This effect remained significant after controlling for other potentially confounding variables such as breastfeeding, birth weight, and gender. These results support the hypothesis that parental pressure to eat has at least a partial causal effect on child weight and/or BMI. As illustrated in the next slide, the relationship is likely to be bidirectional.
  • This study evaluated cognitive development in 3 groups of toddlers: healthy eaters, picky eaters, and toddlers diagnosed with infantile anorexia (IA). IA is a feeding disorder characterized by extreme food refusal, growth deficiency, and an apparent lack of appetite. On average, all 3 toddler groups performed within the normal range of cognitive development, as indicated by their Mental Development Index (MDI) scores However, the MDI scores of the healthy eater group were significantly higher ( P <0.05) than those of the IA and the picky eater groups Determinants of the differences in MDI scores included maternal education, parent-child conflict during feeding, and parent intrusiveness during play Background information on study population and methods: This study included 88 toddlers from 12 to 33 months of age. The toddlers were evaluated by 2 child psychiatrists and placed into 1 of 3 groups: Infantile anorexia—Diagnosis was based on the following criteria: (1) refusal to eat adequate amounts of food for at least 1 month; (2) onset of the food refusal under 3 years of age, most commonly during the transition to spoon- and self-feeding; (3) failure to communicate hunger signals, lack of interest in food, but strong interest in exploration and/or interaction with caregivers; (4) significant growth deficiency; and (5) no evidence that the food refusal followed a traumatic event or was associated with an underlying medical illness Picky eater—Recruited from an urban ambulatory care center; initial criterion was parent report that child was “often” or “always” a picky eater; additional criteria included persistent refusal (for at least 1 month) to eat all types of food or certain types of food of concern to the parents and no evidence of growth deficiency Healthy eater—Recruited from an urban ambulatory care center; initial criterion was parent report that child was “often” or “always” a healthy eater; additional criteria included no food refusal of concern for at least 1 month and no evidence of growth deficiency All 3 groups were matched for age, race, gender, and socioeconomic status. Children were excluded from the study if they had any medical, neurological, or genetic illness or if they demonstrated a psychiatric disorder associated with developmental delays (eg, autism spectrum disorders)
  • A number of studies conducted in young children have reported a significant inverse correlation between parental pressure to eat and child weight and/or body mass index (BMI). For example, this inverse relationship has been demonstrated in preschool children attending full-day care programs at a large state university, 7-year-old children with a predisposition for obesity based on mother’s weight before the child’s birth, and Mexican American fifth-grade students enrolled in an obesity prevention program. However, it is difficult to discern from these studies whether parental pressure to eat causes lower body weight and/or BMI in children or, conversely, whether a child’s lower body weight leads parents to exert greater pressure on the child to eat more. A longitudinal study showed that maternal pressure to eat in children 1 year of age prospectively predicted child weight at 2 years, even after controlling for child weight at 1 year. This effect remained significant after controlling for other potentially confounding variables such as breastfeeding, birth weight, and gender. These results support the hypothesis that parental pressure to eat has at least a partial causal effect on child weight and/or BMI. As illustrated in the next slide, the relationship is likely to be bidirectional.
  • A number of studies conducted in young children have reported a significant inverse correlation between parental pressure to eat and child weight and/or body mass index (BMI). For example, this inverse relationship has been demonstrated in preschool children attending full-day care programs at a large state university, 7-year-old children with a predisposition for obesity based on mother’s weight before the child’s birth, and Mexican American fifth-grade students enrolled in an obesity prevention program. However, it is difficult to discern from these studies whether parental pressure to eat causes lower body weight and/or BMI in children or, conversely, whether a child’s lower body weight leads parents to exert greater pressure on the child to eat more. A longitudinal study showed that maternal pressure to eat in children 1 year of age prospectively predicted child weight at 2 years, even after controlling for child weight at 1 year. This effect remained significant after controlling for other potentially confounding variables such as breastfeeding, birth weight, and gender. These results support the hypothesis that parental pressure to eat has at least a partial causal effect on child weight and/or BMI. As illustrated in the next slide, the relationship is likely to be bidirectional.
  • When referring to problems related to food consumption in young children, the term feeding is preferable to the term eating because feeding captures the actions of both parties involved in food consumption by young children—ie, the child and the parent or caregiver. Eating , on the other hand, reflects only the actions of the child.
  • The presentation comprises 3 main sections: Introduction to types of feeding difficulties that pediatricians commonly encounter in young children, clarification of terminology, and review of available data on prevalence and associated outcomes Description of a systematic approach to the identification and treatment of 7 common types of feeding difficulties in young children Discussion of management strategies that are tailored to each type of feeding difficulty
  • The presentation comprises 3 main sections: Introduction to types of feeding difficulties that pediatricians commonly encounter in young children, clarification of terminology, and review of available data on prevalence and associated outcomes Description of a systematic approach to the identification and treatment of 7 common types of feeding difficulties in young children Discussion of management strategies that are tailored to each type of feeding difficulty
  • The presentation comprises 3 main sections: Introduction to types of feeding difficulties that pediatricians commonly encounter in young children, clarification of terminology, and review of available data on prevalence and associated outcomes Description of a systematic approach to the identification and treatment of 7 common types of feeding difficulties in young children Discussion of management strategies that are tailored to each type of feeding difficulty
  • The presentation comprises 3 main sections: Introduction to types of feeding difficulties that pediatricians commonly encounter in young children, clarification of terminology, and review of available data on prevalence and associated outcomes Description of a systematic approach to the identification and treatment of 7 common types of feeding difficulties in young children Discussion of management strategies that are tailored to each type of feeding difficulty
  • The presentation comprises 3 main sections: Introduction to types of feeding difficulties that pediatricians commonly encounter in young children, clarification of terminology, and review of available data on prevalence and associated outcomes Description of a systematic approach to the identification and treatment of 7 common types of feeding difficulties in young children Discussion of management strategies that are tailored to each type of feeding difficulty
  • Feeding difficulty can be thought of as a comprehensive “umbrella” term that speaks to the wide diversity of problems that can occur in the feeding process. This includes the full spectrum of mild, moderate, and severe feeding problems as well as problems associated with a range of causal factors, outcomes, and duration. In clinical settings, the term feeding difficulty allows pediatricians to fully acknowledge parents’ concerns about feeding their children without using terms that tend to either minimize the problem or add to the parents’ apprehension about it.
  • The following 7 types of feeding difficulties are commonly encountered by pediatricians: Poor appetite due to organic disease Poor appetite that is a misperception on the part of the parents Poor appetite in a child who is fundamentally vigorous Poor appetite in a child who is apathetic and withdrawn Highly selective intake Colic that interferes with feeding Fear of feeding
  • The learning objectives for this presentation are: Define the term feeding difficulty and distinguish it from related terms such as feeding disorder and picky eating Examine data on the prevalence and persistence of feeding difficulties in young children Describe growth, nutritional, and behavioral outcomes associated with feeding difficulties Present a systematic approach to the identification of 7 types of feeding difficulties that are commonly encountered in young children Discuss management strategies that are tailored to each type of feeding difficulty
  • Acknowledging parental reports of feeding difficulties and listening to a parent’s concerns about feeding are important first steps in understanding the nature of the child’s feeding difficulty. Providing superficial reassurance that “it’s just a phase” or “there’s no need for concern” is not advisable as serious pathology can present as a feeding difficulty. In addition, dismissal of the problem is likely to leave many parents frustrated and anxious, which could lead to greater parent-child conflict and/or increased parental pressure on the child to eat.
  • The next step involves careful investigation of the parent’s complaint by gathering relevant information from the history, review of systems, physical exam, and anthropometric measurements. While remaining alert for red flags, pediatricians must also seek out information on behavioral and environmental factors that will help them to classify the specific type of feeding difficulty. This information includes: What does the child consume, in terms of variety and volume? What specific feeding difficulty does the child display? Is there evidence of hunger, a fear of taking food, or pain? What is the parents’ response? Do they express fear or anger? Are they coercive? Do they allow “grazing” between meals? What is the environment for the feeding? Is the child fed in a high chair? Is the television on? Do the parents model appropriate eating behavior for the child?
  • Acknowledging parental reports of feeding difficulties and listening to a parent’s concerns about feeding are important first steps in understanding the nature of the child’s feeding difficulty. Providing superficial reassurance that “it’s just a phase” or “there’s no need for concern” is not advisable as serious pathology can present as a feeding difficulty. In addition, dismissal of the problem is likely to leave many parents frustrated and anxious, which could lead to greater parent-child conflict and/or increased parental pressure on the child to eat.
  • Acknowledging parental reports of feeding difficulties and listening to a parent’s concerns about feeding are important first steps in understanding the nature of the child’s feeding difficulty. Providing superficial reassurance that “it’s just a phase” or “there’s no need for concern” is not advisable as serious pathology can present as a feeding difficulty. In addition, dismissal of the problem is likely to leave many parents frustrated and anxious, which could lead to greater parent-child conflict and/or increased parental pressure on the child to eat.
  • Pediatricians must pursue any red flags implicating organic disease. This slide provides a list of some of the more common and/or serious red flags associated with underlying pathology. For example, dysphagia and odynophagia may implicate esophagitis due to gastroesophageal reflux, eosinophilic esophagitis, infections, or toxic injury. Chronic cough, choking, or recurrent pneumonia suggest the possibility of poorly coordinated swallowing, which is most common in children with developmental limitations and neurological disorders such as cerebral palsy. When anthropometric measurements suggest failure to thrive with no acceptable explanation (eg, underlying congenital anomaly; child born small-for-gestational age or very premature; constitutional factors as suggested by the mid-parental height or a family history of delayed growth), then the clinical investigation should follow the progression of the food. Is food available? Is the interaction between mother and child appropriate? Is there evidence of swallowing difficulties, poor digestion, poor absorption, or failed deposition of assimilated nutrients due to an impaired organ system (eg, neurological, cardiac, pulmonary, renal, hepatic, metabolic, or endocrine)?
  • Pediatricians must pursue any red flags implicating organic disease. This slide provides a list of some of the more common and/or serious red flags associated with underlying pathology. For example, dysphagia and odynophagia may implicate esophagitis due to gastroesophageal reflux, eosinophilic esophagitis, infections, or toxic injury. Chronic cough, choking, or recurrent pneumonia suggest the possibility of poorly coordinated swallowing, which is most common in children with developmental limitations and neurological disorders such as cerebral palsy. When anthropometric measurements suggest failure to thrive with no acceptable explanation (eg, underlying congenital anomaly; child born small-for-gestational age or very premature; constitutional factors as suggested by the mid-parental height or a family history of delayed growth), then the clinical investigation should follow the progression of the food. Is food available? Is the interaction between mother and child appropriate? Is there evidence of swallowing difficulties, poor digestion, poor absorption, or failed deposition of assimilated nutrients due to an impaired organ system (eg, neurological, cardiac, pulmonary, renal, hepatic, metabolic, or endocrine)?
  • The primary feeding difficulty in some children is parental misperception that the child is not eating enough. In the child with normal but often small stature, appetite may appear to be limited although it is commensurate with the child’s size and nutrient needs. The primary risk for these children is parental concern that leads to coercive feeding methods. Parental misperception may be driven by growth expectations that are not suitable for the child, who may be below the 25th percentile but is achieving satisfactory growth based on mid-parental height. Overly anxious parents may adopt coercive methods that adversely affect the child.
  • The primary feeding difficulty in some children is parental misperception that the child is not eating enough. In the child with normal but often small stature, appetite may appear to be limited although it is commensurate with the child’s size and nutrient needs. The primary risk for these children is parental concern that leads to coercive feeding methods. Parental misperception may be driven by growth expectations that are not suitable for the child, who may be below the 25th percentile but is achieving satisfactory growth based on mid-parental height. Overly anxious parents may adopt coercive methods that adversely affect the child.
  • The primary feeding difficulty in some children is parental misperception that the child is not eating enough. In the child with normal but often small stature, appetite may appear to be limited although it is commensurate with the child’s size and nutrient needs. The primary risk for these children is parental concern that leads to coercive feeding methods. Parental misperception may be driven by growth expectations that are not suitable for the child, who may be below the 25th percentile but is achieving satisfactory growth based on mid-parental height. Overly anxious parents may adopt coercive methods that adversely affect the child.
  • The primary feeding difficulty in some children is parental misperception that the child is not eating enough. In the child with normal but often small stature, appetite may appear to be limited although it is commensurate with the child’s size and nutrient needs. The primary risk for these children is parental concern that leads to coercive feeding methods. Parental misperception may be driven by growth expectations that are not suitable for the child, who may be below the 25th percentile but is achieving satisfactory growth based on mid-parental height. Overly anxious parents may adopt coercive methods that adversely affect the child.
  • The primary feeding difficulty in some children is parental misperception that the child is not eating enough. In the child with normal but often small stature, appetite may appear to be limited although it is commensurate with the child’s size and nutrient needs. The primary risk for these children is parental concern that leads to coercive feeding methods. Parental misperception may be driven by growth expectations that are not suitable for the child, who may be below the 25th percentile but is achieving satisfactory growth based on mid-parental height. Overly anxious parents may adopt coercive methods that adversely affect the child.
  • The approach to managing poor appetite that is a parental misperception should focus on educating parents and other caregivers about appropriate expectations for feeding, growth, and nutrition. For example, provide education about the basic feeding principles and underscore the importance of applying these principles consistently. If the parent’s fears of malnutrition or impaired growth and development result in coercive or forceful feeding practices, a nutritional supplement may be offered to allay these fears and reduce the use of force or coercion.
  • Some young children with feeding difficulties display minimal appetite, are quickly satiated, and are easily distracted from eating. Chatoor, who has described these children in detail, has evidence to suggest that they display a unique feeding difficulty that she calls “infantile anorexia.” The onset of food refusal typically occurs during the transition to spoon and self-feeding—between 6 months and 3 years of age. These children are alert, active, and inquisitive and are more interested in their environment than in food. Parents of these children may become anxious and encourage “grazing,” a practice that further inhibits appetite and may lead parents to become coercive with feeding and engage in a power struggle with their child. Eventually, if the feeding difficulty is not addressed, these children will fail to thrive despite there often being no definable underlying pathology.
  • The approach to managing the vigorous child with limited appetite is to increase appetite by promoting hunger, which then allows for subsequent satisfaction from eating. The pediatrician should emphasize feeding principles that focus on structuring meals to foster hunger and appetite, such as providing 3 meals and an afternoon snack, feeding in a high chair or at a table, keeping the child in the chair for 20 to 30 minutes, not extending the meal beyond 30 minutes, and removing the meal if the child does not start or finish within a reasonable amount of time. Parents should understand the importance of discouraging “grazing” and should not offer juices between meals; they should allow the child only water between meals. It is also important for parents to minimize distractions during feeding and use timeout to discourage disruptive behavior. For minor infringements, timeout may be as simple as turning away from the child until the behavior settles. More disruptive behaviors (eg, child throwing food) should be met with a formal timeout, not to induce eating, but to extinguish the undesirable habit.
  • The approach to managing the vigorous child with limited appetite is to increase appetite by promoting hunger, which then allows for subsequent satisfaction from eating. The pediatrician should emphasize feeding principles that focus on structuring meals to foster hunger and appetite, such as providing 3 meals and an afternoon snack, feeding in a high chair or at a table, keeping the child in the chair for 20 to 30 minutes, not extending the meal beyond 30 minutes, and removing the meal if the child does not start or finish within a reasonable amount of time. Parents should understand the importance of discouraging “grazing” and should not offer juices between meals; they should allow the child only water between meals. It is also important for parents to minimize distractions during feeding and use timeout to discourage disruptive behavior. For minor infringements, timeout may be as simple as turning away from the child until the behavior settles. More disruptive behaviors (eg, child throwing food) should be met with a formal timeout, not to induce eating, but to extinguish the undesirable habit.
  • The approach to managing the vigorous child with limited appetite is to increase appetite by promoting hunger, which then allows for subsequent satisfaction from eating. The pediatrician should emphasize feeding principles that focus on structuring meals to foster hunger and appetite, such as providing 3 meals and an afternoon snack, feeding in a high chair or at a table, keeping the child in the chair for 20 to 30 minutes, not extending the meal beyond 30 minutes, and removing the meal if the child does not start or finish within a reasonable amount of time. Parents should understand the importance of discouraging “grazing” and should not offer juices between meals; they should allow the child only water between meals. It is also important for parents to minimize distractions during feeding and use timeout to discourage disruptive behavior. For minor infringements, timeout may be as simple as turning away from the child until the behavior settles. More disruptive behaviors (eg, child throwing food) should be met with a formal timeout, not to induce eating, but to extinguish the undesirable habit.
  • Poor appetite in a child who is also withdrawn and depressed may be a sign of neglect. Often, these children have a flat affect and show little interest in eating. Their loss of appetite is part of an overall withdrawal in which smiling, babbling, and eye contact between the infant and the caregiver are not discernible. These children are at risk for substantial weight loss and malnutrition, which are in themselves is a further cause of anorexia. Chatoor characterizes this feeding problem as a “disorder of reciprocity,” because there is a breakdown in the communication between mother and child. The child may be neglected as a result of socioeconomic circumstances, psychopathology in the mother, or even neurological problems in the child.
  • It is characteristic for children with poor appetite due to neglect to respond positively to an enthusiastic and experienced feeder. Excellent results have been obtained with an inpatient admission to induce a positive feeding environment. The pediatrician must also attempt strategies to address the causal factors for the neglect.
  • Highly selective intake, which Chatoor calls “sensory food aversion,” is a feeding difficulty that is marked by consistent refusal of specific foods of a particular taste, texture, smell, or appearance. With highly selective intake, the behavior goes beyond normal resistance to the introduction of new foods (ie, food neophobia) to a more deep-seated resistance that perseveres. Children with highly selective intake often have additional sensory difficulties such as noise sensitivity or difficulty with messy materials on the hands or with sand under the feet Highly selective intake can limit the child’s dietary intake of some essential nutrients, depending on the types of foods that are consistently avoided. Children with highly selective intake may also lack some developmentally acquired feeding skills, particularly if they consume only foods with soft textures. Highly selective intake can also contribute to difficult interactions with peers or within the family when an event or activity involves food.
  • The approach to managing highly selective intake requires reassuring the parents that the feeding difficulty is part of a broader sensory condition. With feeding, the fundamental principle is to tempt, not push. Parents should model the consumption of new foods without offering any to the child: Try leaving the food within reach without necessarily offering it. Toddlers are more willing to try new foods if they are in control; they are prone to automatically say no when asked to eat something If exposure causes gagging or vomiting, withdraw the food and try something that more closely resembles a preferred food Parents must also remain neutral and relaxed about the child’s intake To support nutrient intake, the pediatrician may recommend a micronutrient supplement or a nutritionally balanced product such as PediaSure to address the risk of micronutrient deficiencies.
  • Fear of feeding is a feeding difficulty characterized by intense fear at the prospect of feeding and strong resistance to any attempts to feed, by crying, arching, or refusing to open the mouth. When wide awake, infants with fear of feeding characteristically refuse to feed. However, they may be more likely to accept a bottle when nearly asleep. A child may develop a fear of feeding after a frightening or noxious oral experience, such as choking or oral intubation. Chatoor refers to these children as having a “post-traumatic feeding disorder.” Fear of feeding may be particularly intense in children being fed continuously via gastric or jejunal tube.
  • Treatment principles for the child with fear of feeding include: Desensitizing children with relatively mild fear of feeding by taking advantage of the child’s propensity to feed when half asleep and relaxed and avoiding the need to feed while the child is wide awake and stressed at the sight of food If the child fears the bottle, offering a sippy cup or a spoon instead Ensuring that feedings are not threatening or coercive
  • Food refusal and/or poor appetite is sometimes a presenting symptom of underlying organic disease. Thus, it is critical to systematically exclude organic causes of poor appetite. As indicated earlier, red flags will identify many but not all of these children and a high index of suspicion may be required for conditions that present with more subtle signs and symptoms.
  • Food refusal and/or poor appetite is sometimes a presenting symptom of underlying organic disease. Thus, it is critical to systematically exclude organic causes of poor appetite. As indicated earlier, red flags will identify many but not all of these children and a high index of suspicion may be required for conditions that present with more subtle signs and symptoms.
  • Food refusal and/or poor appetite is sometimes a presenting symptom of underlying organic disease. Thus, it is critical to systematically exclude organic causes of poor appetite. As indicated earlier, red flags will identify many but not all of these children and a high index of suspicion may be required for conditions that present with more subtle signs and symptoms.
  • Food refusal and/or poor appetite is sometimes a presenting symptom of underlying organic disease. Thus, it is critical to systematically exclude organic causes of poor appetite. As indicated earlier, red flags will identify many but not all of these children and a high index of suspicion may be required for conditions that present with more subtle signs and symptoms.
  • Food refusal and/or poor appetite is sometimes a presenting symptom of underlying organic disease. Thus, it is critical to systematically exclude organic causes of poor appetite. As indicated earlier, red flags will identify many but not all of these children and a high index of suspicion may be required for conditions that present with more subtle signs and symptoms.
  • Food refusal and/or poor appetite is sometimes a presenting symptom of underlying organic disease. Thus, it is critical to systematically exclude organic causes of poor appetite. As indicated earlier, red flags will identify many but not all of these children and a high index of suspicion may be required for conditions that present with more subtle signs and symptoms.
  • Food refusal and/or poor appetite is sometimes a presenting symptom of underlying organic disease. Thus, it is critical to systematically exclude organic causes of poor appetite. As indicated earlier, red flags will identify many but not all of these children and a high index of suspicion may be required for conditions that present with more subtle signs and symptoms.
  • Food refusal and/or poor appetite is sometimes a presenting symptom of underlying organic disease. Thus, it is critical to systematically exclude organic causes of poor appetite. As indicated earlier, red flags will identify many but not all of these children and a high index of suspicion may be required for conditions that present with more subtle signs and symptoms.
  • In summary, there is good evidence in the literature and in clinical practice that feeding difficulties are common in young children and that they will persist in some children for a number of years. Pediatricians are encouraged to pay close attention to all parental complaints about feeding difficulties, since even mild to moderate problems with feeding can affect the child’s dietary intake, growth, and cognitive development and the parent-child feeding relationship.
  • Trastornos Conducta Alimentaria

    1. 1. Pedro Gutiérrez-Castrellón MD, MSc, Dsc Instituto Nacional de Pediatría México [email_address] Reconocimiento de los Trastornos de la Conducta Alimentaria en el Niño y Recomendaciones de Manejo
    2. 2. <ul><li>Abordaje fisiológico </li></ul><ul><li>Propuesta de concepto integrador </li></ul><ul><li>Impacto epidemiológico y en la salud </li></ul><ul><li>Abordaje diagnostico y terapeutico </li></ul>Puntos a cubrir
    3. 3. Que tan frecuente es el problema <ul><li>Niños fisicamente normales 1-3 </li></ul><ul><ul><li>50% a 60% (reporte de los padres) </li></ul></ul><ul><ul><li>25% a 35% (evaluación por profesionales) </li></ul></ul><ul><ul><li>1% a 2% para trastornos prolongados o graves </li></ul></ul><ul><li>Niños con trastornos neurológicos o del desarrollo 1,2 </li></ul><ul><ul><li>Mas del 80% </li></ul></ul><ul><ul><li>Frecuentemente se reportan como trastornos de la deglución </li></ul></ul>1. Manikam R, Perman J. J Clin Gastroenterol. 2000;30:34-46; 2. Nicholls D, Bryant-Waugh R. Child Adolesc Psychiatr Clin N Am. 2009;18:17-30; 3. Satter E. J Pediatr. 1990;117:S181-S189.
    4. 4. Porcentaje de infantes y niños de 4 a 24 meses percibido por los padres como niño melindroso Nationally representative survey of caregivers in US households with infants and toddlers aged 4 to 24 months. N=3022 infants and toddlers. Carruth BR, et al. J Am Diet Assoc . 2004;104:S57-S64.
    5. 5. * P <0.05 vs all children in the study. Wright CM, et al. Pediatrics. 2007;120:e1069-e1075. Variedad Limitada Prefieren Liquidos Poco Interes No toman Solidos Rehusan Porcentaje de Niños * * * Alimentación Lenta * * Todos los Niños Niños problemáticos Trastornos de la Conducta Alimentaria (1 a 3 años)
    6. 6. Que tan frecuente es el problema: Estudios Regionales <ul><li>Encuesta de 1,222 madres- Niños ( Rurales) en Yunnan Provincia de China 1 </li></ul><ul><ul><li>17% en niños de 2 a 6 años </li></ul></ul><ul><li>Encuesta en Shanghai, China </li></ul><ul><ul><li>40% en 1,244 niños de 1 a 6 años </li></ul></ul><ul><li>Estudio en niños pre escolares en Quebec, Canada 2 </li></ul><ul><ul><li>14% a 17% a 2.a 5 años de edad </li></ul></ul><ul><ul><li>29% cumplieron los criterios de niños melindrosos al menos una vez </li></ul></ul><ul><ul><li>5.5% cumplieron los criterios en tres ocasiones </li></ul></ul>1. Li Y, et al. Pediatr Int. 2001;43:651-661. 2. Dubois L, et al. Int J Behav Nutr Phys Act. 2007;4:9.
    7. 7. La conducta Melindrosa, persiste 1 a 10 años Encuesta Mundial de Trastornos de la Conducta Alimentaria: Instituto Científico Abbott (2005-2006) 5,262 entrevistas: México, Canada, Reino Unido, España, Polonia, India, Turquia, Arabia China, Singapur, Filipinas e Indonesia Edad del Niño Total 1-3 4-6 7-10 Top Two Box Scores % % % % “ Mi hijo es melindroso para comer” 72 66 87 73 Caracteristicas de los niños pequeños con comportamiento melindroso para comer No come nada 25 38 26 13 Solo come alimentos seleccionados 58 62 78 48 Caracteristicas de los niños mas grande con comportamiento melindroso para comer Mi hijo no come saludable 40 27 37 53 Mi hijo come alimentos muy salados 76 64 87 83 Mi hijo come demasiadas harinas y azucares 57 50 53 65 Mi hijo come mucho entre comidas 54 38 58 69 Siento que mi hijo come muchas calorias 52 43 47 62 Me preocupo porque mi hijo come muy rapido 80 71 82 88
    8. 8. “ El nino melindroso ” Se correlaciona con comer muy poco Cual de las siguiente ( s) afirmaciones le preocupan de su hijo 5,262 entrevistas: México, Canada, Reino Unido, España, Polonia, India, Turquia, Arabia China, Singapur, Filipinas e Indonesia Total Melindrosos No melindrosos Percentaje % % Come muy poco / nada 69 53 Come muy poco 48 32 No come nada 41 42 Come poco saludable 46 42 No come saludable fuera de casa (vrg, comida rapida, dulces/azucarados , refrescos/ bebidas suaves) 32 32 No come saludable en casa vrg, comida rapida, dulces/azucarados , refrescos/ bebidas suaves) 31 26 Salta comidas 24 22 Come mucho 8 16
    9. 9. Percent of Children With Eating Problems at Home and/or School Percent Dahl M, et al. Acta Paediatr. 1994;83:54-58. <ul><li>Niños con rechazo temprano a alimentarse sin causas médicas identificadas (n=180) </li></ul><ul><li>Promedio de edad= 9.6 años </li></ul><ul><li>Controles: Compañeros de clase (historia negativa) (n=240) </li></ul>Puntos de Preocupación (Seguimiento a 10 años)
    10. 10. Puntos de preocupación <ul><li>Aversion crónica con estigmatización social </li></ul><ul><li>Limitaciones al crecimiento </li></ul><ul><li>Consumo suboptimo de nutrimentos </li></ul><ul><li>Existencia en algunos casos de causas organicas graves </li></ul><ul><li>Trastornos de la interacciones con cuidadores </li></ul>Kedesdy JH, Budd KS. Childhood Feeding Disorders. Baltimore: Paul H Brookes; 1998.
    11. 11. Puntos de preocupación P =0.01 Percent of children Wright CM, et al. Pediatrics. 2007;120:e1069-e1075. <ul><li>Aversion crónica con estigmatización social </li></ul><ul><li>Limitaciones al crecimiento </li></ul><ul><li>Consumo suboptimo de nutrimentos </li></ul><ul><li>Existencia en algunos casos de causas organicas graves </li></ul><ul><li>Trastornos de la interacciones con cuidadores </li></ul>
    12. 12. Puntos de preocupación 1. Galloway AT, et al. J Am Diet Assoc. 2005;105:541-548. 2. Dubois L, et al. Eur J Clin Nutr. 2007;61:846-855. Recomendaciones diarias de Zinc, Vitamina C o E 1 <ul><ul><li>Menor consumo de frutas, vegetales y carne en selectivos 2 </li></ul></ul><ul><ul><li>Ingreso inferior de proteinas, </li></ul></ul><ul><ul><li>Energía y grasa en selectivos 2 </li></ul></ul><ul><li>Aversion crónica con estigmatización social </li></ul><ul><li>Limitaciones al crecimiento </li></ul><ul><li>Consumo suboptimo de nutrimentos </li></ul><ul><li>Existencia en algunos casos de causas organicas graves </li></ul><ul><li>Trastornos de la interacciones con cuidadores </li></ul>
    13. 13. Ingesta de micronutrimentos * * * * P <0.05 for difference vs controls over 2 time points; data shown are for time 1 only. Lindberg L, et al. Acta Paediatr. 2006;95:425-429.
    14. 14. Puntos de preocupación <ul><li>Aversion crónica con estigmatización social </li></ul><ul><li>Limitaciones al crecimiento </li></ul><ul><li>Consumo suboptimo de nutrimentos </li></ul><ul><li>Existencia en algunos casos de causas organicas graves </li></ul><ul><li>Trastornos de la interacciones con cuidadores </li></ul>
    15. 15. Puntos de preocupación <ul><li>Aversion crónica con estigmatización social </li></ul><ul><li>Limitaciones al crecimiento </li></ul><ul><li>Consumo suboptimo de nutrimentos </li></ul><ul><li>Existencia en algunos casos de causas organicas graves </li></ul><ul><li>Trastornos de la interacciones con cuidadores </li></ul>Mean touches/15 minutes * * 0 0.2 0.4 0.6 0.8 1.0 1.2 1.4
    16. 16. <ul><li>Presión de los padres se correlaciona con peso bajo o IMC reducido 1-4 </li></ul><ul><li>Presion materna para alimentar (año) se correlaciono negativamente con el peso del niño a los 2 años </li></ul><ul><li>Permanecio independiente de lactancia materna, peso al nacimiento y genero </li></ul>1. Galloway AT, et al. Appetite. 2006;46:318-323; 2. Faith MS, et al. Pediatrics. 2004;114:e429-e436; 3. Spruijt-Metz D, et al. J Pediatr. 2006;148:314-320; 4. Matheson DM, et al. J Am Diet Assoc. 2006;106:1861-1865; 5. Farrow CV, Blissett J. Pediatrics. 2008;121:e164-e169. Presión de los Padres para la Alimentación
    17. 17. <ul><li>Sanos, selectivos y anorexia infantill (FTT) </li></ul><ul><li>MDI en anorexia y selectivos fue 11 y 14 puntos inferior que controles </li></ul><ul><li>Determinantes: </li></ul><ul><ul><li>Educación parental </li></ul></ul><ul><ul><li>Conflicots durante la alimentación </li></ul></ul><ul><ul><li>Intromisión excesiva parental durante el juego del niño </li></ul></ul>Puntos de preocupación * P <0.05 vs healthy eaters. Chatoor I, et al. Pediatrics. 2004;113:e440-e447. Desarrollo Neurológico * *
    18. 18. J Child Psychol & Psychiat 2004;45:3:641-654 Puntos de Preocupación
    19. 19. Puntos de Preocupación Arch Dis Child 2005;90:925-931
    20. 20. Trastornos de la Conducta Alimentaria <ul><li>Como efectuar el abordaje Inicial </li></ul><ul><li>Como dirigir el tratamiento </li></ul>
    21. 21. <ul><li>< 1994: Falla de Medro (Failure to Thrive) (No orgánico, orgánico y mixto) </li></ul><ul><li>1994 American Psychiatric Association (DSM-IV) “Feeding Disorders of Infancy and Early Chilhood” </li></ul><ul><ul><li>Falla persistente para alimentarse + incapacidad para ganar peso o perdida significativa de peso </li></ul></ul><ul><ul><li>Ausencia de patologia gastrointestinal u otras </li></ul></ul><ul><ul><li>Ausencia de Trastornos Mentales Importantes </li></ul></ul><ul><ul><li>Inicio antes de los 6 años </li></ul></ul>Abordaje Histórico
    22. 22. Fase de Adaptación y Reconocimiento (State Regulation) No soy Melindroso
    23. 23. <ul><li>In utero: demandas nutricionales a traves del CU </li></ul><ul><li>Posterior al nacimiento: </li></ul><ul><ul><li>Llanto específico + busqueda: Hambre </li></ul></ul><ul><ul><li>Detención de la succión: Satisfacción del apetito </li></ul></ul><ul><ul><li>Control del ciclo sueño – vigilia diferenciada (actividad – reposo) </li></ul></ul><ul><li>Aprendizaje de los padres (llanto de hambre, necesidad de sueño) </li></ul>Regulación Etapificada (State Regulation)
    24. 24. <ul><li>2 a 6 meses </li></ul><ul><ul><li>Mayor contacto visual, vocalización reciproca, mayor contacto (cercania física) </li></ul></ul><ul><ul><li>Disminución del apetito reflexivo, inicio del apetito intencional (vocalización) </li></ul></ul><ul><ul><li>Proceso de alimentación mas disfrutable </li></ul></ul><ul><ul><li>Signos debiles o dificiles de comprender </li></ul></ul><ul><ul><li>Preocupación parental por sus necesidades y no las del niño </li></ul></ul><ul><ul><li>Reciprocidad fallida </li></ul></ul>Reciprocidad Facilitada (Dyadic reciprocity)
    25. 25. <ul><li>6 meses a 3 años </li></ul><ul><ul><li>Física y emocionalmente mas independiente </li></ul></ul><ul><ul><li>Negociación diaria de autonomia vs. dependencia. “Quien pone la cuchara en la boca” </li></ul></ul><ul><ul><li>Aprendizaje diferencial de apetito, saciedad, plenitud vs. cariño, enojo, frustración. </li></ul></ul><ul><ul><li>NO ofrecer alimento cuando se necesita cariño </li></ul></ul><ul><ul><li>Reconocer cuando el niño esta saciado y no obligar al “DEJAR EL PLATO LIMPIO” </li></ul></ul>Auto-alimentación y Regulación Emocional
    26. 26. <ul><li>Un paraguas que incluye todos: </li></ul><ul><ul><li>Los problemas de la alimentación </li></ul></ul><ul><ul><li>Los niveles de gravedad </li></ul></ul><ul><ul><li>Los factores etiológicos </li></ul></ul><ul><ul><ul><li>Orgánicos, del desarrollo, psicológicos, conductuales </li></ul></ul></ul><ul><ul><ul><li>Dinámicas familiares </li></ul></ul></ul><ul><ul><ul><li>Influencias sociales y culturales </li></ul></ul></ul><ul><ul><li>Consecuencias </li></ul></ul><ul><ul><ul><li>Ingesta dietética, estados nutricionales, situaciones del crecimiento y desarrollo e interacciones entre el niño y sus padres </li></ul></ul></ul>Terminologia: Trastornos de la Conducta Alimentaria
    27. 27. <ul><li>Causas Orgánicas </li></ul>Apático y retraido Percepción Inadecuada Altamente selectivo Niño Vigoroso, muy inquieto Temeroso Trastornos de la Conducta Alimentaria Trastornos de la Regulación temprana Trastornos de la Reciprocidad
    28. 28. Abordaje Diagnóstico y Terapeutico Inicial
    29. 29. <ul><li>Escuche e identifique el problema a traves del reporte de los padres </li></ul>RECONOCIMIENTO
    30. 30. <ul><li>Efectue una historia clínica detallada con enfasis en la conducta alimentaria y la ingesta dietética </li></ul><ul><li>Efectue una exploración física minuciosa con evaluaciones antropometricas completas </li></ul><ul><li>Identifique en forma temprana los indicadores de sospecha de organicidad </li></ul><ul><li>Siempre intente identificar condiciones subyacentes en las que se piensa poco (enfermedad celiaca, enteropatia alergica) </li></ul>INVESTIGUE
    31. 31. RECONOCIMIENTO <ul><li>Posee poco apetito, no come lo suficiente para crecer </li></ul><ul><li>Tiene poco interes en la comida, prefiere jugar </li></ul><ul><li>Come muy poco y solo algunos alimentos </li></ul><ul><li>Rechaza consistentemente determinados alimentos </li></ul><ul><li>Rechaza ingerir líquidos, pero acepta los solidos </li></ul><ul><li>Rechaza los alimentos enteros, solo acepta pures </li></ul><ul><li>Come bien un dia y dejar de comer varios dias </li></ul>
    32. 32. RECONOCIMIENTO <ul><li>Llora demasiado y se arquea cuando esta comiendo </li></ul><ul><li>Se cansa facilmente cuando esta comiendo </li></ul><ul><li>Le da nausea o vomita al empezar a comer, durante la alimentación o despues de alimentarse </li></ul><ul><li>Se queda dormido durante la alimentación </li></ul><ul><li>Llora intensamente al sentarlo para comer o presentarle la comida </li></ul>
    33. 33. <ul><li>Disfagia </li></ul><ul><li>Deglución incoordinada (tos, ahogo, neumonia recurrente) </li></ul><ul><li>Falla de medro (Failure to thrive) </li></ul><ul><li>Alimentación interrumpida (Llanto con dolor) </li></ul><ul><li>Vomito crónico o regurgitaciónes importantes </li></ul><ul><li>Diarrea o evacuaciones sanguinolentas </li></ul><ul><li>Alteraciones del desarrollo neurológico </li></ul><ul><li>Dermatitis atópica </li></ul><ul><li>Problemas cardiorespiratorios crónicos </li></ul><ul><li>Datos sugestivos de maltrato </li></ul>Signos/Sintomas sugestivos de organicidad
    34. 34. Abordaje Practico Kerzner B. Clin Pediatr 2009;July 15 XXXXXX
    35. 35. <ul><li>Presente en menores de un año </li></ul><ul><li>Incapacidad para reconocer indicadores tempranos de hambre y saciedad </li></ul><ul><li>Demasiado irritables para equilibrar el ciclo alimentación, actividad, calma, sueño </li></ul><ul><li>Puede impactar la ganancia ponderal </li></ul><ul><li>No existe organicidad </li></ul>Trastornos de la Regulación Temprana
    36. 36. <ul><li>Factores que estresan y factores que calman (videograbación) </li></ul><ul><li>Masaje infantil (demasiado somnoliento) </li></ul><ul><li>Ante irritabilidad: Ambientes en calma, manejo gentil por cuidadores en calma </li></ul><ul><li>Abordaje de la ansiedad o depresion materna </li></ul><ul><li>Evitar el cansancio materno </li></ul><ul><li>Buscar apoyo en otros cuidadores </li></ul>Trastornos de la Regulación Temprana: Terapeutica
    37. 37. <ul><li>Frecuente entre los 6 meses y los 3 años </li></ul><ul><li>Ausencia de signos adecuados de reciprocidad social con el cuidador primario durante la alimentación (“enganche” visual, sonrisa, conversacion) </li></ul><ul><li>Frecuentemente existe negación del problema por parte de los cuidadores y el motivo de consulta es FTT </li></ul>Trastornos de la Reciprocidad (Anorexia Infantil)
    38. 38. <ul><li>Descarte Maltrato. Si existe trate adecuadamente </li></ul><ul><li>Si existe desnutrición importante brinde el tratamiento de acuerdo a las deficientes presentes </li></ul><ul><li>Considere, cuando se amerite la utilización de complementos alimenticios </li></ul><ul><li>Brinde apoyo psicologico a la madre, enfocado a lograr el “enganche” psico-social con el niño </li></ul>Trastornos de la Reciprocidad: terapeutica
    39. 39. <ul><li>Mi hijo no quiere comer…..lo que yo quiero que coma </li></ul><ul><li>El crecimiento pondo-estatural del niño y su desarrollo integral es adecuado </li></ul><ul><li>Padres con reglas demasiado estrictas de educación </li></ul><ul><li>Probabilidad de sistemas cohercitivos de alimentación que afectan fisica y psicologicamente al niño </li></ul>Percepción Inadecuada de los Padres
    40. 40. <ul><li>Educación a los padres y cuidadores </li></ul><ul><li>Indicadores objetivos de alimentación adecuada (Ganancia pondo-estatural, desarrollo armónico) </li></ul><ul><li>Principios básicos de alimentación (cantidad, tipo, combinaciones, formas de presentación) </li></ul>Percepción Inadecuada de los Padres
    41. 41. <ul><li>Se trata de niños excesivamente activos e inquisitivos que raramente se acuerdan que “deben de comer” </li></ul><ul><li>Mas intersados en jugar e interactuar con otras personas </li></ul><ul><li>Pueden comer 1 o 2 bocados y dan por terminado el tiempo de la alimentación (dificil de mantenerlos sentados a la mesa), tiran la comida, o la cuchara </li></ul><ul><li>Pueden presentar trastornos leves a moderados de ganancia pondo-estatural </li></ul>Anorexia Infantil: Niños Excesivamente Vigorosos
    42. 42. <ul><li>Descarte la presencia de TDAH y si existe tratelo en forma profesional y multidisciplinaria </li></ul><ul><li>Evalue el grado en el que el temperamento del niño impacta el status psico-social de la familia y en caso necesario brinde tratamiento </li></ul><ul><li>Evalue la conducta familiar </li></ul><ul><li>Ofrezca un Programa Sistematizado de Alimentación </li></ul><ul><li>Ofrezca como medidas coadyuvantes suplementos alimenticios </li></ul><ul><li>Si es necesario utilice el metodo de “tiempos fuera” </li></ul>Anorexia Infantil: Niños Excesivamente Vigorosos
    43. 43. <ul><li>Ofrecer un programa de alimentación a intervalos regulares de tiempo </li></ul><ul><li>No ofrecer alimentos entre las comidas. Si el niño refiere sed, ofrecer “Agua simple” </li></ul><ul><li>Ofrecer porciones acordes con su tamaño corporal y permitir que pida una segunda o tercera ración. “No ofrecer platos que de verlos cansan” </li></ul><ul><li>Mantenerlo en la silla de alimentación el tiempo en el que “La familia termina de comer” (No prolongar el evento mas alla de 20 o 30 minutos) </li></ul><ul><li>No criticar ni premiar por las cantidades que se ingiere (Mama dice que y el niño dice cuanto) </li></ul><ul><li>No deben existir distractores en el momento de la alimentación (Juguetes, la TV o la radio encendidas) </li></ul><ul><li>El momento de la alimentacion debe ser placentero y agradable, con convivencia con al menos uno de los padres. Evite conversaciones distractoras </li></ul>PROGRAMA DE ALIMENTACION ESTRUCTURADA
    44. 44. <ul><li>Una sola llamada de atención </li></ul><ul><li>Poner al niño en “tiempo fuera” en un lugar seguro, acorde con su edad, solo y sin contacto (ni visual) de los cuidadores </li></ul><ul><li>No ceder ante el llanto o la manipulación del niño “papito, papito, que no sabes cuanto te adoro” </li></ul><ul><li>Acudir despues de 1 o 2 minutos de saber que el niño esta en calma y reforzarlo positivamente </li></ul><ul><li>Retirarlo del sitio de time out y comentar con el “en calma” las causas que motivaron su conducta </li></ul>Tiempo Fuera (Time-Out)
    45. 45. Anorexia Infantil: Niño Apático <ul><li>Niño apático, con apariencia “ausente” y apetito ausente o mínimo </li></ul><ul><li>Comunicación verbal o no verbal limitada (contacto visual, sonrisa social, conversaciones) con los padres o cuidadores </li></ul><ul><li>Recuerdo que puede tratarse de niños autistas, con trastornos de la audición o problemas de maltrato </li></ul><ul><li>En ocasiones, manifestaciones raras de alergia a la proteina de la leche de vaca </li></ul>
    46. 46. <ul><li>Solicite apoyo profesional </li></ul><ul><li>Identificación de las causas subyacentes </li></ul><ul><li>Soporte Nutricional Integral </li></ul>Anorexia Infantil: Niño Apático
    47. 47. <ul><li>Rehusan comida especificas debido a su sabor, textura,temperatura, olor o apariencia </li></ul><ul><li>Reaccionan con muecas faciales, nausea, tos, o vomito </li></ul><ul><li>Se rehusa a probar alimentos nuevos </li></ul><ul><li>Presenta trastornos sensoriales adicionales (sonidos altos, pisar el pasto o la arena) </li></ul><ul><li>Frecuentemente presenta deficiencias macro/micro nutrimentales </li></ul>Niños selectivos (Sensory food aversions)
    48. 48. <ul><li>Oriente a los padres sobre lo multisistemico del problema </li></ul><ul><li>Reto a nuevos alimentos depende del grado de aversion </li></ul><ul><li>Pedir a los padres que coman el alimento enfrente del niño y esperar a que el lo pida </li></ul><ul><li>No festejar cuando el niño finalmente lo come </li></ul><ul><li>Brinde terapia oral y motora si se requiere </li></ul><ul><li>Considere suplementos alimenticios mientras se elimina el problema </li></ul>Niños selectivos (Sensory food aversions)
    49. 49. <ul><li>Inicio agudo y consistente </li></ul><ul><li>Generalmente secundario a eventos traumaticos (colocación de sondas orogastricas o ahogamientos) </li></ul><ul><li>Miedo, llanto o histeria al sentarlo frente a la mesa o enfrentarlo a los alimentos </li></ul><ul><li>Diferentes formas de rehusar el alimento </li></ul><ul><li>Se acompaña de trastornos nutricionales, dependiendo de la gravedad y cronicidad </li></ul>Trastornos alimentarios postraumaticos
    50. 50. <ul><li>Proporcione soporte psicologico o psiquiatrico con intensidad variable, acorde con la gravedad del caso </li></ul><ul><li>Programa de alimentación no cohersivo, gentil y paulatino </li></ul><ul><li>Si el problema es a líquidos, ofrezca pures y solidos y poco a poco introduzca la causa del problema </li></ul><ul><li>En caso necesario transfiera a institucionales de tratamiento especializadas </li></ul>Trastornos alimentarios postraumaticos
    51. 51. <ul><li>Representan una causa frecuente de trastornos de la alimentación, </li></ul><ul><li>Sospechar ante la presencia de indicadores sugestivos </li></ul><ul><li>Pensar en patologias poco frecuentes (enfermedad celiaca) </li></ul><ul><li>Tratar la enfermedad subyacente </li></ul><ul><li>Establcer programas de alimentación acordes con la enfermedad de base y el estado nutricional presente </li></ul>Trastornos de la Alimentación por Causas Orgánicas
    52. 52. Programas de Soporte Nutrimental <ul><li>Estudio fase IV, abierto, aleatorizado, de ramas paralelas, multicentrico </li></ul><ul><li>Dos sitios en Filipinas y uno en Taiwan </li></ul><ul><li>Intervención: consejo nutricional profesional vs. Consejo nutricional + suplementación nutricional </li></ul><ul><li>Desenlace: Mejoría del valor percentilar de peso/talla </li></ul><ul><li>Niños selectivos de 36 a 60 meses, < p25 peso/talla </li></ul>Alarcon, PA; Lin, Lung-Huang; Noche, Miguel Jr et al. Clinical Pediatrics 2003; 4 2:209-217
    53. 53. Programas de Soporte Nutrimental Alarcon, PA; Lin, Lung-Huang; Noche, Miguel Jr et al. Clinical Pediatrics 2003; 4 2:209-217
    54. 54. Programas de Soporte Nutrimental Alarcon, PA; Lin, Lung-Huang; Noche, Miguel Jr et al. Clinical Pediatrics 2003; 4 2:209-217
    55. 55. Programas de Soporte Nutrimental Schrezenmeir J, Alarcon P et al. Clin Paediatr 2004;43:239-49
    56. 56. Programas de Soporte Nutrimental Schrezenmeir J, Alarcon P et al. Clin Paediatr 2004;43:239-49
    57. 57. Programas de Soporte Nutrimental Schrezenmeir J, Alarcon P et al. Clin Paediatr 2004;43:239-49
    58. 58. Programas de Soporte Nutrimental Schrezenmeir J, Alarcon P et al. Clin Paediatr 2004;43:239-49
    59. 59. Resumen <ul><li>Trastornos de la conducta alimentaria: Muy frecuentes </li></ul><ul><li>Trastornos negativos de la interacción entre el niño y los cuidadores </li></ul><ul><li>Pueden producir trastornos pondo-estaturales y de desarrollo significativos </li></ul><ul><li>Las etiologias son diversas y requieren un abordaje cuidadoso y ultidisciplinario </li></ul><ul><li>Debe tenerse en cuenta el espectro total del problema </li></ul><ul><li>El enfoque diagnostico terapeutico debe ser basado en la experiencia, las mejores evidencias, los valores y preferencias de los pacientes y familiatres y en los factores economicos presentes </li></ul>

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