A Practical Approach to Classifying and Managing Feeding Difficulties

We appreciate Dr Phalen bringing his concerns to our attention and agree with many of his observations. It would be ideal to have an algorithm that has been put to the test and we hope that in time our algorithm might offer a starting point for such studies.

We agree that severe feeding disorders are most often found in complex medical situations and that a multidisciplinary approach is most efficacious for those feeding disorders. Indeed, the authors represent pediatric gastroenterology, pediatric nutrition, dietetics, speech pathology and child psychiatry. All have experience in multidisciplinary teams.

However, we respectfully contend that a close reading of our paper will show that we have taken Dr. Phalen's concerns into account while sticking to our fundamental goal - the provision of an approach - not for the specialists or the members of a multidisciplinary team - but for the primary care provider. We have used evidence based material to garner red flags to help identify both organic and behavioral concerns which should assist the primary care provider in identifying the children needing prompt specialized intervention, we contend that we have used language that any doctor can comprehend and have gone to lengths to avoid terminology confined to our psychiatric colleagues. We have taken care to avoid the dichotomous approach of organic versus behavioral issues by emphasizing that identifying one in no way excludes others. Moreover, we have added a ready means of differentiating caregiver feeding styles that may assist or compromise the child's progress. Of course we do not want to suggest that the mother is to blame for her child's limitations but feel it is important to acknowledge the reciprocal nature of the feeding relationship.

We know that primary care providers see many children who are thought to have feeding problems but are in fact eating normally or within the bounds of normally prescribed developmental limitations. It is precisely because our classification is not confined to the severely compromised child that it will be of practical advantage to the primary care provider.

Conflict of Interest:

I have lectured for Abbott International

In "A Practical Approach to Classifying and Managing Feeding Difficulties" by Kerzner et al., the authors highlight the medical and social impact of childhood feeding problems. We applaud the authors' efforts towards improving these children's diagnosis and management. However, as members of the Medical Professional Council for Feeding Matters, a parent-organized and multidisciplinary nonprofit organization advocating on behalf of children with feeding problems, we would like to take the opportunity to raise important concerns related to the article.

First, given that the majority of severe feeding problems presents in medically complex children and are multifactorial [Bryant-Waugh 2010, Sharp 2010, Eicher 2012], we must involve multiple disciplines when proposing classification and treatment paradigms. All relevant fields (i.e., general pediatrics, developmental pediatrics, pediatric psychiatry, child/pediatric psychology, pediatric gastroenterology, registered dietetics and nutrition, occupational therapy, and speech-language pathology) must adopt a common language and terminology. The authors use terminology specific to psychiatry, which may be perceived to negatively describe children and blame parents, and they endorse the discarded "organic" versus "behavioral" dichotomy no longer used by most professionals involved in the field [Phalen 2013]. Secondly, we are in an era where empirically derived classification and treatment algorithms are feasible and dearly needed to advance the field; efforts short of this standard become nothing more than an academic exercise that will not likely transition into clinical care.

The work by Kerzner et al. and many of their cited references are based primarily on expert opinion that, in turn, are based on experience, and not necessarily on empirically generated data. This deficit, in part, may lie with the lack of organization of all the relevant disciplines that deal with pediatric feeding problems. With the exception of well- established interdisciplinary programs where some of these discussions and care occur at the local level, there is a glaring void with regard to common terminology, diagnostic criteria, and care that is available and agreed upon by the majority of providers. It is this void that Feeding Matters, by developing cross-disciplinary paradigms and studies that are useful to all relevant disciplines, hopes to fill. We welcome and support any large-scale efforts by the relevant discipline's governing societies to fund and develop such consensus criteria and recommendations.

Conflict of Interest:

*Conflict of Interest: Dr Toomey is a paid consultant for Nestec, a division of Nestle.

We thank Ms. Becker for her letter, which raises two issues, the first being the age range of children covered by our classification. We emphasize that feeding difficulties generally emerge in the early years of life, when the transitions from feeding to eating take place. However, we also recognize that concerns about limited appetite, selective intake and fear of feeding can continue or emerge at a later time; definitions limited by age are too restrictive. Because these problems occur across a wide age range, as Ms Becker pointed out, we believe that our algorithm (Figure 2), which takes severity into account, is useful from infancy through later childhood. The second concern, regarding prolonged breast-feeding, is important and we appreciate the opportunity to put the issue in perspective. We in no way disagree with the recommendations of the American Academy of pediatrics which state that exclusive breast-feeding is ideal in the first six months and should continue for at least a year. We merely encourage the primary care provider to take note of prolonged breast-feeding or formula feeding, that continues after the first year of life and interferes with the acceptance of complementary foods, as either might reflect an underlying problem, notably resistance to more complex textures because of motor or sensory problems. Prolonged breast-feeding offers many benefits to both the child and the mother when it is part of varied and nutrient rich diet, but that does not preclude it being a symptom of an underlying issue.

Conflict of Interest:

None declared

The article does not give any ages for the population of "child" and thus vagueness gives rise to questions and may limit its usefulness. A selective eater at 7 months old is very different from a selective eater who is seven years old. The article refers to "prolonged breastfeeding" as a suggestive symptom of feeding difficulties, however their is no information on what the authors consider is "prolonged", and the reference cited in this table does not mention this symptom. The World Health Organization and other professional health bodies recommend breastfeeding into the second year and beyond. Anthropology research refers to around four years of age being an average for ceasing breastfeeding. Is prolonged thus continuing after the second year or four years or beyond this?

Conflict of Interest:

None declared