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Caitlin Whyte: You are listening to Children's Health Checkup. I'm your host, Caitlin Whyte. Today, we are discussing feeding disorders in children with a panel of experts. Joining us today are Mary Finck, the clinical manager of Physical Medicine and Rehabilitation at Children's Health; Dr. Gaith Semrin, a pediatric gastroenterologist at Children's Health and an associate professor at UT Southwestern; as well as Dr. Laura Austin, a pediatric psychologist at Children's Health. Thank you all for being here today.

The feeding program at Children's Health is one of the largest US inpatient feeding programs and the only multidisciplinary program in Texas. For over 20 years, families have turned to the one of a kind feeding program at Our Children's House when their children struggled to eat. Today, we'll share what a feeding disorder is and how to tell if your child may have one. Let's start with you, Mary, what is a pediatric feeding disorder?

Mary Finck: Well, a pediatric feeding disorder, that's a relatively new definition or new disorder that they're defining. And basically, it's when there's an impaired oral intake that's not age-appropriate. And it's typically associated with a medical issue, a nutritional issue, a feeding skill issue and/or a psychosocial dysfunction. So it affects children, obviously pediatric, of those four domains-- it's affecting those four domains.

Caitlin Whyte: Dr. Austin, what are the symptoms of a feeding disorder? Are there different symptoms for various age groups?

Dr. Laura Austin: So feeding disorders do present a little bit differently at different ages, just because of the stage that the child is in at that time. We absolutely see feeding disorders beginning in early infancy. And the things that we're going to notice are things that are kind of obvious, when we have a baby who really just cannot consume enough to meet overall growth and weight trends or to maintain hydration

One big red flag that families don't always think about is something called sleep feeding or dream feeding. So a really big thing that we want to look for is when babies will only drink their bottles or breastfeed when they are sleepy or sleeping. That is a very big sign of feeding disorder in an infant. Another thing to keep in mind is that eating is actually a reflex until about three to four months of age. So sometimes we'll see babies who are eating fine until three or four months old. And then all of a sudden they start refusing and it can be very confusing because families feel like, "Well, they can eat. they were eating." But at that time, when eating becomes more voluntary, especially for babies who have sensory issues, we start to see a lot of increased food refusal.

From there, we would start to notice things like babies who are unwilling to upgrade to pureed textures. They might gag or choke when they're trying to swallow purees or just refuse to take them at all. Then we might have some babies who are willing to take baby foods, smooth purees, but once we get into little finger foods or other solids, that's when we start to see problems. They're really not able to upgrade. Either they gag when anything solid goes into their mouth or they'll start putting solids in, but they're not using good chewing skills.

And then once we get into toddlerhood and older, again, we're starting to look for issues with kids who are eating foods that are only a certain type of texture. And they may be able to eat softer foods, but they can't upgrade to the higher textured foods like meats, maybe they eat foods that are all one color or they avoid fruits and vegetables altogether, but they'll eat more carby kinds of foods like chips and crackers.

We definitely all along are looking for kids who are not growing and gaining well, but there's a lot more to it than that. So what I like to talk to families about is whether or not you're experiencing dysfunction in the physical or medical area in your family or socially. So obviously, if you have a child who is not growing or gaining weight, or maybe they are growing fine, but they're having nutritional deficits like anemia or other medical concerns, then you would want to have your child evaluated.

Sometimes we have kids who are so picky that it's just very disruptive to the family. So they refuse to eat anything but their exact foods prepared in a very specific way. So the family is unable to go out to restaurants. We have kids, especially as they get older, who refuse to eat in public. So they don't eat the foods that are served at a birthday party. They won't spend the night at a friend's house. So all of these things are ways that we may see feeding manifest across the ages.

In general, we're looking for both sensory and motor red flags. So motor red flags would be coughing or choking when you're trying to drink, not chewing well, avoiding higher textured foods, maybe spitting things out instead of swallowing them. And from a sensory perspective, we're really looking at things like gagging, either overstuffing their mouth, putting only very smooth foods in, but not being able to handle any texture. Sometimes when we see kids who eat best when they're very distracted, so when they're a baby, when they're sleeping or when they're older, maybe they have to watch a video to be able to eat. They have to be fed by somebody else. Those are all things that we might look for that might be a red flag for a feeding problem.

Caitlin Whyte: And what are the causes, Dr. Semrin, of pediatric feeding disorders?

Dr. Gaith Semrin: My part of the feeding program is to make sure that there is nothing medically that's causing the feeding difficulties. And typically, the way I will look at it, one is is it medical? Is it acid reflux or non-acidic reflux? And the other entity that can cause a medical problem is allergic esophagitis, which can lead to difficulty swallowing. The other important thing that we try to rule out all the time with feeding difficulties is there a possibility that it's something anatomical from the mouth all the way down to the esophagus that's leading to feeding difficulties. Obviously, the presentation like this can be choking. coughing, vomiting, gagging.

Caitlin Whyte: Now, Mary, are there different types of feeding disorders? If so, what are they?

Mary Finck: I mean, when you get down and start looking, um, breaking down the feeding disorder, as I think Laura mentioned, some of our kids have problems with oral sensory skills. And so that's a particular type where they don't like certain textures. They don't like the way certain foods taste. And so it's a sensory disorder. Their body just isn't processing the information normally. It's either heightened or underregistered. And so, you know, oral sensory skills.

Then there's the oral motor skills where kids don't have the adequate tongue control to manage the food in their mouth. They're not protecting their airway when they swallow for whatever reason. You know, the muscles aren't working appropriately for the swallow. So you've got the oral motor issues.

And then as Dr. Semrin alluded to, there are a lot of medical issues. You know, he alluded to all the GI, the gastro problems that could cause or be part of a feeding problem, but there's also kids that have respiratory compromises, because when you eat, you also breathe with a lot of the same structures, and so, you know, uh, respiratory can definitely add to that type of feeding disorder.

And then there are structural anomalies. Kids with craniofacial structural anomalies. You know, cleft palates are going to present its own problems with feeding. And then there are kids that have neurological impairments. And those typically are the kids that are going to have difficulty with swallowing and protecting their airway and they're going to have more aspiration.

And then finally, there's a whole group of kids that are on kind of neurodevelopmental disorders or kids on the autism spectrum. And then that's where those sensory disorders come into play.

Caitlin Whyte: Now, what should parents do, Dr. Austin, if they think their child may have a feeding disorder?

Dr. Laura Austin: I would say the first thing to do would be to talk to the pediatrician, just let them know the concerns that you have. So if you're really concerned, if it's something that's been going on for a while, I would really encourage your pediatrician just to ask for a referral for a feeding evaluation. And a good feeding evaluation needs to be interdisciplinary. But as we've been discussing, this is a multifactorial problem and a lot of different specialists are required to make sure that we address all the issues.

So to have an effective feeding evaluation, you need to have a physician involved, ideally, a gastroenterologist who's looking for any of the medical issues that could be impacting the child's willingness to eat certain foods. You want to have a feeding therapist, a speech therapist, who's going to be looking at strength, sensitivity, coordination and the mouth that are impacting food choices. An occupational therapist who will be looking at strength, sensitivity, coordination in the body and overall self-regulation to support eating. We need a dietician to look at overall growth and weight trends and nutrition. And then a psychologist who's going to be talking about any habits that may have formed around the eating process.

Caitlin Whyte: In wrapping up here, Dr. Semrin, can you share some information about the feeding program that Children's Health offers?

Dr. Gaith Semrin: Our program is one of the few in the country. It's an interdisciplinary program. We started this program three, four years ago. And it involves me as a pediatric gastroenterologist, Dr. Austin as a psychologist. We have a speech therapist involved, occupational therapist, and a dietician. The benefit of having all of these services at the same time is you get everything that you need in one clinic visit, which it covers everything for the family. And from there, the evaluation will start. And, typically all of these patients when they come for the feeding evaluation, we discuss these patients and we decide what kind of diagnostic testing they need. If they need a referral like Mary was saying, you know, Pulmonary. Sometimes we refer to the Pulmonary, we refer to ENT. It's one big step into getting appropriate feeding therapy.

Dr. Laura Austin: Well, I would just add that, you know, as Dr. Semrin alluded, we do our team assessment and then we make those referrals. And then at Our Children's House, that's where we have the intensive programs, the 30-day inpatient program and then our four-week day patient program, which are intensive programs. And in addition to that, then our kids often then go out to our outpatient therapy sites to continue their process of getting their feeding skills up to par. So we have lots of options and that initial team assessment kind of helps guide where the family kind of is at and what treatment they'll go through.

Caitlin Whyte: Well, thank you all so much for joining us today and for your expertise. And thank you, of course, for listening to this episode of Children's Health Checkup. You can find more information at Childrens.com. I'm Caitlin Whyte. Stay well.