The goal of all therapy is directed toward allowing parents to safely feed their children in a develop-mentally appropriate manner. The physician in the treatment team must ensure that all appropriate diagnostic studies have been performed to determine if an underlying medical condition has predisposed a child to developing an unusual feeding pattern. This includes appropriate utilization of consultants and diagnostic modalities (Table 4). Once these studies have been performed, the physician must coordinate all the resources and direct care so that feeding therapy may proceed with minimal risk to the patient—keeping the child safe from aspiration and other complications.
The initial, and perhaps most important, part of any therapeutic approach to introducing or increasing oral food intake is to establish the safety of eating as well as the types and textures of food the child can consume most efficiently. Approaches to therapy are often described as nutritive or nonnutri-tive. Nonnutritive oral stimulation is performed to decrease hypersensitivity, facilitate management of secretions, establish or retrain the swallowing mechanism, maintain coordination of breathing and swallowing, and develop oral movement for sound production and communication.
Objectives for a nutritive approach include increasing oral intake, advancing food texture, tran-sitioning to utensil use, and improvement of self-feeding. Oral motor techniques to improve muscle tone and postural control as a foundation for feeding and swallowing are largely based on a neuro-developmental framework. The use of adaptive seating systems is a key component to feeding a child with physical disabilities that require external devices to provide head, neck, and trunk support. Attention must be paid to how positioning affects the feeding process because a change in head and neck posture and oral motor structures may affect oral motor control.
Once airway safety, positioning, and sensitivity have been controlled, a variety of treatment approaches have been suggested for children with pediatric feeding disorders. These range from individual child psychotherapy to interactional therapy between child and caregiver. However, the most widely employed treatments for feeding disorders are behavioral interventions usually included within an interdisciplinary team approach that also addresses physiology, oral motor functioning, parent-child interactions, and community or social support.
Behavioral interventions for pediatric feeding disorders are the most common modality of therapy and are often a mixture of antecedent and consequence-based treatment packages. Antecedent interventions include the establishment of a systematic feeding routine (i.e., the same time and place to eat), reducing or increasing the level of texture of food
(i.e., puree vs chopped fine), and presenting a preferred food along with a nonpreferred food. Consequence-based treatments include rewarding appropriate eating behavior and/or ignoring (i.e., escape extinction) or punishing food refusal behavior. Thus, if a child accepts a bite, he or she is rewarded with attention or an arbitrary reinforcer, such as a toy or music. If the child engages in food refusal behavior, such as batting at the spoon or turning his or her head away from the food, the consequence is to ignore or extinguish the food refusal behavior and continue to present the bite to the child until it is accepted. If the child continues to refuse by expelling the food, this refusal behavior is ignored/extinguished by re-presenting the expelled bite of food to the child. In some cases, a child refuses food by holding the bite of food in his or her mouth. This form of food refusal behavior can also be ignored or extinguished by moving or redistributing the food from between the child's cheek and teeth onto the tongue, where it is more likely to be swallowed. Finally, training the parents in the use of the various feeding techniques is critical in maintaining long-term treatment gains. Skill-based parent training involving step-by-step criteria-based training has been shown to be superior to didactic methodology. Parent training, including instruction, discussion, handouts, role-playing, feedback, and the practice of techniques with a trained clinician, can result in increased parent treatment integrity.
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