How to Improve Eating Behaviour during Early Childhood
Identifieur interne : 000357 ( Pmc/Corpus ); précédent : 000356; suivant : 000358How to Improve Eating Behaviour during Early Childhood
Auteurs : Robin John Green ; Gamal Samy ; Mohamad Saleh Miqdady ; Mohamed Salah ; Rola Sleiman ; Hatim Mohamed Ahmed Abdelrahman ; Fatima Al Haddad ; Mona M. Reda ; Humphrey Lewis ; Emmanuel E. Ekanem ; Yvan VandenplasSource :
- Pediatric Gastroenterology, Hepatology & Nutrition [ 2234-8646 ] ; 2015.
Abstract
Eating behaviour disorder during early childhood is a common pediatric problem. Many terminologies have been used interchangeably to describe this condition, hindering implementation of therapy and confusing a common problem. The definition suggests an eating behaviour which has consequences for family harmony and growth. The recent Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition does not cover the entire spectrum seen by pediatricians. Publications are substantive but level of evidence is most of the time low. This purpose of this review is to clarify terminology of eating behaviour problems during early childhood; including benign picky eating, limited diets, sensory food aversion, selective eating, food avoidance emotional disorder, pervasive refusal syndrome, tactile defensiveness, functional dysphagia, neophobia and toddler anorexia. This tool is proposed only to ease the clinical management for child care providers. Diagnostic criteria are set and management tools are suggested. The role of dietary counselling and, where necessary, behavioural therapy is clarified. It is hoped that the condition will make its way into mainstream pediatrics to allow these children, and their families, to receive the help they deserve.
Url:
DOI: 10.5223/pghn.2015.18.1.1
PubMed: 25866727
PubMed Central: 4391994
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PMC:4391994Le document en format XML
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<author><name sortKey="Miqdady, Mohamad Saleh" sort="Miqdady, Mohamad Saleh" uniqKey="Miqdady M" first="Mohamad Saleh" last="Miqdady">Mohamad Saleh Miqdady</name>
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<front><div type="abstract" xml:lang="en"><p>Eating behaviour disorder during early childhood is a common pediatric problem. Many terminologies have been used interchangeably to describe this condition, hindering implementation of therapy and confusing a common problem. The definition suggests an eating behaviour which has consequences for family harmony and growth. The recent Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition does not cover the entire spectrum seen by pediatricians. Publications are substantive but level of evidence is most of the time low. This purpose of this review is to clarify terminology of eating behaviour problems during early childhood; including benign picky eating, limited diets, sensory food aversion, selective eating, food avoidance emotional disorder, pervasive refusal syndrome, tactile defensiveness, functional dysphagia, neophobia and toddler anorexia. This tool is proposed only to ease the clinical management for child care providers. Diagnostic criteria are set and management tools are suggested. The role of dietary counselling and, where necessary, behavioural therapy is clarified. It is hoped that the condition will make its way into mainstream pediatrics to allow these children, and their families, to receive the help they deserve.</p>
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<pmc article-type="review-article"><pmc-dir>properties open_access</pmc-dir>
<front><journal-meta><journal-id journal-id-type="nlm-ta">Pediatr Gastroenterol Hepatol Nutr</journal-id>
<journal-id journal-id-type="iso-abbrev">Pediatr Gastroenterol Hepatol Nutr</journal-id>
<journal-id journal-id-type="publisher-id">PGHN</journal-id>
<journal-title-group><journal-title>Pediatric Gastroenterology, Hepatology & Nutrition</journal-title>
</journal-title-group>
<issn pub-type="ppub">2234-8646</issn>
<issn pub-type="epub">2234-8840</issn>
<publisher><publisher-name>The Korean Society of Pediatric Gastroenterology, Hepatology and Nutrition</publisher-name>
</publisher>
</journal-meta>
<article-meta><article-id pub-id-type="pmid">25866727</article-id>
<article-id pub-id-type="pmc">4391994</article-id>
<article-id pub-id-type="doi">10.5223/pghn.2015.18.1.1</article-id>
<article-categories><subj-group subj-group-type="heading"><subject>Review Article</subject>
</subj-group>
</article-categories>
<title-group><article-title>How to Improve Eating Behaviour during Early Childhood</article-title>
</title-group>
<contrib-group><contrib contrib-type="author" corresp="yes"><name><surname>Green</surname>
<given-names>Robin John</given-names>
</name>
<xref ref-type="aff" rid="A1"></xref>
</contrib>
<contrib contrib-type="author"><name><surname>Samy</surname>
<given-names>Gamal</given-names>
</name>
<xref ref-type="aff" rid="A2">*</xref>
</contrib>
<contrib contrib-type="author"><name><surname>Miqdady</surname>
<given-names>Mohamad Saleh</given-names>
</name>
<xref ref-type="aff" rid="A3">†</xref>
</contrib>
<contrib contrib-type="author"><name><surname>Salah</surname>
<given-names>Mohamed</given-names>
</name>
<xref ref-type="aff" rid="A4">‡</xref>
</contrib>
<contrib contrib-type="author"><name><surname>Sleiman</surname>
<given-names>Rola</given-names>
</name>
<xref ref-type="aff" rid="A5">§</xref>
</contrib>
<contrib contrib-type="author"><name><surname>Abdelrahman</surname>
<given-names>Hatim Mohamed Ahmed</given-names>
</name>
<xref ref-type="aff" rid="A6">∥</xref>
</contrib>
<contrib contrib-type="author"><name><surname>Al Haddad</surname>
<given-names>Fatima</given-names>
</name>
<xref ref-type="aff" rid="A7">¶</xref>
</contrib>
<contrib contrib-type="author"><name><surname>Reda</surname>
<given-names>Mona M.</given-names>
</name>
<xref ref-type="aff" rid="A8">**</xref>
</contrib>
<contrib contrib-type="author"><name><surname>Lewis</surname>
<given-names>Humphrey</given-names>
</name>
<xref ref-type="aff" rid="A1"></xref>
</contrib>
<contrib contrib-type="author"><name><surname>Ekanem</surname>
<given-names>Emmanuel E.</given-names>
</name>
<xref ref-type="aff" rid="A9">††</xref>
</contrib>
<contrib contrib-type="author"><name><surname>Vandenplas</surname>
<given-names>Yvan</given-names>
</name>
<xref ref-type="aff" rid="A10">‡‡</xref>
</contrib>
</contrib-group>
<aff id="A1">Department of Paediatrics and Child Health, University of Pretoria, Pretoria, South Africa.</aff>
<aff id="A2"><label>*</label>
Department of Child Health and Nutrition, Institute of Postgraduate Childhood Studies, Ain Shams University, Cairo, Egypt.</aff>
<aff id="A3"><label>†</label>
Division of Hepatology and Nutrition, Department of Pediatric Gastroenterology, Sheikh Khalifa Medical City, Abu Dhabi, United Arab Emirates.</aff>
<aff id="A4"><label>‡</label>
Wyeth Nutrition, Dubai, United Arab Emirates.</aff>
<aff id="A5"><label>§</label>
Doctor Soliman Fakeeh Hospital, Jeddah, Kingdom of Saudi Arabia.</aff>
<aff id="A6"><label>∥</label>
Cornell Medical College and Hamad Medical Corporation, Doha, Qatar.</aff>
<aff id="A7"><label>¶</label>
Salmaniya Medical Complex, Manama, Kingdom of Bahrain.</aff>
<aff id="A8"><label>**</label>
Institute of Psychiatry, Ain Shams University, Cairo, Egypt.</aff>
<aff id="A9"><label>††</label>
Department of Pediatrics, University of Calabar and University of Calabar Teaching Hospital, Calabar, Nigeria.</aff>
<aff id="A10"><label>‡‡</label>
Department of Pediatrics, UZ Brussel, Vrije Universiteit Brussel, Brussels, Belgium.</aff>
<author-notes><corresp>Corresponding author: Robin John Green, Department of Paediatrics and Child Health, University of Pretoria, PO Box 667, Pretoria 0001, South Africa. Tel: +27-12-354-5276, Fax: +27-12-354-5275, <email>robin.green@up.ac.za</email>
</corresp>
</author-notes>
<pub-date pub-type="ppub"><month>3</month>
<year>2015</year>
</pub-date>
<pub-date pub-type="epub"><day>30</day>
<month>3</month>
<year>2015</year>
</pub-date>
<volume>18</volume>
<issue>1</issue>
<fpage>1</fpage>
<lpage>9</lpage>
<history><date date-type="received"><day>21</day>
<month>1</month>
<year>2015</year>
</date>
<date date-type="accepted"><day>30</day>
<month>1</month>
<year>2015</year>
</date>
</history>
<permissions><copyright-statement>Copyright © 2015 by The Korean Society of Pediatric Gastroenterology, Hepatology and Nutrition</copyright-statement>
<copyright-year>2015</copyright-year>
<license license-type="open-access" xlink:href="http://creativecommons.org/licenses/by-nc/3.0/"><license-p>This is an open-access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (<ext-link ext-link-type="uri" xlink:href="http://creativecommons.org/licenses/by-nc/3.0/">http://creativecommons.org/licenses/by-nc/3.0/</ext-link>
) which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited.</license-p>
</license>
</permissions>
<abstract><p>Eating behaviour disorder during early childhood is a common pediatric problem. Many terminologies have been used interchangeably to describe this condition, hindering implementation of therapy and confusing a common problem. The definition suggests an eating behaviour which has consequences for family harmony and growth. The recent Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition does not cover the entire spectrum seen by pediatricians. Publications are substantive but level of evidence is most of the time low. This purpose of this review is to clarify terminology of eating behaviour problems during early childhood; including benign picky eating, limited diets, sensory food aversion, selective eating, food avoidance emotional disorder, pervasive refusal syndrome, tactile defensiveness, functional dysphagia, neophobia and toddler anorexia. This tool is proposed only to ease the clinical management for child care providers. Diagnostic criteria are set and management tools are suggested. The role of dietary counselling and, where necessary, behavioural therapy is clarified. It is hoped that the condition will make its way into mainstream pediatrics to allow these children, and their families, to receive the help they deserve.</p>
</abstract>
<kwd-group><kwd>Eating behaviour disorders</kwd>
<kwd>Eating disorders</kwd>
<kwd>Picky eater</kwd>
<kwd>Early childhood</kwd>
<kwd>Meals</kwd>
</kwd-group>
</article-meta>
</front>
<body><sec sec-type="intro"><title>INTRODUCTION</title>
<p>The eating process is of importance for survival and health. Eating disorders have been adequately addressed and discussed in adults and adolescents with many randomized controlled trials and system atic reviews. They have been classified in Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM5) [<xref rid="B1" ref-type="bibr">1</xref>
]. By contrast, eating behaviour of early childhood, a common problem for pediatric practitioners, is a topic without clarity. Moreover, in DSM5 [<xref rid="B1" ref-type="bibr">1</xref>
] both "Other Specified Feeding or Eating Disorder, 307.59" and "Unspecified Feeding or Eating Disorder 307.50" cannot adequately explain many of the problems observed during early childhood. The chapter on eating disorders of infants and early childhood was replaced in DSM5 by "Avoidant/Restrictive Food Intake Disorder: 307.59" but it was not analysed in sufficient detail to help plan a therapeutic approach. The picky eater category was not included, considering it a non-mental problem. This confusion can be attributed to lack of agreement on the terminology used, little available original research and possible psycho-behavioural and organic, multifactorial nature of this problem. The aim of this review is to evaluate the publications and opinions in the context of the disorder and in light of the available levels of clinical evidence.</p>
<p>The terminology "eating behaviour disorder of early childhood" which we introduce includes conditions such as picky eating [<xref rid="B2" ref-type="bibr">2</xref>
], limited diets, sensory food aversion [<xref rid="B3" ref-type="bibr">3</xref>
], selective eating [<xref rid="B4" ref-type="bibr">4</xref>
], food avoidance emotional disorder [<xref rid="B5" ref-type="bibr">5</xref>
], pervasive refusal syndrome [<xref rid="B6" ref-type="bibr">6</xref>
], tactile defensiveness [<xref rid="B7" ref-type="bibr">7</xref>
], neophobia [<xref rid="B8" ref-type="bibr">8</xref>
] and toddler anorexia [<xref rid="B9" ref-type="bibr">9</xref>
]. This tool is proposed to ease the clinical management for child care providers. The DSM5 classification of "Avoidant/Restrictive Food Intake Disorder: 307.59" will overlap with eating behaviour of early childhood as the former includes all age groups and the latter will include other disorders excluded in the former group.</p>
</sec>
<sec sec-type="methods"><title>METHODOLOGY</title>
<p>An exhaustive search of Pubmed for the last 20 years was conducted. Keywords used included "childhood feeding" and "childhood eating (problems, disorders or difficulties)". All works were retrieved and their level of evidence and quality was determined (<xref ref-type="table" rid="T1">Table 1</xref>
) [<xref rid="B10" ref-type="bibr">10</xref>
]. The most valid and recent literature was used in this review.</p>
</sec>
<sec><title>DEFINITION</title>
<p>The proposed definition of eating behaviour disorders of early childhood states "a condition that imposes a short-term eating behaviour of the child with possible risk of long-term health consequences" (<xref ref-type="table" rid="T2">Table 2</xref>
) [<xref rid="B11" ref-type="bibr">11</xref>
]. These effects are important for both child and family. Wherever possible, the definition builds on the definitions used in the many conditions described above [<xref rid="B1" ref-type="bibr">1</xref>
,<xref rid="B2" ref-type="bibr">2</xref>
,<xref rid="B3" ref-type="bibr">3</xref>
,<xref rid="B4" ref-type="bibr">4</xref>
,<xref rid="B5" ref-type="bibr">5</xref>
,<xref rid="B6" ref-type="bibr">6</xref>
,<xref rid="B7" ref-type="bibr">7</xref>
,<xref rid="B8" ref-type="bibr">8</xref>
,<xref rid="B9" ref-type="bibr">9</xref>
].</p>
</sec>
<sec><title>PREVALENCE</title>
<p>Based on the previous definition, eating behaviour disorders of early childhood are a common chronic condition and prevalence rates vary from 13% to 22% or 13% to 50%, depending on age and various definitions [<xref rid="B12" ref-type="bibr">12</xref>
,<xref rid="B13" ref-type="bibr">13</xref>
].</p>
</sec>
<sec><title>RISK FACTORS</title>
<p>Many risk factors that predispose to eating behaviour disorders of early childhood (<xref ref-type="table" rid="T3">Table 3</xref>
) [<xref rid="B14" ref-type="bibr">14</xref>
,<xref rid="B15" ref-type="bibr">15</xref>
,<xref rid="B16" ref-type="bibr">16</xref>
,<xref rid="B17" ref-type="bibr">17</xref>
,<xref rid="B18" ref-type="bibr">18</xref>
,<xref rid="B19" ref-type="bibr">19</xref>
,<xref rid="B20" ref-type="bibr">20</xref>
,<xref rid="B21" ref-type="bibr">21</xref>
,<xref rid="B22" ref-type="bibr">22</xref>
,<xref rid="B23" ref-type="bibr">23</xref>
,<xref rid="B24" ref-type="bibr">24</xref>
]. Risk identification may provide a clue to early intervention.</p>
</sec>
<sec><title>DIAGNOSIS</title>
<p>A high index of suspicion for the diagnosis of eating behaviour disorders of early childhood should be raised if one or more of the following factors are present:
<list list-type="order"><list-item><p>Parents are concerned about an abnormal established eating behavior that is related to diet or meal time regarding [<xref rid="B12" ref-type="bibr">12</xref>
,<xref rid="B25" ref-type="bibr">25</xref>
,<xref rid="B26" ref-type="bibr">26</xref>
] (level of evidence: B): content (avoidance/preference), quality, texture/color, duration (slow/incomplete), unpleasant, messy, behavioral abnormalities</p>
</list-item>
<list-item><p>Health care worker identified consequences where objective history and examination of the child reveal [<xref rid="B14" ref-type="bibr">14</xref>
,<xref rid="B27" ref-type="bibr">27</xref>
,<xref rid="B28" ref-type="bibr">28</xref>
]: growth faltering (B), micro-nutrient deficiency (C), obesity (B), behavioral disorders (B), chronic illness (C), sleep disturbance (B), anemia (C), constipation (C), family disharmony (B)</p>
</list-item>
<list-item><p>Occurs at any age (usually after the age of 2 years) in which a child independently begins to eat and is usually present for more than one month [<xref rid="B14" ref-type="bibr">14</xref>
]</p>
</list-item>
<list-item><p>Not related to food availability due to poverty or food insecurity</p>
</list-item>
<list-item><p>Thorough clinical evaluation excluded a significant underlying organic disease that may, on its own, produce micro- or macro-nutrient deficiencies</p>
</list-item>
</list>
Questionnaires to identify eating behaviour disorders of early childhood have been developed [<xref rid="B15" ref-type="bibr">15</xref>
]. In making an assessment of a child with an eating behaviour disorders of early childhood it is important to assess food quality and quantity (consumption) and behavior during meals and to perform a thorough examination of the child. Some important elements of assessment are listed in <xref ref-type="table" rid="T4">Table 4</xref>
.</p>
</sec>
<sec><title>CONSEQUENCES AND PROGNOSIS OF EATING BEHAVIOUR DISORDERS OF EARLY CHILDHOOD</title>
<p>The condition is, in some cases, not benign and if left untreated may result in a number of consequences such as anorexia, growth disturbance, conduct disorders, food preferences into adulthood and, importantly, macro- and micro-nutrient deficiencies [<xref rid="B13" ref-type="bibr">13</xref>
,<xref rid="B14" ref-type="bibr">14</xref>
].</p>
</sec>
<sec><title>DIFFERENTIAL DIAGNOSIS</title>
<p>Although eating behaviour disorders of early childhood is proposed as a specific entity in this context, it should be remembered that many conditions may cause disordered eating such as cow's milk protein allergy and medication side effects [<xref rid="B29" ref-type="bibr">29</xref>
].</p>
<p>Co-morbidities may include other behavioral problems especially around meal times, including messiness, poor manners, foul language and lack of attention.</p>
<p>Specific neurological or psychological disorders that form their own syndrome may overlap with eating behaviour disorders of early childhood but are not a natural extension of this specific syndrome. These may include pervasive developmental disorder, attention deficit disorder, conduct disorders and sensory integration disorder [<xref rid="B30" ref-type="bibr">30</xref>
]. However, some chronic illnesses do not affect appetite but may disturb family or eating behaviors that set the scene for eating behaviour disorders of early childhood.</p>
</sec>
<sec><title>STAGING-SEVERITY ASSESSMENT</title>
<p>As the proposed definition of eating behaviour disorders of early childhood encompasses a heterogeneous group of disorders, a severity score is mandatory to plan a protocol of management and follow up. This will avoid managing all children with eating behaviour disorders of early childhood in the same way.</p>
<p>Important features to assess severity include:
<list list-type="bullet"><list-item><p>Parental perception of severity (words such as "always", "severe", "worried" and "concerned" should be noted)</p>
</list-item>
<list-item><p>Family disharmony (with or without overt reference to the 'picky eater' child) must be factored into judging severity of all stages</p>
</list-item>
<list-item><p>Careful plotting of anthropometric measurements (including body mass index and growth velocity) and focus on growth pattern</p>
</list-item>
<list-item><p>Assessment of clinical signs of possible micro-nutrient deficiencies</p>
</list-item>
</list>
Attention to the diagnosis of other chronic illnesses that may interfere or cause eating behavior disorders are required.</p>
<p>Growth faltering and micro-nutrient deficiencies are related to severity of eating disorders [<xref rid="B13" ref-type="bibr">13</xref>
,<xref rid="B18" ref-type="bibr">18</xref>
] (<xref ref-type="table" rid="T5">Table 5</xref>
).</p>
</sec>
<sec><title>CLINICAL SUSPICION OF MICRO-NUTRIENT DEFICIENCIES</title>
<p>Iron, zinc and vitamin A are the most common micro-nutrients which could be affected in eating disorders [<xref rid="B31" ref-type="bibr">31</xref>
,<xref rid="B32" ref-type="bibr">32</xref>
].</p>
<p>Symptoms of iron deficiency range from fatigue and inability to concentrate to impaired physical and cognitive development of children. The most common reason for iron deficiency is insufficient iron intake from food [<xref rid="B32" ref-type="bibr">32</xref>
].</p>
<p>The health consequences of zinc deficiency include poor immune system function, growth retardation. Diets with poor meat and fish intake increase the risk of zinc deficiency, because zinc in cereals is poorly bioavailable [<xref rid="B31" ref-type="bibr">31</xref>
].</p>
<p>Vitamin A is another essential nutrient in the human diet, contributing to the functioning of the retina, the growth of bone and the immune response [<xref rid="B33" ref-type="bibr">33</xref>
]. Beta-carotene is a precursor of vitamin A found in fruits and vegetables. However, investigations have shown that beta-carotene is not as bioavailable as once thought [<xref rid="B34" ref-type="bibr">34</xref>
].</p>
</sec>
<sec><title>MANAGEMENT PLAN</title>
<p>Whilst therapy will have to be individualized, it seems prudent to a select management plan based on the severity of the eating disorder (<xref ref-type="table" rid="T6">Table 6</xref>
) [<xref rid="B8" ref-type="bibr">8</xref>
]. Whilst vitamin, mineral and nutritional supplements are helpful in treating or preventing macroand micro-nutrient deficiencies, these should be seen as transient supportive interventions. They may allow time for dietary and behavioral modification. These supplements should not be given during the main meals. Pharmacological therapy has not been shown to be of any efficacy in improving eating behavior and is thus not recommended [<xref rid="B35" ref-type="bibr">35</xref>
].</p>
<p><xref ref-type="table" rid="T7">Table 7</xref>
summarizes the tools and interventions that may be of benefit in children with eating behavior disorders [<xref rid="B36" ref-type="bibr">36</xref>
].</p>
<sec><title>Dietary management</title>
<p>The role of a dietician or nutritionist is critical in these children [<xref rid="B35" ref-type="bibr">35</xref>
,<xref rid="B37" ref-type="bibr">37</xref>
,<xref rid="B38" ref-type="bibr">38</xref>
,<xref rid="B39" ref-type="bibr">39</xref>
,<xref rid="B40" ref-type="bibr">40</xref>
]. The dietician will analyse the specificities of the composition of the diet, including quality, quantity, nutritional content and type.</p>
<p>Nutritional management of an eating behavior disorder plays a major role in determining health outcome.</p>
<p>The determinants of a successful nutritional intervention revolve around three main concepts:
<list list-type="order"><list-item><p>A systematic method of nutritional assessment (gathering objective data)</p>
</list-item>
<list-item><p>A thorough evaluation of nutritional intake</p>
</list-item>
<list-item><p>A solid, structured (nutritional counseling) plan</p>
</list-item>
</list>
</p>
</sec>
</sec>
<sec><title>GATHERING OBJECTIVE DATA</title>
<p>Anthropometric assessment is important in assessing nutritional status of children [<xref rid="B40" ref-type="bibr">40</xref>
]. Weight and height should be measured using standardized methods and the evaluation of these parameters should be plotted on appropriate curves. In addition, results from objective measurements (serum, bone density, etc.) can be used to further complete the assessment.</p>
</sec>
<sec><title>EVALUATING NUTRITIONAL INTAKE</title>
<p>Several methods are available to assess dietary intake [<xref rid="B35" ref-type="bibr">35</xref>
]. At the initial visit a 24-hour recall is noted. This is followed by a 3-day to 1-week food prospective diary (which should include a weekend day) for further assessment.</p>
<p>Food logs or 24-hour food recalls are important for dieticians to collate and must include:
<list list-type="bullet"><list-item><p>All food groups</p>
</list-item>
<list-item><p>Well defined meal times</p>
</list-item>
<list-item><p>Food textures at each meal</p>
</list-item>
<list-item><p>Certain behaviors during meal-time such as gaging or spitting out food should also be noted</p>
</list-item>
</list>
</p>
</sec>
<sec><title>NUTRITIONAL COUNSELING AND SUPPLEMENTATION</title>
<p>The important elements to be stressed in nutritional counseling are [<xref rid="B41" ref-type="bibr">41</xref>
]:
<list list-type="bullet"><list-item><p>Developing a meal-time routine</p>
</list-item>
<list-item><p>Planning three main meals and 2-3 snacks, avoiding food fillers</p>
</list-item>
<list-item><p>Encouraging new foods (remembering that it may take up to 15 offerings before a child can be confidently determined to be refusing that food and giving up)</p>
</list-item>
<list-item><p>Considering nutritional supplementation</p>
</list-item>
</list>
</p>
<sec><title>Behavioral treatment</title>
<p>Early intervention is important. Treatment of highly selective or low overall eating may prevent the development of more serious feeding difficulties. Caregiver-friendly intervention strategies that can be implemented with children in their community environments (e.g., in the child's home or school) may reduce the need for tertiary care [<xref rid="B42" ref-type="bibr">42</xref>
]. A psychotherapeutic approach that addresses dysfunctional emotions, behaviors, and cognitions through a goal-oriented, systematic process is required. Several researchers have suggested that behavioral mismanagement (i.e., inadvertent reinforcement of inappropriate eating patterns) frequently contributes to the onset and maintenance of feeding problems [<xref rid="B43" ref-type="bibr">43</xref>
,<xref rid="B44" ref-type="bibr">44</xref>
,<xref rid="B45" ref-type="bibr">45</xref>
]. For example, negative reinforcement may be created if a caregiver typically removes undesired food items or terminates meals when a child refuses to eat or to consume age-appropriate quantities of food, the child may be more likely to display inappropriate behavior during meals to escape or avoid less preferred food items or larger quantities of food.</p>
<p>Behavioral interventions have been demonstrated to be effective for treating feeding problems in children. A multi-component treatment package consisting of positive reinforcement and escape extinction is the most commonly used intervention [<xref rid="B44" ref-type="bibr">44</xref>
,<xref rid="B46" ref-type="bibr">46</xref>
,<xref rid="B47" ref-type="bibr">47</xref>
,<xref rid="B48" ref-type="bibr">48</xref>
]. The positive reinforcement component typically involves providing the child with access to preferred stimuli (e.g., food, toys, praise, tokens) for desired eating behavior (i.e., accepting or swallowing bites). Escape extinction which is implemented when a child's feeding problem is presumed to be maintained by negative reinforcement, is a procedure in which escape from, or avoidance of, the demand of eating is no longer permitted. Non-removal of the spoon is an example of an escape extinction procedure that involves positioning the spoon in front of the child's mouth until the bite is accepted, thus preventing escape from or avoidance of the bite presentation [<xref rid="B44" ref-type="bibr">44</xref>
,<xref rid="B46" ref-type="bibr">46</xref>
,<xref rid="B47" ref-type="bibr">47</xref>
,<xref rid="B48" ref-type="bibr">48</xref>
]. An alternative escape extinction procedure, physical guidance, consists of exerting gentle pressure on the child's mandibular joint or chin so that the mouth is guided open and the food is placed in the child's mouth [<xref rid="B47" ref-type="bibr">47</xref>
,<xref rid="B48" ref-type="bibr">48</xref>
].</p>
<p>Although a common component of interventions for childhood feeding problems, escape extinction has been associated with a number of undesirable side effects, including response bursts (i.e., initial increases in problem behavior), extinction-induced aggression, and emotional responding (e.g., crying) [<xref rid="B49" ref-type="bibr">49</xref>
]. Moreover, meals may become difficult for caregivers if they must physically prevent escape from or avoidance of eating while managing the side effects of extinction, particularly if increases in desired behaviors (e.g., bite acceptance) do not occur immediately. Thus, escape extinction procedures may not be ideal for treatment programs conducted in natural settings (e.g., in the child's home or school) or by inexperienced care givers (e.g., parents, teachers, paraprofessionals).</p>
<p>Differential (positive) reinforcement of alternative behaviors involves providing the child with access to preferred stimuli contingent on desired behaviors, such as accepting or swallowing bites of food.</p>
<p>An alternative to providing preferred foods or liquids contingently is to provide other types of preferred stimuli continuously throughout the meal. Preferred toys or activities are the most common stimuli used when non-contingent (positive) reinforcement is utilized in the treatment of feeding problems [<xref rid="B50" ref-type="bibr">50</xref>
,<xref rid="B51" ref-type="bibr">51</xref>
].</p>
<p>Simultaneous presentation involves presenting a less preferred food at the same time as a more preferred food. The foods may be presented together on the spoon or blended together, or the non-preferred food may be inside or covered by the preferred food.</p>
<p>Stimulus fading is a technique of gradually changing the ratio or concentration of paired preferred and non-preferred foods or liquids which may reduce the risk associated with pairing non-preferred and preferred foods [<xref rid="B52" ref-type="bibr">52</xref>
].</p>
<p>High-probability instructional sequence involves presenting a series of instructions for which compliance is highly likely followed by a request for which compliance is unlikely (i.e., a low-probability instruction). The high-probability sequence consists of three presentations of an empty spoon; the low-probability instruction is the presentation of a spoon with food. Results of this study suggest that a high-probability instructional sequence may be effective in increasing compliance (acceptance) with food in the absence of escape extinction if a child demonstrates high levels of compliance with a similar request such as acceptance of an empty spoon [<xref rid="B53" ref-type="bibr">53</xref>
].</p>
<p>Parents of children with eating behavior disorders should learn the key points of behavioral management of their children as shown in <xref ref-type="table" rid="T8">Table 8</xref>
[<xref rid="B54" ref-type="bibr">54</xref>
].</p>
</sec>
</sec>
<sec sec-type="conclusions"><title>CONCLUSION</title>
<p>The term eating behaviour disorders of early childhood is meant to be the umbrella under which all problems of eating are listed at this specific age. Diagnostic features are proposed and a difference from the DSM5 classification of "Avoidant/Restrictive Food Intake Disorder: 307.59" is shown. Detailed history taking from parents and a thorough clinical examination by the health care worker are essential. A classification of severity is proposed to separate children with meal-time abnormal behavior only from those who have associated risk, or actual consequences, of growth disturbance and micro-nutrient deficiencies. Following staging, therapy, although required to be tailored to children and families, should incorporate dietary and behavioral education and/or therapy. Nutritional supplements are a useful but transient addition to the management of such a condition.</p>
</sec>
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<floats-group><table-wrap id="T1" orientation="portrait" position="float"><label>Table 1</label>
<caption><title>Evidence Level and Quality</title>
</caption>
<graphic xlink:href="pghn-18-1-i001"></graphic>
<table-wrap-foot><fn><p>RCT: randomized controlled trial.</p>
<p>Modified from American Academy of Pediatrics Steering Committee on Quality Improvement and Management (Pediatrics 2004; 114:874-7) with permission [<xref rid="B10" ref-type="bibr">10</xref>
].</p>
</fn>
</table-wrap-foot>
</table-wrap>
<table-wrap id="T2" orientation="portrait" position="float"><label>Table 2</label>
<caption><title>Definition of Eating Behaviour Disorder of Early Childhood</title>
</caption>
<graphic xlink:href="pghn-18-1-i002"></graphic>
</table-wrap>
<table-wrap id="T3" orientation="portrait" position="float"><label>Table 3</label>
<caption><title>Risk Factors for Eating Behaviour Disorder Early Childhood</title>
</caption>
<graphic xlink:href="pghn-18-1-i003"></graphic>
</table-wrap>
<table-wrap id="T4" orientation="portrait" position="float"><label>Table 4</label>
<caption><title>Assessment Form for a Child with a Suspected Eating Behaviour Disorder Early Childhood</title>
</caption>
<graphic xlink:href="pghn-18-1-i004"></graphic>
</table-wrap>
<table-wrap id="T5" orientation="portrait" position="float"><label>Table 5</label>
<caption><title>Staging Assessment of Severity</title>
</caption>
<graphic xlink:href="pghn-18-1-i005"></graphic>
</table-wrap>
<table-wrap id="T6" orientation="portrait" position="float"><label>Table 6</label>
<caption><title>Management Plan for Eating Behaviour Disorder Early Childhood [<xref rid="B8" ref-type="bibr">8</xref>
]</title>
</caption>
<graphic xlink:href="pghn-18-1-i006"></graphic>
</table-wrap>
<table-wrap id="T7" orientation="portrait" position="float"><label>Table 7</label>
<caption><title>Tools in the Management of Eating Behaviour Disorder Early Childhood [<xref rid="B36" ref-type="bibr">36</xref>
]</title>
</caption>
<graphic xlink:href="pghn-18-1-i007"></graphic>
</table-wrap>
<table-wrap id="T8" orientation="portrait" position="float"><label>Table 8</label>
<caption><title>Tips for Nutritional and Behavioral Management by Parents of Children with Eating Behaviour Disorder Early Childhood [<xref rid="B54" ref-type="bibr">54</xref>
]</title>
</caption>
<graphic xlink:href="pghn-18-1-i008"></graphic>
</table-wrap>
</floats-group>
</pmc>
</record>
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