Medical Overview

As discussed previously, pediatric feeding disorders often accompany general medical conditions. For example, feeding disorders are often associated with digestive problems and may suggest a gastrointestinal disorder (Manikam and Perman 2000). Gastrointestinal difficulties can impact feeding on a number of levels, including the intake, retention, digestion, absorption, and elimination of food (Man-ikam and Perman 2000). Ultimately, discomfort and decreased appetite related to digestive problems can lead to food refusal and escape behaviors, which in turn may lead to more severe feeding issues. For example, children with gastroesophageal reflux disease may experience pain or discomfort during or after feedings as a result of esophagitis. This discomfort, coupled with an interruption of normal oral feeding as a result of surgical treatment to address related reflux, increases the likelihood of feeding problems (Linscheid et al. 2003; Mathisen et al. 1999).

Prolonged difficulty in feeding may have significant negative developmental and behavioral outcomes. More specifically, these disorders can lead to growth retardation and may have a negative impact on the body at the organ level, depending on the child's caloric and nutrient intake. Furthermore, infants with feeding problems may be at increased risk of difficulties with language development, reading skills, social maturity, and behavioral issues and may

Age (months)

Foods introduced

Developmental milestones

Sensitive or critical periods

Stages of socioemotional development

Birth

0-4 months: liquids

0-4 months: sucking reflex; head control

4-6 months: pureed foods

4-5 months: tongue control; reaching when hungry; passive feeding; sitting balance

4-6 months: introduction of new tastes (sensitive)

6-9 months: pureed foods; soft chewable foods

9-12 months: ground solids; mashed, lumpy, pureed foods

12-18 months: all textured foods (e.g., smooth, crunchy); table foods

18-24 months: increased variety of chewable foods (e.g., meat, raw fruit, vegetables)

24+ months: introduction of tougher solid foods

6-8 months: hand transfer; hand-to-mouth feeding; beginning of spoon feedings

6-7 months: development of chewing (critical); introduction and acceptance of new textured foods (sensitive)

8-10 months: crawling; use of hands to take foods; eating of finger foods

10-12 months: beginning of walking; chewing of firmer foods; beginning of finger feeding

12-18 months: tongue lateraliza-tion; emergence of rotary chewing; scooping of foods; weaning from formula and breast feeding

18-24 months: rotary chewing; internal jaw stability with cup drinking

24+ months: total self-feeding; independent cup drinking

0-2 months: homeostasis (e.g., irregular feeding patterns, cries to cue hunger)

2-6 months: attachment (e.g., exerts control over nipple feeding, increased regularity in feeding patterns, socialization during feedings)

6-36 months: separation/individu-ation (e.g., establishment of food preferences, child loses interest in food quickly, noncompliant behaviors with feeding and other situations)

Figure 11-1. Development of normal feeding

Source. Adapted from Arvedson 1997; Delaney and Arvedson 2008; Stevenson and Allaire 1991.

cn have lower cognitive abilities later in life (Heffer and Kelly 1994). For example, some early studies suggested that children with severe feeding problems have cognitive delays compared with their healthy counterparts and are more likely to require special education services (Dowdney et al. 1987; Drotar and Sturm 1988). More recent studies, however, found no significant impact on cognitive outcomes of children with failure to thrive after controlling for socioeconomic status (Rudolf and Logan 2005). Moreover, in their systematic review of failure to thrive, Rudolf and Logan (2005) argued that the identified IQ differences found between children with a history of failure to thrive and their healthy counterparts (i.e., ~3 points) are of questionable clinical significance. Given the heterogeneity of pe-diatric feeding difficulties, these outcomes may be dependent on the classification schemes used to categorize infants and toddlers with feeding issues.

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