Reporting treatment processes and outcomes for paediatric feeding disorders: A current view of the literature

Figures & data

Figure 1. Search process.

Figure 2. Surveyed components of the literature.

University settings were coded under “clinic”. ID = interdisciplinary, defined as the involvement of at least one other discipline during evaluation or treatment.

Table 1. Interdisciplinary roles and expertise.

Physician/Medical* (Gastroenterologist, Immunologist/Allergist) (see Yeung et al., 2015)

Evaluate medical stability for treatment and provide clearance or required further evaluation prior to treatment. Expertise required in testing, treatment and monitoring for: Timing of endoscopy coordinated with reflux medications and elimination diets/food exposure Anatomical throat and swallowing problems (Laud et al., 2009; Vaz et al., 2012; Wilkins et al., 2011) Emptying, motility and absorption problems and conditions (Vaz et al., 2012) Vomiting and reflux (Levin et al., 2014; Wilkins et al., 2011) Food allergy, eosinophilic conditions (including repeat testing schedules) (Alaimo et al., 2018; Gonzalez et al., 2013) Nutritional deficiencies (e.g., scurvy, pellagra, rickets, xerophthalmia), malnutrition, dehydration and dental health Constipation, diarrhea, bowel management regimens, hydration, diet (Peterson et al., 2015) Medications and any side effects (e.g., appetite, nausea) impacting feeding Conditions such as H. pylori, stomach ulcers, gastritis, gastroenteritis (Laud et al., 2009)

Dietitian

Evaluate and recommend intervention for nutritional deficiencies (Laud et al., 2009; Peterson et al., 2019) and conditions such as malnutrition and dehydration Recommend appropriate food types to use in treatment (Addison et al., 2012; Bachmeyer et al., 2019; Seiverling et al., 2018; Sharp et al., 2010, 2012) After food allergy testing, advise foods/liquids allowed or eliminated and train caregivers on label reading. For children who have not consumed solids or with food allergy or intolerance, inform plan for novel food introduction including order of foods to introduce, amount and time frame (Rivas et al., 2010; Sharp et al., 2017). Recommend formula types and adjustments for food allergies, food intolerances and eosinophilic conditions. Adjust recommendations with required repeat testing and reintroduction schedules/amounts. Coordinate and adjust dietary recommendations during treatment for blood sugar conditions, celiac disease, phenylketonuria, reflux, vomiting, constipation, diarrhea and emptying, motility, and absorption problems and conditions. Provide recommendations (e.g., types, schedule) for medication and supplement refusal and side effects impacting feeding; impact of liquid (e.g., milk, formula, baby bottle) dependence on dental health, constipation and absorption (e.g., iron) Monitor growth (Williams et al., 2019) Adjust tube calories and fluids as oral intake increases (Sharp et al., 2017; Taylor et al., 2017)

Speech Pathologist

Conduct swallow studies (prior to/during treatment), advise related recommendations (Sharp et al., 2010, 2015; Wilkins et al., 2011) If swallow study preparation is required, recommend solid textures and liquid consistencies and volume to reach criteria (Girolami et al., 2007) Provide recommendations/advise testing or treatments for anatomical oral motor and swallowing conditions (Sharp et al., 2010) Recommend consistencies for liquids, e.g., swallowing safety (Wilkins et al., 2011), textures or bolus sizes (Bachmeyer et al., 2009; Kadey et al., 2013; Seiverling et al., 2018; Sharp et al., 2012; Wilkins et al., 2014) Recommend modifications to reduce aspiration risk (Bachmeyer et al., 2013; Sharp et al., 2017; Vaz et al., 2012) Evaluate oral motor skills, e.g., chewing (Alaimo et al., 2018; Peterson et al., 2016; Vaz et al., 2011); therapy alongside behaviour-analytic sessions (Laud et al., 2009; Taylor et al., 2017)

Behaviour Analyst

Conduct a comprehensive thorough intake evaluation (including all areas listed above) Record review from other disciplines, tests and treatment recommendations, comprehensive review of systems* Caregiver forms and interview Direct observation and assessment of skills and mealtimes Determine when above evaluation has cleared the child for appropriate and safe treatment Determine if child may need treatment in a specialised behaviour-analytic hospital/medical school setting such as for intensive medical oversight, for severe problem behaviour or need for timely clinical outcome (e.g., prevent G-tube placement Rubio et al., 2015) Determine if the case and circumstances are in line with the behaviour-analyst’s level of competence or require referral. Seek supervision and consultation as needed. Determine the individualised treatment intensity and resources needed (e.g., adaptive and safety equipment, seating, staff, funding) Determine consultation involvement needed from other disciplines before and during treatment. Monitor for symptoms requiring referral to other disciplines. Determine support needed for caregivers before, during and after treatment. Provide the support and/or refer to others. Determine what foods, textures and bolus sizes to start treatment with, and progress to, in what timeframe Perform systematic, data-based, individualised treatment evaluations and progress monitoring Prioritise goals over time (e.g., based on nutrition, hydration and growth; when to target certain textures or feeding/drinking skills) Perform intensive caregiver training, generalisation and maintenance (Alaimo et al., 2018; Gonzalez et al., 2013; Seiverling et al., 2012)

Note: This table refers to examples identified in the literature search but is not exhaustive. The reader may wish to refer to further additional literature that details more standard interdisciplinary roles and processes (Babbitt et al., 1994; Cohen et al., 2006; González et al., 2018; Ibañez et al., 2020; Kozlowski et al., 2015; Manikam & Perman, 2000; Milnes & Piazza, 2013; Patel, 2013; Piazza et al., 2020; Sharp et al., 2017; Silverman, 2010; Yeung et al., 2015). *A physician’s clearance checklist form is provided in Supplementary Information.

Table 2. Recommendations for the literature.

Area	Recommendation
Participants	Observable description of feeding problems before treatment including full range of outcome measures (nutritional intake, growth, bolus, variety, volume, texture, skills, independence) Specific duration of feeding problem and supplements (formula, tube) Prescribed medications or supplements (formula, tube) Type and intake of foods and liquids Other feeding-related impacts on the child and family Type and duration of previous treatments and effects Other: socioeconomic status, cultural considerations, adaptive functioning, outside of meal behaviour, ongoing therapies
Study Quality	Design meets either single-case or group quality criteria Demonstrate experimental control Interobserver agreement (IOA) and procedural integrity (with IOA) Report intention to treat data Report effect size
Procedures	Report disciplinary involvement roles in intake, consultation and direct sessions, and qualification level (i.e., type and years of feeding training) of behaviour analyst Report duration of treatment evaluation, admission length and intensity of services Describe all procedures in a replicable manner, specifically escape extinction variations Report entire course of treatment, not just analyses of specific procedure
Outcomes	Define treatment goals and time to effect (consumption across food groups) Include directly observed behaviour change Include nutritional intake and permanent product data: grams of consumption, images of items consumed (e.g., meal plate pictures), list of food group varieties, liquids, supplements and medications consumed; oral and tube calories, volume, fluid and percentage of needs Boluses, variety, volume (per session, meal, day), texture (including range for regular texture), skills, independence (self-scooping, utensils [e.g., finger, spoon, fork], self-drinking from open cup, biting off portions) Growth: Parameters and percentiles for weight for age, height for age and proportion, pre- and post- treatment and change Caregiver training, integrity data and generalisation (including settings outside of home, nonadaptive equipment and seating) Report social validity measure data for the full range of procedures before, during and after treatment
Follow-up	Observational follow-up data Follow-up at a minimum of 6 months from treatment, consideration for long-term follow-up (1 to 2 years or more)

Table 3. Progress monitoring and goals for intensive treatment.

Food items: Novel nutritional food group items, not including snack/junk foods.
Example standard goals
(applicable to all goal areas that follow e.g., variety, liquids, independence, texture, volume, generalisation)
1. Accept within 10 s (entire bolus past the plane of the lips)
2. Swallow within 30–45 s (mouth clean; no food/liquid more than size of a pea left in the mouth and not due to expulsion/spitting out)
3. Decrease inappropriate mealtime behaviour (e.g., turning head 45 degrees, covering mouth, batting at the utensil/feeder) to <1 per minute
4. Decrease negative vocalisations (e.g., crying, whining, negative statements) to <20% of the meal
5. Train caregivers to implement protocol with procedural integrity (<1 incorrect per minute or >85% correct) (Alaimo et al., 2018; Seiverling et al., 2012)
Achieve in less than 3 months:
Solids
6. Increase variety to 16 new foods (4 from each food group: protein, starch, vegetable, fruit) (Bachmeyer et al., 2013; Peterson et al., 2019; Pizzo et al., 2012; Taylor et al., 2019; Wilkins et al., 2011). Continue to further increase variety once this goal is met.
7. Teach utensil use (e.g., closing lips on spoon) for 75% of bite presentations
8. Teach self-feeding independence to 75% of bite presentations (Rivas et al., 2014; Rubio et al., 2018; Vaz et al., 2011)
Liquids
1. Teach open cup drinking to 75% of drink presentations (closing lips on cup) (Shalev et al., 2018)
2. Increase liquid variety to water and formula/milk (if applicable)
3. Teach self-drinking independence to 75% of open cup presentations (Peterson et al., 2015)
Medication
1.Increase acceptance and swallowing of medication/laxatives/supplements
Individual factors (e.g., chewing skills, volume tolerance, growth, medical/health status, food allergies, swallowing) will determine progression of goals below (achieve in 6 months to a year):
Texture (Volkert et al., 2013, 2014)
1. Assess texture and individualise goals in order of difficulty and teach chewing:
a. Lower textures (Bachmeyer et al., 2013)
i. Naturally lower texture foods (e.g., yoghurt, pureed initial baby foods)
ii. Increase thickness/consistency to table purees
iii. Increase texture (junior, wet ground, fork mashed)
b. Toddler meals/soft saucy combos; soft regular (e.g., mac & cheese, baked beans)
c. Dissolvables
i. Infant/toddler products with increased ages (e.g., rusks, veggie straws, puffs, biscuits)
ii. Easy crackers/chips and dry cereals
iii. Harder (e.g., pretzel, crustini, breadsticks, vitawheat)
d. Dissolvable combinations with spreads/mashables
e. Soft, mashable solid bites (e.g., avocado, banana, cooked carrot, potato, pumpkin, strawberry, kiwi, zucchini, eggplant)
f. Regular texture bites of more difficult textures and foods:
i. Soft (e.g., soft ripe fruits, tofu, soft cooked vegetables, quiche, eggs, muffins, soft cheeses, soft/tender meats [nuggets, meatballs, deli slices])
ii. Regular (e.g., melons, cucumber, capsicum, pear, water chestnut, raw zucchini, blanched green bean)
iii. Hard (e.g., raw fruit [apple] and veg [carrot, celery, snow pea], tougher meats)
g. Mixed regular texture scoop (e.g., yogurt with fruit/granola, uneven chunks in thin soup)
2. Increase texture ratio (amount of lower and regular texture in meals) to age-appropriate
Volume
1. Increase solid bolus (spoon size for lower texture; bite size for regular texture)
2. Increase liquid bolus
3. Increase oral solid volume (Laud et al., 2009; Taylor et al., 2017)
4. Increase oral liquid volume (Peterson et al., 2015)
5. Increase volume to 100% solids orally (Bachmeyer et al., 2013; Volkert et al., 2014)
6. Increase volume to 100% liquids orally (water and formula/milk if applicable)
7. 100% medications/laxatives/supplements orally independently
Independence
1. Full plate meals (rather than single-bite presentations)
2. Teach self-scooping
3. Teaching biting off portions (instead of pre-cut-up bites)
4. Teach full open cup sipping
5. Change from adaptive to typical age-appropriate equipment (e.g., spoon, cup)
6. Eliminate baby bottle use (Alaimo et al., 2018)
7. Evaluate independent access procedures prior to prompting sequences
8. Teach fork use
Generalisation
1. Intersperse drinks and other targets into one meal
2. Generalise protocol (e.g., to natural age-appropriate seating, settings [school, community, childcare, relatives], utensils, plates/bowls, cups, water bottles, family meals) (Alaimo et al., 2018; Gonzalez et al., 2013; Taylor et al., 2019)
3. Simplify protocol; fade reinforcement and prompting

Note: This table refers to examples identified in this literature search, but is not exhaustive. A further example is also available in Milnes and Piazza (2013, p. 402; Fig 22.7).

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Data availability statement

The data that support the findings of this study are available from the corresponding author upon reasonable request.