When a child has difficulty eating, whether it is due to dysphagia, dysfunction in the esophageal or gastrointestinal muscles, or for other reasons, there are certain things parents can do to ensure their child gets the nutrition they need. The first step is to make sure that the child is properly evaluated by a team of medical professionals, which can include a clinical dietician, occupational therapist, speech-language pathologist (SLP) or deglutologist, pediatrician, neurologist, gastroenterologist, or ear/nose/throat (ENT) specialist. These professionals work in conjunction with the child’s primary care provider to evaluate the child’s feeding habits and abilities. Once the child’s health conditions are evaluated, specialists can recommend a plan of action. In some cases, this can mean fairly simple interventions (such as changing the caloric density or texture of your child’s food), or, in other cases, it may mean finding alternate methods of food intake. Meal planning service providers and dieticians can be found in a variety of settings, including at community/public health facilities, in the educational setting, at government agencies and healthcare settings, hospitals, private medical offices, research programs, school and daycare facilities and university centers.
How do I know whether to take my child to a nutritionist or a registered dietician?
The differences between nutritionists and dieticians boil down to the level of training each receives. Registered dieticians go through a formal registration, certification and education process, while the job title ‘nutritionist’ is much less strictly regulated. Registered Dietitian Nutritionists (RDNs)are trained in programs approved by the Academy of Nutrition and Dietetics and accredited by the Accreditation Council for Education in Nutrition and Dietetics (ACEND). Most states have laws regarding licensure of dieticians, though the job titles can vary state to state (including such titles as Certified Dietitian (CD), Clinical Nutritionist, Community Nutritionist, Licensed Dietitian (LD), Licensed Dietician and Nutritionist (LDN), Licensed Nutritionist (LN), Registered Dietitian (LD), or Therapy Nutritionist). Nutritionists are not always required to have a college degree, and, in some states, the title is not regulated. In other cases, nutritionists are in the process of working towards a full RDN degree but have not yet completed all requirements.
What are some of the tests that specialists do to evaluate my child’s nutritional problems?
While every child’s situation will be different, there are a few tests that physicians can sometimes order:
- Esophageal manometry: A test that evaluates the function of the esophageal muscles.
- Esophageal acid testing: A test that evaluates whether a child has acid reflux.
- Fiberoptic Endoscopic Evaluation of Swallowing (FEES) or Flexible Endoscopic Evaluation of Swallowing with Sensory Testing (FEESST): A test that allows for the direct observation of the swallowing process (a non-radioactive alternative to barium swallow studies).
- Ultrasound testing: A low-cost non-invasive evaluation method for identifying muscular dysfunction.
- Videofluoroscopy swallowing studies or modified barium swallowing study: Tests that observe the swallowing process using X-rays and barium; used to determine optimal food consistencies.
- CT scans or MRIs
- Abdominal angiograms
- Biopsies and blood tests
The kinds of tests doctors will recommend will vary depending on a child’s medical history, reported concerns, and other factors.
What can parents do to help their child obtain adequate nutrition if their child has nutritional difficulties?
First and foremost, dietary interventions should always be done under the supervision of a medical professional. Parents should consult with their child’s medical team before beginning new interventions. Generally, the medical team will recommend non-surgical interventions first. If non-surgical approaches don’t work, they may then recommend surgical interventions.
Considerations that medical professionals may ask caregivers to change include:
- Changing the consistency or texture of certain foods: If food is too solid or liquid is too thin, it can be harder to manipulate into the esophagus. Parents can be recommended to:
- Puree solid food
- Cut food into small pieces
- Thicken liquids
- Changing the child’s bodily position during eating: sometimes physicians may recommend tucking the chin during mealtimes to facilitate swallowing and decrease the risk of food entering the trachea.
- Adding high-calorie supplements or smoothies to the child’s diet: Prevents malnutrition.
- Adding leafy greens: For added vitamins and minerals, as well as fiber/bulk to prevent constipation.
- Adding healthy fats for increased calorie density.
- Decreasing foods that are known to trigger constipation or acid reflux.
- Slowing down meals: Encouraging slower and more thorough chewing.
- Doing muscle exercises at home: Some speech-language pathologists (SLPs) may recommend doing exercises to strengthen the muscles involved in chewing and swallowing.
- Increasing fluid intake
- Developing detailed meal plans
- Providing medications (such as antacids or gastric enzyme inhibitors) for related health issues
- Methods of feeding (providing methods for the individual can self-feed and use adaptive eating equipment, providing enough time for swallowing, and modifying meal sizes for more frequent feedings)
- Providing more frequent or thorough oral health care to prevent drooling- or medication-related tooth decay, gum disease and oral infections.
In some cases, medical professionals may counsel parents to place the child on certain medications or have the child attend therapy to attempt to decrease the severity of the child’s chewing, eating and/or swallowing limitations. Surgery is typically used as a last resort, after evaluation by a medical professional, and can include:
- Inserting a feeding tube (such as an enteric tube, PEG tube, or G-tube): Surgeons insert a tube directly into the stomach, bypassing the mouth and esophagus entirely.
- Obstruction removal: Correcting physical defects and obstructions in the esophagus.
- Surgical management of achalasia: This can be done with a myotomy, where the lower esophageal sphincter is cut.
- Nissen fundoplication: For the control of gastroespohageal reflux disease (GERD).
What are some of the considerations that meal planning will take into account?
Parents may work with a nutritionist or dietician to evaluate and monitor a child’s nutritional needs, and develop a plan to help ensure the child’s nutrient intake is sufficient. There are numerous considerations that a comprehensive plan takes into account, and they can be seen here (pages 22-41). In very general terms, the elements of nutritional assessment include basic food/nutrient intake, the food intake process, the use of medications and supplements, knowledge about meal planning and nutrition, behavioral considerations, physical activity and function, and medical, diagnostic, treatment and social history.
What are some of the considerations that will make a meal plan successful?
To ensure that meal plans will be properly followed, there are certain factors that must be taken into account. A dietitian or nutritional counselor must take into account the following items when making a meal plan:
- The individual’s readiness to take action
- The individual’s desire to be healthier
- Perceived benefits of a dietary plan change
- Self-monitoring, evaluation and enforcement
- Expense and ease of meal plan enforcement
What are some of the signs that a child has a serious digestive issue?
Certain children with hypoxic-ischemic encephalopathy may have digestive difficulty due to secondary conditions stemming from the initial brain insult. Because this injury can cause effects in the gastrointestinal system, a consultation with a gastroenterologist may be warranted if a child has the following:
- Chronic pulmonary aspiration
- Bladder infections
- Gastrointestinal pain/discomfort
- Unexplained weight gain or loss
- Urinary incontinence
- Celiac disease
- Crohn’s disease
- Gallbladder disease
- Gastroesophageal Reflux Disorder (GERD)
- Irritable Bowel Syndrome (IBS)
- Peptic ulcers
Parents who are concerned about their child’s gastrointestinal health may seek an evaluation from their child’s primary care physician for a referral to a gastrointestinal specialist.