2. Agenda
• Definition, Prevalence and categories of
feeding difficulties.
• Nutritional requirements of healthy
growth.
• Consequences of feeding difficulties.
• Importance of early HCP intervention.
• Effect of Oral Supplementation on Catch-
Up Growth in Picky Eaters.
• Safety and growth outcomes term using
long term ONS.
3. 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.
Eating reflects only
the child’s action
Feeding involves an
interaction between the
child and the caregiver
Feeding Eating
4. What is a feeding
difficulty?
The term feeding
difficulties is a broad
term used to describe a
variety of feeding or
mealtime behaviors
perceived as problematic
for a child or family. This
may include behaviors
such as:
•Picky eating
•Food
fussiness
•Food refusal
•Food
neophobia
•Restricted
variety of
foods.
•Limited,
excessive or
variable
appetite
•Prolonged
mealtimes
•Disruptive
mealtime
behaviors
This may include behaviors such as:
5. How common are feeding
difficulties?
Prevalence rates of up to 20-50% in
normal children have been reported.
Such a high prevalence of eating
behavior problems in otherwise
typically developing children
perhaps suggests that many reported
difficulties are in fact a ‘normal’
feature of toddler life.
For children with developmental
delays and chronic illness, estimates
of prevalence of up to 80 -90% have
been reported.
6. Prevalence of feeding difficulties
Variability in Estimates
Study Prevalence
Age, Location of
Study Population
Carruth et al, 2004 50% 19 to 24 months, US
Jin et al, 2009 40% 1 to 6 years, China*
Dubois et al, 2007 29% 3 to 6 years, Canada
McDermott et al,
2008
28% 2 to 4 years, Australia
Jacobi et al, 2003 21% 3 to 6 years, Germany
Wright et al, 2007 20% 29 to 33 months, UK
Li et al, 2001 17% 2 to 6 years, China†
1. Carruth BR, et al. J Am Diet Assoc. 2004;104:S57-S64; 2. Jin X, et al. Chinese J Child Healthcare. 2009;17:387-389; 3. Dubois L, et al. Int J Behav
Nutr Phys Act. 2007;4:9; 4. McDermott BM, et al. J Dev Behav Pediatr. 2008;29:197-205; 5. Jacobi C, et al. J Am Acad Child Adolesc Psychiatry.
2003;42:76-84; 6. Wright CM, et al. Pediatrics. 2007;120:e1069-e1075; 7. Li Y, et al. Pediatr Int. 2001;43:651-661.
7.
8. What is the impact of
feeding difficulties?
Feeding difficulties may be mild or transient with no adverse outcomes or
severe and prolonged impacting on the health and development of the child
and family relationships.
Children with severe feeding difficulties are at risk of nutritional
deficiencies, poor growth, cognitive impairment, emotional dysfunction and
even death. Early detection of feeding problems and appropriate intervention
improves outcomes for children.
3-10% of children develop chronic feeding issues that exceed expected
variations in development and are possibly associated with negative outcomes
in terms of growth and development.
10. Social and Emotional Development
1. Underlying medical conditions or prolonged hospitalization may be
associated with disruptions in social and emotional development.
2. Disrupted parent-child interactions characterized by lack of mutual
engagement .
3. Need for independence is not recognized or supported by parent e.g. Parent
insist on feeding child to ensure all food is eaten.
4. Delays in social and emotional development e.g. Autism Spectrum Disorder.
5. Ongoing difficulties with emotional and behavioral regulation – older child
e.g:
•Generally anxious or depressed and withdrawn
•Lacks psychological flexibility to cope with minor disruptions or variations in
routines. Tantrums easily - difficult to calm.
•Lacks confidence to engage in age appropriate exploration and independent
activities including feeding. Relies on parent more than peers.
•Irregular eating and sleep patterns.
11. Physical, Sensory and Oral Motor Development
1.Developmental delay e.g.,
Cerebral Palsy
2.Movement disorders
e.g. Ataxia
3.Hyposensitive to taste
4.Anatomical /structural
anomalies e.g. Cleft palate
12. Mealtime Environments
1. Lack of enjoyment at mealtimes e.g. :
•Mealtime environment is distracting or unpleasant causing
decreased appetite or interest in eating.
•Focus is on the type or amount of food eaten rather than
social interactions and enjoyment.
•Typical variations in appetite are not recognized.
•Use of force feeding.
2. Foods offered are not matched to developmental skills for
feeding e.g.
Introducing solids too soon or too late.
Textures of food offered are based on age expectations rather
stage of physical or oral motor development.
Graded experiences to promote development are not
provided.
13. Child learns from experience that eating is painful or
unpleasant leading to food refusal or limited food choices e.g.
Pain with eating may be associated with gastro-esophageal
reflux, allergic reactions to food, use of force feeding such
that eating is not enjoyable.
Communication delays - difficulty communicating, hunger,
satiety and food preferences.
Cognitive delays - difficulty understanding mealtime
routines, and generalizing skills to different environments.
Communication and
Cognitive Development
14.
15. 1. Calcium metabolism (main function):
Vitamin D regulates Ca++ levels in the blood and tissues. A fall in
blood Ca++ stimulate active vitamin D production stimulates
Ca++ absorption from food + release of Ca++ from bones + renal
excretion of Ca++.
FUNCTIONS OF VITAMIN D
16. 2.Essential for normal bone growth
during childhood (as it increases Ca++
absorption from foods + increases Ca++
deposition into the skeleton).
3.Integrated function with parathyroid
hormone in stabilization of Ca++ level in
blood.
4.Regulation of cell growth and
development (particularly WBCs and
epithelial cells).
17. Vitamin D Deficiency
SUBCLINICAL DEFICIENCY
1. Silent epidemic, Present in
approximately 30% to 50% of the
general population.
2. More prevalent in infants.
3. Often unrecognized by clinicians.
23. Affects of Vitamin D on
Brain Function
• Active form of Vitamin D is synthesized
and eliminated in the brain
• Numerous Vitamin D receptors in
cortical neurons, and glia
• Enzymes involved in metabolism of
Vitamin D also expressed in brain cells
• Metabolites of Vitamin D reported in
CSF
• Holmoy,T. & Moen,S.M. (2010). Assessing vitamin D in the central nervous system. Acta
Neurol Scand. 122: 88-92.
24. Vitamin D affects the
development of
neurons as well as
their maintenance
and survival.
25. Vitamin D
and the
Brain
• Influences brain development:
cell growth, neuronal
differentiation, axonal
connectivity, neurotransmitter
function, brain structure,
learning, memory.
• Crucial role in
neuroprotection,
neurotransmission and
neuroplasticity.
• Regulates catecholamine levels.
• Synthesizes acetylcholine,
serotonin and dopamine.
