Feeding difficulties•Feeding difficulties may potentiallyinterfere with the parent-child feedingrelationship•Children who accept very few foodsmay be at risk for nutrient deficiencies•Feeding difficulties have the potentialto compromise nutrition, growth, andcognitive development•Causes vary widely and feedingdifficulties require tailored therapy toaddress this variation
Contributing Factors• Organic, developmental, psychological, and behavioral issues• Family dynamics• Social and cultural influences
Food(contributing to feeding problems and poor appetite )• Nature of the child• Food likes and dislikes• Preferring outside food• Very choosy• Improper presentation• Food timing• Type of food• Preoccupation during meal time
Poor appetiteThe feeders:• Creating an appropriate feeding environment?• Sensitive to the childs hunger and satiety cues?• Overly controlling or too uninvolved?• Misinformed about nutrition?• Working mother• Mood/attitude/health• Preoccupation during meal time• Knowledge about food and nutrition
The feeder• Method/time of feeding• Interaction with the child• Poor judgment about child’s hunger• Dissatisfaction about child’s appetite• Weight and growth concern• Influenced by others• Fear (falling sick/being compared/criticized)• Proper time interval• Un tasted food• Misconceptions about food(egg/bitter gaurd /neem leaves)• No. of children
The feeder-Role of care giver or Ayahs• Age/experience• Nature (sympathetic/not sympathetic)• Wrong method of feeding• Lack of knowledge and interaction• Patience and irritability• Monotonous and repeated meals• Food served (too hot/too cold)• No innovation or improvisation in food
Family and cultural influence• Type of family(joint/nuclear)• Traditions• Economic status• Poor living conditions
Media influence• Role models(promoting zero figure)• Taboos and stigma• More propaganda on junk food (Mc Donald/Pizza Hurt )• Conceptualizing “fit and fine”• Turning vegetarians• Importance on “X-factor/body image and personality)• Following food which is popular
Prevalence• Estimates in physically normal children – 50% to 60% for parent-reported feeding difficulty – 25% to 35% for specific difficulties (e.g., food refusal, selective eating) – 1% to 2% for severe and prolonged difficulties• Estimates in children with neurological and developmental disorders/delays – > 80% in some studies – Swallowing disorders are especially common
Issues of Concern• Chronic aversion with socially stigmatizing meal behavior• Some children do have growth limitations• Some have suboptimal consumption of nutrients• Serious organic and nonorganic causes exist• Impaired parent-child interactions indicated by touching behavior
Parent-child relations• Maternal education• Parent-child conflict during feeding• Parent intrusiveness during play• Parental pressure to eat appears to increase feeding resistance• feeding resistance associated decelerating weight gain
Type of feeding difficulties• Fear of Eating• Highly Selective Intake• Vigorous Child• Organic Disease• Apathy• Concerned parents
Features demonstrated in feeding difficulties• Child may cry at the sight of food or the bottle or resist feeding by crying, arching, or refusing to open his/her mouth• May occur in a child who has experienced a frightening feeding experience (e.g., choking) or in a child who has been tube fed• consistently refuses specific foods because of taste, texture, smell, or appearance.• Child may become visibly anxious if asked to eat aversive foods• Additional sensory difficulties are often present; e.g., the child may be upset by loud noises or the sensation of sand or grass under his/her feet• Child is more interested in playing and interacting with people than in feeding• Child may take only 1 or 2 bites and be finished with eating
Features demonstrated in feeding difficulties• Child is easily distracted from feeding; may be difficult to keep at table or in high chair during meals• Limited verbal and nonverbal communication (e.g., smiling, babbling, eye contact) between child and caregiver• Possible evidence of neglect and/or signs of abuse• Child is small but achieving satisfactory growth based on mid-parental height• Excessive parental concern may lead to coercive feeding methods that adversely affect the child
systematic approach to the identification and management of feeding difficulties• Acknowledge• Investigate• Identify• Manage
Assessment of Feeding Behavior• Background history • History of prenatal, birth, hospitalizations• Observation and • Early feeding history Assessment of Child’s Feeding • Developmental Behavior milestones • Temperament• Assessment of • Regulation: sleeping, Caregiver Feeding soothing, toileting Behavior • Previous evaluations
Assessment of Feeding Behavior• Background history • Cooperates with setup • Sits appropriately• Observation and • + interaction with feeder (e.g., Assessment of smiles, claps) Child’s Feeding • positive comments about food • Opens mouth, anticipates food Behavior • Feeds self• Assessment of • Responds to prompts to Caregiver Feeding continue • Requests food Behavior
Assessment of Feeding Behavior• Background • Refuses to sit in chair history • Cries • Spits food out of mouth• Observation and • Gags, vomits Assessment of • Verbally says “no “ to food Child’s Feeding • Moves head away from spoon Behavior • Refuses to open mouth •• Assessment of Puts hands in front of mouth • Throws food or utensils Caregiver Feeding • Gags before food is introduced Behavior
Assessment of Feeding Behavior• Background history • Eye contact with child • Positions child appropriately• Observation and • Presents appropriate food, Assessment of utensils Child’s Feeding • Prompts child verbally and non- Behavior verbally • Pays attention to child during• Assessment of meal Caregiver Feeding • Models appropriate eating Behavior
Assessmet of Feeding Behavior• Background history • Reminds child to swallow completely• Observation and • Paces child at reasonable pace Assessment of • Interacts positively during meals Child’s Feeding • Praises child for appropriate Behavior behavior• Assessment of • Sets limits on throwing food, leaving table Caregiver Feeding • Persists Behavior
Chronic Underlying Pathology(organic)• Dysphasia• In coordinate swallowing suggested by cough, choking, or recurrent pneumonia/chest phenomena• Failure to thrive• Feeding interrupted by pain• Regurgitation/chronic vomiting• Diarrhea or blood in stool• Neurodevelopment abnormalities• Atopic and eczema• Chronic cardio respiratory disease• Signs of neglect
Non-organic pathology Psychological disorders/conditions• Fear of feeding• Poor appetite• child who is fundamentally vigorous• child who is apathetic and withdrawn• parental misperception• Colic that interferes with feeding (< 3 months of age)• Developmental delays• MR and PDD• ADHD(attention deficit and hyper active)• Problem behavior• Autism• Somatoform disorder
General complaints(outcomes)• Feeding problem in both poor and rich.• ‘My child eats nothing’,• ‘My child eats like a bird’• ‘I have tried everything’• Meal times are virtual mini-wars• Child is coaxed, cajoled, forced, bribed• Story, showing a picture book, T.V.,• Mother chasing the child with plate• The whole family revolves around child• Meal time becomes unpleasant, emotionally surcharged and stressful• Morale of the child is high while the family is gloomy.
General complaints(outcomes)• Child is the usual winner.• Worst is forcing food after restraining child.• Spits or vomits.• Low growth rate• Loss of appetite• Physical illness/constipation• Fear/phobia• Irritability/excessive crying• Is there any food supplements
Addressing eating disorders- role of clinical psychologist• More than just eating disorders – it is psychological• Consult with dietitian, psychologist or medical doctor to come up with an effective treatment plan• Parents should give comfort and support during treatment• Give love, compassion, appreciation and quality time
Addressing eating disordersAn initial evaluation should focus:• feeding history- detailed information on type and timing of food intake• feeding position• meal duration• energy and nutrient intake• behavioral and parental factors
Treatments and interventions• Behavioral therapy can help the parent and child overcome conditioned feeding problems and food aversions.• Parents must be educated to recognize their childs hunger and satiety cues accurately and to promote a pleasant, positive feeding environment.• Changing the texture of foods• the pace and timing of feedings• the position of the body• even feeding utensils• forcing a child to eat or punishing a child for not eating should be avoided
Addressing eating disorders• Cognitive behavioral therapy :(CBT)– Acceptance and commitment therapy– Dialectical behavior therapy– Cognitive Remediation Therapy• Family therapy• Behavioral therapy : focuses on gaining control and changing unwanted behaviors.• Interpersonal psychotherapy :(IPT)• Music Therapy :• Recreation Therapy• Art therapy
How to tackle? Rule out serious illness• Prevention is easier than treatment.• Avoid over indulgence not paying excessive attention and concern to child’s food.• Honor the likes and dislikes.• Offer variety to break monotony.• Best way is “not to try”• Relaxed attitude at meal time.• Enjoy.
How to tackle?• “Intelligent neglect”.• More attention and pleasure when eats.• Ignore when does not eat or fiddles.• Self feed, even if creates mess.• Most like to eat when others are eating.• After reasonable time remove plate quietly without any concern or anxiety.• Negative statement may help
How to tackle?• The whole family to participate in training including grand parents.• It is a behavior disorder.• No loss of appetite or ‘sluggish liver’• No role of tonics and appetizers. Placebo? Iron/multivitamin.• Understand the family dynamics of fussiness. Needs change in attitude and approach in feeding the child.• May take long time - Patience.• Do not talk of his food habits in front of him• Do not lecture or find faults during mealtime.• Give less than what he normally takes.
How to tackle?• Meals with more eye appeal, shapes/size.• Let him help in preparing meal.• Never bribe for a few more spoons• In the beginning do not offer food which child does not like.• Cut down between meal snacks/drinks• Look at the bigger picture• Adopt a relaxed and common sense approach without any sense of frustration.• Be aware of other influences such as peer pressure and advertising• Individualize the approach
Refuses vegetables• Serve and eat a variety of vegetables. Parents eating habits influence the children• Prepare vegetable to retain its eye appeal and vitamins.• Many like to eat raw.• Vegetable shapes. Carrot coins, flowers• Add cheese, sauce etc• Gradually reintroduce vegetables• Mix with paranthas, pizzas.• Make soup.• Extra fruits.• Visit farms and gardens.• Help him to plant seeds, watch them grow into something to eat.
Refuses milk• Drink milk yourself along with child• Substitute e.g. curd, butter, cheese etc.• Serve in small colorful glass which child can hold.• Straw can be used.• Small quantity to be served frequently• No problem even if does not take.
ConclusionWhen I was growing up, I wouldhear people say, "You can lead ahorse to water but you cant makehim drink." That saying remindsme of childrens eating habits. Youcan slave for hours in the kitchen,use your finest place settings,even dine by candlelight but ifyour child isnt hungry or doesntlike the cuisine, you cant, usingreasonable methods, make themeat it.