Children with feeding tubes benefit most from multidisciplinary care

Nov. 11, 2016

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Holly Korschun
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William Sharp

A new study finds positive outcomes associated with intensive multidisciplinary treatment for children with pediatric feeding disorder who may require a feeding tube to support growth and development. The results are reported in the early edition of The Journal of Pediatrics, from researchers at the Marcus Autism Center, Children's Healthcare of Atlanta and Emory University School of Medicine.

The meta-analysis of published work on feeding treatment methods in the United States and Europe showed that, on average, dependence on tube feeding was eliminated in 71 percent of children at discharge from multidisciplinary day hospital and inpatient treatment programs. Treatment gains endured over time, with 80 percent of patients tube-free at follow-up. Treatment was also associated with increased oral intake, improved mealtime behaviors and reduced caregiver stress.

"Our findings suggest that intensive multidisciplinary intervention holds clear benefit for children and families impacted by pediatric feeding disorders," says co-author William Sharp, PhD, director of the Pediatric Feeding Disorders Program at Marcus Autism Center and assistant professor in the Department of Pediatrics at Emory University School of Medicine. "Our hope is that this study raises awareness regarding the significant daily struggle too many families face surrounding mealtimes."

While many toddlers and early school-age children experience some mealtime difficulties, a subset of children – many with complex medical histories –refuse most or all food presented during meals. Feeding problems of this magnitude are referred to as pediatric feeding disorders due to their chronic and more severe course, often involving the complex interaction among biological, psychological and social factors. Pediatric feeding disorders lead to significant disruptions in a child's nutritional and caloric intake – which may manifest as faltering growth, significant nutritional deficiencies and/or reliance on a feeding tube to meet energy needs.

Estimates suggest this level of severe feeding problem affects as many as five percent of children, representing a common source of stress and anxiety for caregivers. Children with chronic medical concerns, such as respiratory, cardiac or gastrointestinal problems, face an even greater risk of developing a significant feeding concern. As many as 70 percent of children with complex medical histories experience chronic feeding difficulties. This study is the first meta-analysis of all published, peer-reviewed research focusing on children receiving intensive multidisciplinary intervention at day hospital and inpatient treatment programs.

"In many cases, children learn to avoid food by engaging in significant disruptive behaviors – such as tantrums and tearful protests – aimed at avoiding contact with food," says Sharp. "These behaviors often arise after food is consistently paired with medical problems that cause pain or nausea. Understandably, caregivers may remove food in response to intense refusal behaviors and increasingly rely on artificial supports – such as the use of a feeding tube – to support growth and development. A primary goal of intervention is to help children develop a positive relationship with food while re-establishing a constructive parent-child interaction during meals."

A multidisciplinary approach, Sharp adds, also provides important safeguards when introducing food to children with little or no experience consuming food.
In addition to providing support for multidisciplinary intervention, recommendations from the study include: 1) active participation of caregivers in the treatment process – ideally with structured training procedures to support generalization into the home; 2) a formal discharge plan that involves regular outpatient follow-up to support families in maintaining and expanding upon treatment gains; and 3) use of a behavioral approach to structure meals and address mealtime difficulties (e.g., tantrums; food refusal) that prohibit consumption. The authors suggest that advancement in this field will require improved outcome measures (e.g., more consistent reporting of follow-up data); providing increased specificity regarding children receiving intervention.

"Our study also provides important guidance for enhancing the standard of care while identifying important key areas to improve the evidence base," says co-author Barbara McElhanon, MD, pediatric gastroenterologist at Children's Healthcare of Atlanta and assistant professor in the Department of Pediatrics at Emory University School of Medicine.

"At a minimum, treatment of pediatric feeding disorders should involve a professional team that includes psychology, medicine, nutrition and speech-language pathology or occupational therapy during treatment. This allows intervention to be designed with consideration to the unique combination of behavioral, organic, dietary and oral-motor concerns often ubiquitous in pediatric feeding disorders."

McElhanon also noted that "better documentation of specific medical diagnoses and types of behaviors most impeding progress toward oral intake will allow the field to better predict patients at risk for needing this type of intervention as well as those who attain greatest results."



Marcus Autism Center
Marcus Autism Center is a not-for-profit organization and an affiliate of Children's Healthcare of Atlanta that treats more than 5,700 children with autism and related disorders a year. As one of the largest autism centers in the U.S. and one of only three National Institutes of Health Autism Centers of Excellence, Marcus Autism Center offers families access to the latest research, comprehensive evaluations and intensive behavior treatments. With the help of research grants, community support and government funding, Marcus Autism Center aims to maximize the potential of children with autism today and transform the very nature of autism for future generations. Visit marcus.org for more information.

Children's Healthcare of Atlanta
Children's Healthcare of Atlanta, a not-for-profit organization, is dedicated to making kids better today and healthier tomorrow. Our specialized care helps children get better faster and live healthier lives. Managing more than 850,000 patient visits annually at three hospitals and 24 neighborhood locations, Children's is the largest healthcare provider for children in Georgia and one of the largest pediatric clinical care providers in the country. Children's offers access to more than 60 pediatric specialties and programs and is ranked among the top children's hospitals in the country by U.S.News & World Report. With generous philanthropic and volunteer support, Children's has impacted the lives of children in Georgia, the United States and throughout the world. Visit www.choa.org for more information.

Emory University School of Medicine Department of Pediatrics
Faculty-physicians in the Emory Department of Pediatrics provide the highest quality state-of-the-art clinical care, with a commitment to improving treatment for children through scientific research as well as training the next generation of leaders in pediatrics.