Chapter 3

Pediatric feeding disorders may be defined as problems with the developmentally appropriate intake of food. This broad category includes difficulties that objectively result in nutritional or medical risk (e.g., refusal of dietary protein leading to protein energy malnutrition), as well as those perceived as problematic by the child’s family that result in stressful mealtimes without objective medical consequence. These do not include eating disorders (i.e., anorexia and bulimia) or obesity. Pediatric feeding disorders may be associated with medical disease (often gastrointestinal), malnutrition or failure to gain weight, developmental delays affecting skill acquisition, and interpersonal disorders. Feeding problems have been characterized simply along axes of ability and desire,1 by biophysical etiology,2 or by criteria that focus on interpersonal relationships.3 Children with feeding disorders are best assessed and managed by interdisciplinary teams that address all sides of the problem, given that distinct facets of the disorder require individual expert assessment and intervention.

Feeding disorders occur in children with an incidence as high as 25% in normal children,4 with a higher incidence in those with neurologic disability.5–7 While children with feeding disorders require evaluation by a gastroenterologist due to the high coincidence with gastrointestinal disorders,1,8 skill acquisition and behavioral components are often present and require behavioral evaluation and management beyond what a gastroenterologist may provide.9

An individual patient’s feeding disorder is unique. Environmental and family social-dynamic issues are different for each individual with the same underlying pathology (e.g. hypoplastic left heart syndrome). Furthermore, feeding, the airway, and the upper gastrointestinal tract exist in a reciprocal relationship system where problems with one of these components may produce problems in the others (Figure 3–1); such may be seen in an infant with pulmonary disease, where cough and tachypnea may aggravate reflux and feeding problems, respectively. Additionally, the central nervous system, with respect both to basic motor and sensory function and to its higher order processes such as personality development, exists in the background of this relationship and can both contribute to, and be affected by, problems of the airway, upper GI tract, and feeding ability (Figure 3–1).

###### FIGURE 3–1

Interplay between airway, gastrointestinal tract, and feeding ability. Feeding ability has a reciprocal relationship with the airway and the upper gastrointestinal tract, where one affects the others. In the background, the central nervous plays a role, in regard to both the motor and sensory function and the higher order personality and social dynamic issues.

Achievement of normal feeding is a function of skill acquisition as permitted by the child’s internal and external environments. The progression of feeding that occurs over infancy is governed by neuromuscular and anatomic maturation that limit the manner of feeding at any specific age.10 A newborn is limited by neurologic immaturity and unique anatomy that helps isolate the oral cavity ...

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