Medical Considerations

When planning management strategies priority should be given to optimizing the treatment of  any underlying medical conditions contributing to the feeding difficulty [10].   While feeding difficulties may continue despite treatment of underlying medical issues [5, 9] it is reasonable to expect that this is a prerequisite to achieving change  e.g. child who experiences pain with eating is unlikely to achieve improvements with eating while pain persists.  Link to why do feeding difficulties develop.

Nutrition counselling may be a high priority for children with poor growth or dietary deficiencies.  For example providing strategies for increasing energy intake to improve growth or increase intake of iron containing foods for those with iron deficiency or fibre for children with constipation or fibre intake.  Sensitive discussions regarding the benefits of tube feeding may be indicated. 

Links for increasing energy intake

Westmead resources:

http://kidshealth.schn.health.nsw.gov.au/fact-sheets

http://kidshealth.schn.health.nsw.gov.au/fact-sheets/high-energy-eating-infants-toddlers

http://kidshealth.schn.health.nsw.gov.au/fact-sheets/high-energy-eating-children

http://kidshealth.schn.health.nsw.gov.au/fact-sheets/high-energy-additions-foods

Links for iron

http://kidshealth.schn.health.nsw.gov.au/fact-sheets/ways-boost-iron-intake

Links for Fibre

http://www.rch.org.au/uploadedFiles/Main/Content/nutrition/2013Fibre.pdf

Involving the family in management

While an interdisciplinary team approach is frequently recommended for the management of more complex feeding difficulties, the role of the parents as a member of the team is critical and should not be overlooked.  A family centered approach that involves parents in prioritising and setting realistic goals can result in more successful outcomes [14].  Providing parents with education and training is also essential as parents may struggle to implement strategies for which the benefits are not fully understood.

For some children feeding development will be slow.  Parents frequently express feelings of frustration and may struggle to continue implementing suggested management strategies.  Ongoing support and measuring changes in terms of parental attitudes and feelings and not just the child’s progress can be beneficial.  Providing realistic expectations of change is important to parents.

Goal setting

A sound understanding of feeding development provides a framework for understanding feeding difficulties and facilitates goal setting [14-16].

Regardless of the feeding difficulties of the individual child, a goal for all children and their families is that mealtimes become a time of  enjoyment and pleasant interaction [16].  Children are unlikely to accept new foods and learn positive new behaviours in a stressful environment while parents may have difficulty implementing strategies if mealtimes are not enjoyable or alternatively stress-filled.  

Examples of goals based on the clinical assessment and identification of factors contributing to the development of feeding difficulties are included in the case scenarios. Link to case scenarios below.

Choosing management strategies

As children often have more than one type of feeding difficulty it is recommended that clinicians focus on managing the problematic behaviour rather than targeting their input to any specific diagnosis [17]. 

The choice of strategies for management and goal setting are determined by the outcomes of the clinical assessment and should be individualised to the child and family’s needs and strengths taking account of the duration and severity of the problem and the impact on growth.   

• Children with food refusal may benefit from a supportive mealtime environment

Parents decide the what, when and where of feeding and

Children decide how much they will eat or if they will eat at all.

• Children who are willing to eat but who experience difficulties with chewing and swallowing will benefit from speech or occupational therapy based interventions [10]. 
• Identification of disrupted child-parent interactions or high levels of child distress may indicate the need for referral for psychological support and intervention.

Children with delayed development learn in a similar way to typically developing children.  However acquisition of new skills usually takes longer.  Strategies may need to be implemented in small steps.  Parents may need support to be consistent with strategies and recognise achievements.