Expert Interview: What is a Feeding Disorder and When Should a Parent Worry?

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Have you ever wondered if your child’s picky eating is “normal?” If so, you’re not alone. The next couple posts will be a series from an interview with Dr. Ramasamy Manikam, PhD, a clinical psychologist and top expert on feeding disorders with over 20 years of practice. Dr. Manikam is the Director of the Center for Pediatric Feeding Disorders at St. Mary’s Healthcare System for Children.
 
Dr. Manikam has been kind enough to answer some questions for me. The first post will cover some background on what feeding therapy is and what conditions are most often related to a feeding disorder. The posts will also cover when a parent should — and shouldn’t — be concerned about a food issue. 

The second post, for those of us who are blessed with kids who are just “picky eaters,” Dr. Manikam shares some of his perspective as a medical professional as well as a parent and grandparent on some of our “common” food concerns with our kids. 

What is a Feeding Disorder and When Should a Parent Worry?

A genuine feeding disorder can be devastating. The symptoms, causes and actual behaviors of a food disorder vary. However, one constant is that dealing with a child’s food disorder can be especially hard for parents who blame themselves for the disorder.

Some parents I’ve talked with have children with eating habits that cause both the parents and children in these situations to dread daily mealtimes. Their children may gag when eating a disliked food or have another type of adverse reaction to some foods. Situations like this feel anything but "normal." Where is the line between “picky” and when there may be an actual disorder? When should a parent seek medical help?

“The index I would use is the health, growth, and development of the child in relation to the food intake,” says Dr. Manikam. “Some children ‘pick’ during meals but then graze all day long and are healthy.  If the child is not receiving balanced nutrients with sufficient intake for proper growth and development then it becomes a disorder that requires medical evaluation and feeding therapy if warranted.”

Growth and development issues are gradual symptoms, but there may be short-term indications of a food issue as well.

“Weight loss, illness, allergy, crying during meals due to pain, etc. should be a call for medical evaluation to determine the nature of the problem,” says Dr. Manikam.

Other symptoms that can be indicators of an underlying medical problem include; difficulty with swallowing, vomiting during and after meals, choking and gagging during meals, poor appetite, and crying while holding the stomach.

“[These signs] can be indicators of an underlying medical problem that should be evaluated by trained and experienced medical professionals,” he continues.

What Causes Feeding Disorders?

The causes of a feeding disorder are most often a medical condition. Less commonly, a feeding disorder develops from inappropriate interactions with a parent. Feeding disorders affect approximately 25-40 percent of children from newborns to adolescents, a statistic that seems alarmingly high.

“These percentages are averages,” explains Dr. Malikam.  “The percentage varies depending on the definition of what a ‘feeding disorder’ is, the time of study, and the population and even the country where the study is conducted. The percentage can be as high as 80% for special needs children with developmental disabilities. I consider an individual to have a ‘feeding disorder’ when his or her health is adversely affected.”

Feeding disorders are more common for children who are born prematurely, or had a low birth weight as well. According to Dr. Manikam, other physical causes of a feeding disorder, eating aversion or failure to thrive, include:

• Celiac Disease
• Down Syndrome
• Prader-Willi Syndrome
• Heart defects
• Breathing difficulties
• Oral-facial malformations such as cleft palate
• Other Syndromes (e.g., Stickler, Cri du chat, Pierre Robin, Russell-Silver, Fetal Alcohol, Treacher-Collins, Smith-Lemli-Opitz)
• Food allergies, including milk allergy, and lactose intolerance.

Other physical causes may include gastroesophageal reflux (GERD) and Crohn’s disease. Sensory disorders, autism, and ADHD can sometimes be linked to food issues.

Only about one in ten food disorders are caused from behavior issues. These food disorders can be caused by negative interaction with a parent.

Examples Dr. Manikam provided include a parent that has low tolerance; has a poor understanding of developmental norms; or has been affected by the knowledge that other children were doing better or eating table foods earlier. Other negative interactions can include a parent who cannot read his or her child’s hunger cues, or who forces food on a child when the child is not hungry.

Parental aggression or anger during feeding times, a lack of nurturing, and parental apathy are other negative parental interactions that can lead to a feeding disorder in children.

How Are True Feeding Disorders Treated?
Treatment for a true feeding disorder can require an expert such as a feeding therapist. Dr. Manikam is a clinical psychologist, but feeding therapists may have different backgrounds. Feeding therapy, in some cases, requires a team of individuals with different specialties.

“Feeding therapists are professionals trained in the assessment and treatment of individuals with feeding problems. Generally, Speech Pathologists, Occupational Therapists, and Behavioral Psychologists provide feeding therapy services to individual with feeding problems,” says Dr. Manikam.

Feeding therapy team members may sometimes include a nutritionist, or a social worker or other medical professionals. The therapy process may focus on the patient only, or the parent, or both. This article on Dr. Manikam from the New York Times, has some specific examples of patient experiences.

“Depending on the patient’s age and developmental levels and the nature of feeding problems professionals might work with the patient and/or with the guardian. For example, therapists might work with an adolescent who develops ‘anxiety’ or ‘post-traumatic anxiety disorder’ due to a choking incident.  In the case of younger children, therapists might work with the child and train the guardians when an effective intervention is established. In some cases, the therapist might train the guardian to implement the intervention strategies.  The model of service delivery depends on the information obtained from the assessment,” says Dr. Manikam.

Many thanks to Dr. Manikam, Director of the Center for Pediatric Feeding Disorders at St. Mary’s Healthcare System for Children, for his insights shared here. In the next post, he shares his experience and perspective for all parents, including how to deal with “picky” eating issues such as color, texture, food jags and other common food concerns.