Tips for feeding or eating disorders

• 20-40% of 0-2 year olds have some problems reported, usually colic, vomiting, slow feeding or refusals to eat, but beware of
  1. the possibility of underlying conditions and e.g. Gastrointestinal Reflux, Pyloric Stenosis, and other upper airway/upper gastrointestinal physical causes
  2. Slow feeding development onto solids or aversions to certain tastes or textures of food may be an early indicator of developmental delay, sensory sensitivity or other neurodevelopmental conditions
  3. May also indicate parent-infant stress-distress; this can be complex. It may include emotional needs and or interactional and relationship issues.

• For typically developing infants and young children a key role of a parent or carer is to provide and offer the most nutritious well-balanced meals and snacks
• However, the growing child’s decision in deciding what and how much they eat is important as part of normal development. It helps the child retain their internal regulation of eating
• The infant learns, over time, to respond to their own sense of hunger and fullness. In young children with feeding or eating disorders this balance may change

• Parents do not always have the confidence to allow infants and toddlers to ‘eat to their appetite’
• Children whose sense of internal regulation of satiety becomes dysregulated may go on to overeat frequently and might become overweight, obese or have other health consequences
• Look out for young children who appear to have limited drive to eat as they may need some additional support and encouragement to ensure their energy, nutritional and emotional needs are met

• Infants should have the opportunity to learn to like all the tastes and flavours of their family foods by around 12-months of age
• Toddlers who reject certain textures of food may have lacked the opportunity to learn to manage them during infancy when most children are more receptive to accepting new foods/textures. This is more common if the infant has sensory needs or has neurodevelopmental conditions like autism. It is usually best to learn about different food types earlier than middle toddlerhood, around age 2 years
• Infants are born with an innate liking for the sweet taste and most happily drink breast milk as it has a sweet taste. Over time they learn to also like the other tastes (salt, sour, bitter and umami) and flavours, and to accept the new textures of solid food
  1. Umami meaning: Umami, or savouriness, is one of the five basic tastes. It is characteristic of broths and cooked meats and fermented products
• During the early stages of complementary feeding, infants learn to like new tastes after just a few exposures. Older infants need more exposure to a new food to learn to like it.

• Reluctance to try new foods may be an innate phase to prevent the now mobile toddler trying poisonous foods they can now reach independently e.g. deadly berries or mushrooms etc. However, it can debilitate in normal life if not enough new foods were tried earlier in development
• Toddlers may be less likely to grow out of fears of new foods if they are self-directed and therefore less likely to copy what others are doing, or if they are particularly sensitive to oral sensations of taste and texture (oral hypersensitivity) – such children may show strong preferences for mainly soft, sweet food options
• Normal feeding development begins in utero and is a dynamic physiological as well as psychological process. It takes two forms (which might be seen as having links to later psychological aspects of eating):
  1. Non-nutritive sucking can be seen in the foetus between 18-30 weeks gestation. This is a fast, non-feeding rhythmical suck which isn’t coordinated with swallowing. It has comforting and settling effects on infants 
  2. Nutritive sucking is a more mature and complex process and is designed to deal with fluid. It can first be seen between 34-37 weeks gestation and requires coordination of the suck, swallow and respiration. It is rhythmical and slower than non-nutritive sucking
  3. Premature infants before 34 weeks don’t have the same level of ability to suck and swallow at the same time
  4. Between 3-12 months a series of stages (7 steps) occur in ability to sit, swallow, chew and manage increasingly solid foods, this is complex to achieve
  5. Infants learn from daily experience and reflexes how to deal with solids; relationships, pacing and emotions do matter in this process
  6. The infant has to learn to deal with the initial gag reflex on trying solids and this gag reflex diminishes with time in normal development. Some people (children as well as adults) gag in relation to a strong disgust response. Some gag on touch (sensory sensitivity)
  7. Infants who are not introduced to lumpy food by about 9-months are more likely to be fussy eaters as toddlers 
  8. To be able to use hand and arm movements to self-feed, an infant needs to be able to control the head and neck and balance the trunk
  9. Drinking from a cup requires a change from sucking to sipping with controlled lip, jaw, and tongue-tip movements
• Feeding and eating are part of everyday life and for this reason can be taken for granted. In reality they are complex developmental tasks that require sophisticated sensory, motor, psychological and social skills
• This is a complex interface of senses, motor skills, and social relationships - smell, taste, feel, colours, textures, chewing, swallowing, digesting, while sharing or in relation to other people. Such complex systems can become disturbed, and any vulnerabilities make such disturbance more likely.

• If there are difficulties in the parent-infant feeding relationship, then parents will need sensitive caring support to try new things. This is very important.

• Who have general anxiety: triggered further by any food rejection by the infant
• Who have anxiety about cleanliness: leading to overly fussy eating and fear of sticky hands and so forth
• Who are struggling to recognise satiety cues: when parents might for example, misinterpret, ignore or overrule feeding cues, children can become confused about hunger and satiety
• Where there are difficulties in the parental-child interaction: for example if the parent has mental health challenges or adult relationship difficulties, for example if the parent is withdrawn, depressed or in conflict with their partner
• Who appear anxious about the whole feeding process or try to over manage it all. Over time the infant may develop counter-preferences. Inadvertently and over time, conflicts in the feeding relationship may escalate

• How is the problem manifested?
• Is the child suffering from any disease or other known condition?
• What is the child’s current food and fluid intake?
• Have the child’s weight, development, emotional health been affected?
• What is the emotional climate like during the child’s meals?
• Are there any major stress factors in the family?
• Is there any family history of eating disorders, neurodevelopmental conditions, or mental health conditions?

• Problems with swallowing is an anatomical problem that may be caused by structural abnormalities or neurological developmental disability
• Poor progression through the food textures may indicate a wide range of things, including difficulty with change, strong preferences, sensory sensitivities, infant carer interaction challenges and issues and/or neurological impairment.
• A history of recurrent pneumonia may be due to chronic aspiration and 70-94% of episodes of aspiration are ‘silent’
• Stridor (high-pitched wheezing) in relation to feeding is an anatomical problem that could be due to glottic or subglottic abnormalities
• Food refusal could be a result of an anatomical problem or an emotional/ behavioural problem, or both
• Vomiting may be due to anatomical, such as pyloric stenosis, or behavioural issues as vomiting may be a strategy a child uses to indicate they wish to end the meal. It may also result from easy gag reflex
• Projectile-very forcible, vomiting in a 3–6-week-old indicates possible pyloric stenosis
• Constipation can be related to poor diet and or behavioural withholding, but may be due to Gastroesophageal reflux or Pyloric Stenosis
• Diarrhoea, vomiting, and or colic can be related to Gastroesophageal reflux or infections
• Gastroesophageal reflux may be physiological or can be caused by cows’ milk, protein allergy or intolerance
• Colic can also be caused by allergies
• Poor weight gain - there are many medical reasons that might cause this, anything that means energy requirements are increased e.g. cardiac problems etc. Similarly, poor growth. Both should always be carefully and systematically investigated

• Remember how complex feeding is
• The following are all required for the infants to be able to eat!
  • The infant’s fundamental anatomical structures of eating all working properly e.g. swallowing, chewing etc.
  • Their neurological system working well - including appetite sensitivity levels: there are 30 separate nerves and muscles involved in eating and swallowing
  • A gastrointestinal system working well and in good health, including digestion processes and bowel movement and possibly impact of microbiomes
  • Their cardio-respiratory working e.g. cough reflexes and linked gagging response, breathing and swallowing all coordinated and working effectively
  • Positive and healthy emotional and behavioural interactions around food, body, weight, shape, looks and relationships
  • Parents supporting and scaffolding it all by:
    • Sensitive and timely responses to feeding cues
    • The choice and timing or foods they make accessible to their children
    • Their own eating styles
    • Their own behaviour at mealtimes

• Some may require referral to a multidisciplinary feeding team, if a local one exists

Remember to take a full bio-psycho-social-developmental approach

• Some examples are given below of the support that can be put in place. Not all will be relevant for all children – selection of the most appropriate steps requires an understanding of what appears to be contributing to and maintaining the difficulty. NOTE: This list relates to situations where explanatory medical conditions have been ruled out or are appropriately managed alongside.
  • Explain the nutritional and developmental needs of the infant
  • Support the replacement of behaviours that have become problematic with developmentally appropriate eating behaviours; remember that achieving behavioural change requires consistency in approach over a period so the child is not confused and has time to learn
  • Explore ways to help reduce refusal or sensory based avoidance – this may include messy food play to help with sensitivity to touch and texture if present; offering very small amounts of new foods over at least 10 consecutive days to allow the child to learn to tolerate and accept new tastes or textures; or offering foods only slightly different from those already accepted to slowly build up confidence in trying new things.
  • Support parents to understand how their responses may inadvertently contribute to maintaining difficulties
  • Help parents know that eating with and together helps model positive food related behaviours
  • Advise parents on positive reinforcement messages about foods that they wish their infant to eat
  • Highlight and reinforce parents’ positive behaviours during feeding, such as eye contact, reciprocal vocalisation, praise, touch, setting clear time limits for meals, recognising satiety cues and accepting them, active praising of good mealtime behaviours, encourage appropriate independence e.g. with finger foods and self-feeding in later infancy/toddlerhood

• Benjasuwantep B, Chaithirayanon S, Eiamudomkan M. Feeding problems in healthy young children: prevalence, related factors and feeding practices. Pediatr Rep 2013;5(2):38-42. 
• Cooke L, Carnell S, Wardle J. Genetic and environmental influences on children’s food neophobia. Am J Clin Nutr 2007;86(2):428-433. View here
• Iwaniec D. Children Who Fail To Thrive: A Practice Guide. London: John Wiley & Sons, 2004.
• Lewinsohn P, Holm-Denoma JM, Gau JM et al. Problematic eating and feeding behaviours of 36 month old children. Int J Eat Disord 2005;38(3):208-219. 
• Matsuo K, Palmer JB. Anatomy and Physiology of Feeding and Swallowing – Normal and Abnormal. Phys Med Rehabil Clin N Am 2008;19(4):691-707. View abstract
• NICE Guideline NG75-Faltering growth: recognition and management of faltering growth in children. Published: 27 September 2017 
• Scaglioni S, Salvioni M, Galimberti C. Influence of parental attitudes in the development of children eating behaviour. Br J Nutr 2008;99 Suppl 1:S22-S25. 
• Southall A, Martin C, eds. Feeding Problems in Children: a Practical Guide. 2nd edn. Florida: CRC Press, 2010. View Description
• Swallowing - Refer to the following link for more information: The swallowing mechanism

4) Feeding Difficulties

Description: For wider general health audience (0-5 yrs olds)

This session describes the normal developmental progress of children from birth to five; from breast/bottle to eating independently and the difficulties encountered by parents during this developmental process.

Author(s):

Judy More 

The following Healthy Child Programme (RCPCH) sessions may be of further interest:

• 08_02 Infant Feeding Part 1: Breastfeeding (402-0042)
• 08_03 Infant Feeding Part 2: Formula Feeding (402-0008)
• 08_05 Feeding Preterm Infants in Neonatal Units (402-0043)
• 08_06 Healthy Eating for Toddlers: 1- 4 years (402-0045)
• 08_10 Common Nutritional Problems in Pre-schoolers (402-0049)

Growth and Nutrition

Description:

From pre-pregnancy through to adulthood, nutrition plays a vital role in healthy development. Focussing on the first five years of life, this module provides you with guidance on nutrition, feeding, weaning, growth and growth charts, the social context of food and obesity in the early years.

Assessing Infants and Mothers

Description:

This session is aimed at a universal audience and provides an overview of assessing infant and parent interactions including problems that indicate infant mental health problems.