1 EVIDENCE-BASED FEEDING STRATEGIES FOR CHILDREN WITH SPECIAL NEEDS Sandee Dunbar DPA, OTR/L, FAOTA Professor – Occupational Therapy Assistant Dean of Professional Development Nova Southeastern University – Ft. Lauderdale, Florida Provider Disclaimer • Allied Health Education and the presenter of this webinar do not have any financial or other associations with the manufacturers of any products or suppliers of commercial services that may be discussed or displayed in this presentation. • There was no commercial support for this presentation. • The views expressed in this presentation are the views and opinions of the presenter. • Participants must use discretion when using the information contained in this presentation. Objectives ■ Identify key evidence that supports therapeutic feeding intervention ■ Apply evidence-based literature to case examples ■ Examine various strategies for improved feeding among children ■ Recognize the significance of family-centered care approaches for feeding intervention
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EVIDENCE-BASED FEEDING STRATEGIES FOR CHILDREN WITH
SPECIAL NEEDSSandee Dunbar DPA, OTR/L, FAOTA
Professor – Occupational Therapy
Assistant Dean of Professional Development
Nova Southeastern University – Ft. Lauderdale, Florida
Provider Disclaimer
• Allied Health Education and the presenter of this
webinar do not have any financial or other associations
with the manufacturers of any products or suppliers of commercial services that may be discussed or
displayed in this presentation.
• There was no commercial support for this presentation.
• The views expressed in this presentation are the views and opinions of the presenter.
• Participants must use discretion when using the
information contained in this presentation.
Objectives
■ Identify key evidence that supports therapeutic feeding intervention
■ Apply evidence-based literature to case examples
■ Examine various strategies for improved feeding among children
■ Recognize the significance of family-centered care
approaches for feeding intervention
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Is Feeding an Issue?
■ At least 5% of infants and young children have feeding issues
■ Children with developmental disabilities have an increased risk (40-70%)
■ Feeding, eating and swallowing difficulties are caused by multiple underlying factors.
■ Represents one of the most frequent concerns in pediatric settings
Sharp et al (2017)
Definitions
■ Feeding – process of setting up, arranging, and bringing food from a plate or mouth
■ Eating – ability to keep and manipulate food in mouth, then swallow
■ Swallow – food or fluid moving through mouth, then pharynx, then esophagus, then stomach
Feeding Project Example■ My own question – How can we move children from tube to
oral feeding successfully? What are the outcomes of a multidisciplinary feeding program?
■ Relevant evidence – Articles related to tube to oral feeding programs (Blackmon and Nelson) – Specific steps (introduce/prepare, compliance, cooperation, parent ed)
■ Evaluation – compare/contrast to others, what fit with OT philosophy
■ Implement – intense inpatient program for 2-3 weeks with MD, Dietician, OTs
■ Evaluate – 3/4 children had significant improvements in oral intake
Dunbar, Jarvis and Breyer, ‘91
Treatment Notes into Graphs -
Single Subject Research
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Outline
■ Autism
■ Developmental Delays
■ Prematurity
■ Sensory Processing Issues
■ Models for Eval and Treatment
Family Centered Care
Person Environment Occupation
■ Advancing the Evidence Approach
Autism
■ Complex disorder with varying levels of severity of symptoms
■ Characterized by impairments in social interaction, communication and activity participation (APA, 2013)
■ Diagnosis typically in the preschool years (CDC, 2014), but behaviors may indicate differences much earlier
■ Children with autism often display issues related to feeding (Smith, 2016)
Autism and Feeding
Challenges■ Up to 89% with feeding difficulties
■ Restricted variety in diets
■ Strong food preferences
■ Aversion to certain textures
■ Excessive mouthing of objects
■ Extreme attachment to routines with resistance to change in routines
■ Repetitive movements
■ Food neophobia
■ Restrictive interests
■ Difficulty with sensory processing
(Smith, 2016; Marshall, 2014)
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Feeding Video – Child with Autism and Oral Aversion
■ Cognitive delays – Difficult to understand mealtime concepts, instructions etc.
■ Motor delays and differences – CP, exaggerated reflexes, limited use of UEs to assist with feeding, poor postural control, poor lip closure, low or high tone
■ Synactive Theory – Autonomic, Motor, State, Attention, Self-Regulation differences
■ Suck/swallow/breathe coordination – 34 weeks plus
■ Low tone
■ Sensory issues
■ Prolonged intubation and other negative experiences
■ Need for adaptive devices
■ Need for parental collaboration and understanding
Synactive Theory of Neurobehavioral Development
H. Als■ Autonomic - respiration, heart rate, skin color
■ Motor - tone, posture, movement
■ State - level of arousal
■ Attention-interaction – efforts at engaging
■ Self regulation - ability to achieve, maintain, or regain balance in each subsystem.
Feeding the Premature Infant
■ Take breaks for babies who do not have an established suck-swallow-breathe pattern yet. You can help to develop with strategic breaks.
■ Be intentional about integrating the family
■ Listen/collaborate with the nurses, dieticians
■ Posture is essential
■ Monitor the influence of the environment
■ Jaw control, cheek stroking
■ Tongue stroking
■ Massage for high tone, tap lightly for low tone
■ Supplemental oxygen as needed for those how have respiratory issues
■ Caution – Aspiration – Swallow studies will assist for ensuring safest feeding
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Feeding the Premature Infant
Intervention continued■ Non-nutritive sucking
■ Tactile input around face
■ Nuk brush for older, more regulated babies, to stimulate tongue mobility
■ Try various nipples, based on suck strength and mouth size
■ Watch for signs of previous subsystems to assess readiness for feeding. If still in autonomic, then not ready.
So many choices
The Feeding Evidence -Prematurity
Chorna et al Pediatrics, 2014
■ Vanderbilt Children’s Hospital in Tennessee
■ 94 premature infants at 34-36 weeks, randomly selected in experimental and control group
■ Experimental group – 5 days for 15 minutes
■ Sucking on pacifier (non-nutritive sucking)- resulted in hearing recorded mothers voice
■ Tubes out one week earlier, increased intake and faster feeding rate
■ Way to engage families for family centered developmental care
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Oral Readiness in Premature Babies
Harding et al (2016)
Assessed 15 nurses on their ability to assess oral readiness in their study. None of the nurses indicated parental teaching regarding states or use of formal assessments.
Howe & Wang (2013) – Systematic Review with positive results – 1. Behavioral, 2. Parental training, 3. Physiological interventions.
Sigan et al; (2013) – Parental training- 81 children randomized into training and non-training groups. Training group significantly improved on feeding scores.
Other studies have moderate to strong support. No consensus on best form of parental training. Combined with tx seems more effective.
Key Literature
Howe & Wang (2013) Systematic Review – 21 studies
■ Physiological interventions
■ Breathing, sucking, swallowing
■ Physical and sensory aspects
Results – Prep Activities (non nutritive sucking) decreases hospital stays, improves breastfeeding, but not weight gain.
Feeding Skill Training – shortens tube feeding time, improves quality of oral feeding, increases oral intake
Sensory Aspects of Feeding
■ Tactile Defensiveness – observable aversive or negative behavioral responses to certain types of touch stimuli that most people find to be non-painful. Inability to interpret/process touch in a meaningful way
■ Think of skin as a receptive organ with multiple receptors
(Murray, Fisher and Bundy, 1991 – based on Jean Ayres original work in Sensory Integration)
■ Professional involvement (membership, conferences etc.)
■ Dialogue with peers
■ Learn something new every day!
Case
Matthew is a 5 year old with a diagnosis of developmental delay, functioning around a 2-3 year old level for many skills. You receive a feeding referral, due to his very limited food diet. During your general assessment, you observe that he is tactilely defensive when you present different toys for him to play with. He withdraws when objects aren’t smooth. You also observe with his snacks that he barely wants to touch them on the tray. When you observe his general play, while talking to his parents, Matthew has poor postural control and doesn’t maintain anti-gravity postures for more than a couple seconds on the gym swing. What are three areas of intervention that you would prioritize for Matthew?
1.
2.
3.
Case continued
Describe 3 specific treatment strategies that you would use with Matthew during the first month of therapy. Be specific for your area (PT, OT, ST etc.)
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Summary
Creating intentionality for being an evidence-based practitioner is essential. As therapists, we are obligated to engage in best practices for optimal therapeutic gains. Stay updated, have conversations, record your success and read, read, read. Feeding is a very critical area of need among so many children with and without specific disabilities. Use the very available opportunities to get involved and make a difference for increased participation in what can be one of life’s most enjoyable occupations!
ReferencesBrown, C. (2017). The evidence based practitioner. Philadelphia, PA: F.A. Davis
Bundy, A.C., Lane, S J., & Murray. (2002). Sensory Integration: Theory and Practice (2nd
ed). Philadelphia, PA: F.A. Davis
Chorna, O. D., Slaughter, J. C. & Wang, L. et al. (2014). A pacifier-activated music player with
mother’s voice improves oral feeding in preterm infants. Pediatrics. 133:462-68.
Clay, A.M. & Parsh, B. (2016). Patient and family centered care: It’s not just for pediatric
anymore. American Medical Association Journal of Ethics, 18, 40-44. doi: 10.1001/journalofethics.2016.18.01.medu3-1601.
Dunbar, S.B., Jarvis, A.H., Breyer, M. (1991). The transition from nonoral to oral feeding
in children, American Journal of Occupational Therapy, 45, 402-408.
Harding, C., Frank, L., Botting, N., & Hilari, K. (2015). Assessment and management of infant feeding.
Infant, 11, 85-89.
Heffernan, J., Gustafson, K., Packard, S. & Toole, C. (2014). What works: All in the family –
How a family advisory council promotes family-centered care in the NICU. American
Nurse Today, 9.
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References Cont.Howe, T., & Wang, T. (2013). Children with feeding difficulties ages birth- 5 years.
American Journal Occupational Therapy, 67, 405-412.
Law, M. & MacDermid, J. (2002). Evidence-based rehabilitation. Thorofare, New Jersey: Slack Inc.
Marshall, J., Ware, R., Ziviani, J., Hill, R.J., & Dodrill, P. (2014). Efficacy of interventions to improve feeding difficulties in children with autism spectrum disorders: A systematic review and meta-analysis. Child: Care, Health and Development, 41, 278-302 doi:10.1111/cch.12157.
Sharp, W.G., Volkert, V.M., Scahil, L., McCracken, C.E., McElhanon, B. (2017). A systematic review and meta-analysis of intensive multidisciplinary intervention for pediatric feeding disorder: How standard is the standard of care? Journal of Pediatrics, 181, 116-124.
Smith, J.A. (2016). Sensory processing as a predictor of feeding: Eating behaviors in children with autism spectrum disorder. The Open Journal of Occupational Therapy, 4 dx.doi.org/10.15453/2168-6408.1197.