1. Rush is a not-for-profit health care, education and research enterprise comprising Rush University Medical Center, Rush University, Rush Oak Park Hospital and Rush Health.
Feeding Therapy for an Ex-24 week
Preterm Infant
Alexandra Munroe, B.S.
Department of CommunicaFon Disorders and Sciences
Rush University • Chicago, IL
Case Supervisor: Sara Shapiro, CCC-SLP
Case Moderator : Lisa LaGorio, PhD, CCC-SLP
September 21, 2016

2. Learning ObjecFves
Understand how prematurity affects the
development of feeding skills
Discuss the new diagnosFc category of
Avoidant/RestricFve Food Intake Disorder
Understand theoreFcal background behind
Sensory IntegraFon (SI) therapy approach
Understand the role of the SLP in pediatric
feeding disorders

3. Premature Birth
• 1 in 10 births in the USA
• Greatest contributor to infant death
• Leading cause of long-term neurological
disabiliFes in children
CDC, 2016

4. Extremely Preterm <28 weeks
Very Preterm 28 to <32 weeks
Moderate to Late Preterm 32 to <37 weeks

5. Child A – Medical History
• 23 month old male
– Born at St. Joseph’s in Fall 2014
– 24 gestaFonal weeks
– Born via C-secFon due to placenta abrupFon
– Birth Weight: 1 lb 6 ounces
– Pulomonary Hypertension (PH)
– Bronchopulomonary Dysplasia (BPD)
• Medical stay included the following procedures:
– Inguinal hernia bilateral repairs
– ASD lec to right shunFng
– PDA ligaFon repair

6. Child A – Medical history cont.
• Treated for the following at discharge home
– VenFlaFon and tracheostomy dependency
– Steroid dependency
– GERD
– Subglodc stenosis
– Osteopenia of prematurity
– ReFnopathy of prematurity (ROP)
– Hearing loss
• 100% tube dependent
• No clinical signs or symptoms of aspiraFon

7. Child A – Developmental History
• Winter 2016 – (14 months olds)
– RecepFve Expressive Emergent Language Test
(REEL)
• RecepFve Language: 5 months (55% delay)
• Expressive Language: 4 months (64% delay)
– Oral Mech Exam : Within normal limits
– Sensory Processing
• Some sensiFviFes to oral and tacFle input
• Dislikes light touch and more comfortable with deep
pressure input
• Sensory over-responsiveness in the areas of oral,
tacFle, and vesFbular movement

8. QuesFon for the Audience
What is a feeding
disorder?

9. Feeding Disorders
– VariaFons in food intake or feeding
behavior sufficiently different from the
norm to result in child or family distress,
social or developmental risk, or negaFve
health consequences.
Thoyre, 2007

10. Food Refusal
• Specific behaviors ocen associated with refusal of
food such as head turning and mouth closure
conFngent upon presentaFon of food, spidng out
food, dawdling, gagging, and even vomiFng.
Williams, Field, Seiverling, 2010

11. Avoidant/RestricFve food intake disorder
(ARFID)
1. An eaFng or feeding disturbance (e.g., apparent lack of interest in eaFng or food; avoidance based on
the sensory characterisFcs of food; concern about aversive consequences of eaFng) as manifested by
persistent failure to meet appropriate nutriFonal and/or energy needs associated with one (or more) of
the following
– Significant weight loss (or failure to achieve expected weight gain or faltering growth in children)
– Significant nutriFonal deficiency
– Dependence on enteral feeding or oral nutriFonal supplements
– Marked interference with psychosocial funcFoning
2. The disturbance is not bener explained by lack of available food or by an assoicated culturally
sancFoned pracFce
3. The eaFng disturbance does not occur exclusively during the course of anorexia nervosa or bulimia
nervosa and there is no evidence of a disturbance in the way in which one’s body weigth or shape is
experienced
4. The eaFng disturbance is not anributable to a concurrent medical condiFon or not bener explained by
another mental disorder. When the eaFng disturbance occurs in the context of another condiFon or
disorder, the severity of the eaFng disturbance exceeds that rouFnely associated with the condiFon or
disorder and warrants addiFonal clinical anenFon.
Norris, Spetigue, Katzman, 2015
Kenney & Walsh, 2013
Diagnostic Criteria

12. Rommel,N., De Meyer, A.M., Feenstra, L., & Veereman – Wauters, G. (2003). The complexity of
feeding problems in 700 infants and young children presenFng to a terFary care insFtuFon.
Journal of pediatric gastroenterology and nutri3on, 37(1), 75-84.

13. Rommel,N., De Meyer, A.M., Feenstra, L., & Veereman – Wauters, G. (2003). The complexity of
feeding problems in 700 infants and young children presenFng to a terFary care insFtuFon.
Journal of pediatric gastroenterology and nutri3on, 37(1), 75-84.

14. Rommel,N., De Meyer, A.M., Feenstra, L., & Veereman – Wauters, G. (2003). The complexity of
feeding problems in 700 infants and young children presenFng to a terFary care insFtuFon.
Journal of pediatric gastroenterology and nutri3on, 37(1), 75-84.
• CorrelaFons
– Significant relaFonship found between type of
feeding problem and age
– Oral sensory based feeding disorders
corresponded with nasogastric and gastrostomy
tube feeding
– Significant associaFon between oral sensory
based feeding disorders and hx of aspiraFon and
venFlaFon

15. 2 Types of Feeding Disorders
Sensory Based Presenta7on Behaviorally Based
Presenta7on
• Avoid whole foods or texture
groups
• Difficulty toleraFng sensory input
• Eats the same regardless of
people/place
• Overstuffs oral cavity/ takes Fny
bites
• Excessive Drooling
• Rarely presents with selecFve
avoidance
• Eats bener for certain people
• Gags to get anenFon
• Rarely underlying neurologic or
medical issue

16. Sensory Processing
North Shore Pediatric Therapy

17. Sensory processing in preterm infants
Blackburn, 1998
Cabral, Silva, Martinez, & Tudella, 2016

18. Cabral, T. I., da Silva, L. G., MarFnez, C. M., & Tudella, E. (2016). Analysis of
sensory processing in preterm infants. Early human development, 103, 77-81.
• 30 infants
– Experimental group of 15 preterm infants
– Control group of 15 full term infants
– Aged between 4 and 6 months corrected
• Infants assessed using the Test of Sensory
FuncFons in Infants

19. • Results
– 80% of preterm infant group showed risk for
sensory abnormaliFes
– Significant difference in total score of the test
(p=0.0113)
– Significant difference in reacFvity to deep
pressure (p<.00001)
Cabral, T. I., da Silva, L. G., MarFnez, C. M., & Tudella, E. (2016). Analysis of
sensory processing in preterm infants. Early human development, 103, 77-81.

20. Sensory IntegraFon Therapy
• Developed by Ayres in 1972
• Designed to help a child process and integrate
sensory informaFon
Schaaf & Miller, 2005

21. Schaaf & Miller,
2005

22. Interdisciplinary team approach
McComish, 2016
Medical Motor Behavioral
Underlying
medical
issues
Delays in
gross and
fine motor
skills
NegaFve
feeding
behaviors

23. Update on Child A
• Currently accepFng 10-15 bites of puree each
session

24. Take Home Points
• When treaFng preterm children we have to consider their
sensory development when planning treatment.
• The new diagnosFc category of ARFID is a more inclusive
diagnosFc category that will help to idenFfy children with
feeding disorders that were previously un-idenFfied or
untreated.
• The sensory integraFon approach to therapy can guide
intervenFon for children with difficulty processing sensory
informaFon.
• An interdisciplinary collaboraFve team approach to feeding
therapy increases collaboraFon between professionals and
progress towards the child’s goals.

25. References
• American Psychiatric AssociaFon. DiagnosFc and StaFsFcal Manual of Mental Disorders, 5th ed. Arlington, VA:
American Psychiatric Associa3on, 2013.
• Blackburn, S. (1998). Environmental impact of the NICU on developmental outcomes. Journal of pediatric nursing,
13(5), 279-289.
• Hawdon, J. M., Beauregard, N., Slanery, J., & Kennedy, G. (2000). IdenFficaFon of neonates at risk of developing
feeding problems in infancy. Developmental Medicine and Child Neurology, 42(4), 235-239.
• McComish. (2016). Interdisciplinary Feeding Team: A Medical, Motor, Behavioral Approach to Complex Pediatric
Feeding Problems. MCN, the American journal of maternal child nursing, 41(4), 230-236.
• Morris, S. E., & Klein, M. D. (2000). Pre-feeding skills: A comprehensive resource for mealFme development.
AusFn, TX: Pro-Ed.
• Norris, M. L., Spedgue, W. J., Katzman, D. K. (2016). Update on eaFng disorders: current perspecFves on
avoidant/restricFve food intake disorder in children and youth. Neuropsychiatric Disease and Treatment, 12,
213-218.
• Pagliaro, C. L., Bühler, K. E., Ibidi, S. M., & Limongi, S. C. (2016). Dietary transiFon difficulFes in preterm infants:
criFcal literature review. Jornal de pediatria, 92(1), 7-14.
• Rommel,N., De Meyer, A.M., Feenstra, L., & Veereman – Wauters, G. (2003). The complexity of feeding problems
in 700 infants and young children presenFng to a terFary care insFtuFon. Journal of pediatric gastroenterology
and nutri3on, 37(1), 75-84.
• Ross, E. S., Browne, J. V. (2002). Developmental progression of feeding skills: an approach to supporFng feeding in
preterm infants. Seminars in neonatology, 7(6), 469-475.
• Thoyre, S. M. (2007). Feeding outcomes of extremely premature infants acer neonatal care. Journal of obstetric,
gynecologic, and neonatal nursing, 36(4), 366-75; quiz 376.
• Patel, R. M. (2016). Short- and Long-Term Outcomes for Extremely Preterm Infants. American journal of
perinatology, 33(3), 318-328.
• Williams, K. E., Field, D. G., Seiverling, L. (2010). Food refusal in children: a review of the literature. Research in
developmental disabili3es, 31(3), 625-633.