CHAPTER 8

Exclusive breastfeeding is recommended by the American Academy of Pediatrics (AAP) for about the first 6 months of a child’s life. Readiness skills indicate when to offer solids in addition to breast milk (Box 8.1).

Box 8.1. Readiness Skills for Solids

Mastering the ability to eat solid foods requires oromotor control and reduction in sensitivity to touch around the mouth and lips. Infants first exposed to food textures after 9 months of age are more likely to have feeding difficulty and be experienced as fussy eaters. First foods can be mashed or pureed meat, a single grain, fruit, or vegetable; one new food should be offered every 2 to 3 days, so caregivers can monitor for reactions. Within a few months, the infant should be eating a variety of food groups.

Finger feeding requires an infant to sit independently (expected at around 6 months of age) and to have a pincer grasp (expected at around 9 months of age). Small pieces of soft food that are easy to pick up and swallow include noodles, banana, scrambled egg, tofu, sweet potato, avocado, or ripe pear. From early on, anticipatory guidance can promote healthy eating behaviors for the developing child (Table 8.1).

By 19 to 24 months of age, from 20% to 60% of toddlers are described as picky eaters.¹ Picky eaters have strong preferences about food groups and/or preparation, agree to a limited variety of options, and often impact mealtime harmony for their families.² Food preference results from a combination of genetics, exposures, feeding context, and associated physical and social consequences.³ Clinicians can educate parents of young children about their ability to encourage healthy eating to impact lifelong health.⁴ However, picky eating itself is common, and children who are growing and developing well need not be referred to a specialist unless there is excessive family distress.

The feeding and eating disorders described in the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5)5 include pica, rumination disorder, avoidant/ restrictive food intake disorder, anorexia nervosa (AN), bulimia nervosa (BN), and binge eating disorder (BED). Primary pediatric health care professionals may see many children diagnosed with the avoidant/restrictive food intake disorder (ARFID), which replaces the previous diagnosis of “feeding disorder of infancy or early childhood.” It no longer requires onset before 6 years of age. Avoidant/restrictive food intake disorder therefore captures both children and adolescents. Initial studies characterize affected children as often having picky eating since early childhood, along with generalized anxiety and/or gastrointestinal symptoms and/or fears of eating related to vomiting, choking, or food allergies.⁶

Anorexia nervosa, BN, and BED typically present in adolescence. A final diagnosis of “other specified feeding or eating disorder” (OSFED) includes 5 disorders: AN, BN of low frequency and/or limited duration, BED of low frequency and/or limited duration, purging disorder, and night eating syndrome. Unspecified feeding or eating disorder (UFED) is warranted for patients not meeting more specific diagnostic criteria.

Assessment always begins with a careful history (perinatal, developmental, feeding, medical, family, and social history), dietary assessment, and physical examination (including growth parameters over time). Medical conditions (eg, dysphagia and aspiration), environmental factors, and cultural practices must be explored and addressed when appropriate. Details about mealtime activities and behaviors should be elicited, and ideally, the clinician should observe a live or videotaped feeding interaction. Organic and behavioral red flags are listed in Box 8.2. Investigation routinely includes complete blood counts, full biochemistry panel, thyroid function tests, urinalysis and culture,⁷ and celiac serology. Referral to a speech and language pathologist and/or occupational therapist is indicated with suspicion of oral motor delay and oropharyngeal dysphagia. A dietitian might evaluate caloric and nutritional intake. Gastroenterologists and developmental-behavioral pediatricians might evaluate (and co-manage) contributing causes. Inpatient hospitalization is warranted only for the most difficult cases.

Box 8.2. Red Flags in the Evaluation of Feeding Concerns

Adapted with permission from Kerzner B, Milano K, MacLean WC, et al. A practical approach to classifying and managing feeding difficulties. Pediatrics. 2015;135(2):346.

Treatment

Behavioral interventions start with anticipatory guidance in the medical home. If office-based counseling is not successful, referral to an expert in behavioral treatment is indicated. Pica rarely requires surgical removal of ingested contents. Subsequently, for pica, RD, and ARFID, behavioral treatment with a specialist is indicated. Milder cases are often treated successfully with a nutritionist or registered dietitian. Some children will require referral to a psychologist, speech pathologist, and/or occupational therapist with specific expertise in treating children with feeding disorders. Overall, limited randomized controlled trials exist to guide treatment, but behavioral intervention is the principal method for more involved cases and is backed by a preponderance of evidence suggesting positive outcomes. Behavioral methods often used include relaxation to reduce arousal, desensitization, and positive reinforcement. Treatment is ideally multidisciplinary, with a primary focus on responding to hunger and satiety with patience and encouragement within developmentally appropriate expectations. Treatment is typically outpatient, can be individual or group, and must include a caregiver component. Calorie concentration and off-label use of appetite-enhancing medication may take place while or after behavior and context are addressed; nonoral methods of feeding, such as temporary nasogastric tube use, should occur only after multidisciplinary treatment has been unsuccessful in the context of nutritional compromise. Inpatient therapy is indicated only for those most severely involved. Follow-up focuses on anthropomorphic trajectory.

As a first step, it is helpful to be familiar with the necessary amount of time a typical child should sleep each day; a child’s sleep requirement varies with age. Sleep recommendations vary, as listed in Figure 8.1.

Figure 8.1. Recommended hours of sleep by age group.

Republished with permission of American Academy of Sleep Medicine, from Paruthi S, Brooks LJ, D’Ambrosio C, et al. Consensus Statement of the American Academy of Sleep Medicine on the recommended amount of sleep for healthy children: methodology and discussion. J Clin Sleep Med. 2016;12(11):1549-1561; permission conveyed through Copyright Clearance Center, Inc.

Anticipatory guidance around sleep and the identification of sleep problems are an important component of well-child care. Allen et al8 proposed use of the mnemonic, ABCs of SLEEPING, as a tool for primary pediatric health care professionals to identify sleep problems and to counsel patients and families regarding healthy sleep. The mnemonic is as follows:

ABCs: Age-appropriate Bedtimes and wake-times with Consistency of

   Schedules and routines

  Location

  Exercise and diet

  No Electronics in the bedroom or before bed

  Positivity

  Independence when falling asleep

  Needs of child met during the day

  Equal Great Sleep

Sleep recommendations, and the level of empirical support for these recommendations, are summarized in Table 8.2.⁸

Sleep Disorders

The prevalence of sleep problems presenting in the primary care setting varies widely depending on the method of data collection (parent report versus primary care provider report versus record review). Overall, primary pediatric health care professionals estimate that sleep challenges occur in approximately 20% of children aged 6 months to 4 years.⁹ However, primary pediatric health care professionals may underestimate sleep problems in older children and adolescents and underdiagnose sleep disorders.

The following describes the most common disorders of sleep development encountered in pediatrics:

1. Sleep terrors/night terrors: Sleep terrors are nighttime arousals that occur during nonrapid eye movement (NREM) sleep. Because NREM sleep occurs earlier in sleep, sleep terrors do as well. Sleep terrors present as episodes of abrupt terror associated with an alarming vocalization and signs of autonomic arousal in children typically between the ages of 2 and 12 years. Children who experience night terrors are confused during the episode (often not recognizing their parents), are difficult to console, and cannot recall the episode afterward. As a result, families are more distressed by sleep terrors than the child is.

Potential factors that may be linked to both sleep terrors and sleepwalking include: sleep deprivation, stress, obstructive sleep apnea syndrome (OSAS), restless legs syndrome (RLS), and sleeping in unfamiliar settings.10 Children who experience sleep terrors often have a family history of sleep terrors as well.

Aside from screening for sleep disorders like OSAS and RLS, management of sleep terrors primarily focuses on counseling families. However, in the case of nightly sleep terrors, scheduled awakenings 15 to 30 minutes before the time at which episodes typically occur may be helpful for 2- to 4-week periods that can be repeated as needed. If sleep terrors persist, low-dose clonazepam (0.125–0.5 mg at bedtime) for 3 to 6 months, with a slow taper, may be helpful. Common side effects of clonazepam include drowsiness, ataxia, and behavioral problems.¹¹

2. Somnambulism: Somnambulism, or sleepwalking, is also an arousal disorder that occurs during NREM sleep. Again, because NREM sleep occurs earlier in sleep, sleepwalking does as well. Sleepwalking behaviors are quite variable and can include walking, running, as well as complex tasks out of the bed. When others attempt to intervene or redirect the sleepwalker, the individual may be inappropriate or unresponsive.

The diagnosis of sleepwalking is made by parent/caregiver history, as individuals have partial to complete amnesia of sleepwalking episodes. Key components of the history, in addition to those just described, include the recurrent nature of these episodes of incomplete awakening, as well as limited to no associated dream imagery.

Given the potential for some children who sleepwalk to leave the home during an episode, safety considerations are a key component of overall management (Box 8.3).

Box 8.3. Safety Considerations for Sleep Walkers

If sleepwalking persists, clinicians can consider low-dose clonazepam at bedtime for a period of 3 to 6 months, followed by a slow taper.

3. Obstructive Sleep Apnea Syndrome: Obstructive sleep apnea syndrome is a sleep disorder commonly resulting from upper airway obstruction that causes partial to complete airway obstruction during sleep. These periods of obstruction cause increased respiratory effort, disrupted sleep, and alterations in gas exchange.

Greater than 95% of cases of OSAS are caused by structural airway obstruction, with the small remainder resulting from neurological causes. The prevalence of OSAS in children from 2 to 8 years of age is between 1% and 5%. This peak incidence period may be due to the relative size of the tonsils and/or adenoids in comparison to the upper airway at this time in development.

The pathophysiology of OSAS is not completely known; however, factors that decrease upper airway size or increase upper airway collapsibility increase the likelihood of OSAS.12 These can include adenotonsillar hypertrophy, obesity, craniofacial abnormalities, and inflammatory causes like rhinosinusitis. When caring for children with Down syndrome, providers should ask regularly about symptoms of OSAS. In addition, all children with Down syndrome should complete a sleep study by 4 years of age.

At night, individuals with OSAS present with snoring, witnessed apnea, gasping or snorting, mouth breathing, restless sleep, sleepwalking, night terrors, diaphoresis, frequent awakenings, nocturnal enuresis, unusual sleep position, and/or paradoxical chest wall movement. These individuals may present with daytime sleepiness, difficulty waking, headaches, hyponasal speech, inattention, hyperactivity, impulsivity, irritability, depression, and/or aggression.

The gold standard for diagnosis of OSAS is nocturnal in-lab polysomnography. Treatment options for OSAS fall into the broad categories of surgery (eg, tonsillectomy/adenoidectomy), medications (eg, topical nasal glucocorticoids), and positive airway pressure. Positive airway pressure is indicated when a child experiences persistent OSAS symptoms despite adenotonsillectomy, in the setting of minimal adenotonsillar tissue, or when surgery is contraindicated.

Untreated OSAS can have a variety of consequences ranging from cardiovascular (increased susceptibility to pulmonary hypertension and right heart failure in severe cases) to impaired cognitive and behavioral functioning (attention-deficit/ hyperactivity disorder [ADHD]-like symptoms, learning challenges) to metabolic effects (fatty liver disease, dyslipidemia).

4. Restless Legs Syndrome: Restless legs syndrome is a condition that is characterized by the urge to move one’s legs or by an unpleasant feeling described by some children as pain, difficulty getting comfortable, or a “creepy crawly” sensation. These unpleasant sensations are relieved by movement or distraction. Children with RLS experience these sensations during both the day and night; however they can become more notable at nighttime. As such, approximately 85% of children with RLS experience sleep disturbance.

Although the pathophysiology of RLS is not completely known, genetic factors as well as the dopamine pathway are thought to contribute to RLS. It is important for clinicians to note that low iron status also is a risk factor for RLS. Iron plays a role in dopamine synthesis, myelin synthesis, energy production, and neurotransmitter systems that may contribute to RLS.¹³ Recognizing the role of iron in RLS is important, as it provides a potential source of intervention. Serum ferritin levels are found to be low in more than 80% of children with RLS.

The diagnosis of RLS is made through a focused history (see Box 8.4 for criteria). Once diagnosed, serum ferritin levels should be obtained. There is some disagreement among experts regarding a threshold for a low ferritin. Some suggest iron supplementation for a ferritin level below 50 mcg/L, while others suggest a cutoff of 75 mcg/L. Children with low ferritin levels should be treated with 2 mg/kg to 4 mg/kg of elemental iron up to twice a day (but check for maximum dosing, to avoid overdosing children with obesity). In 3 months, symptoms should be reassessed and serum ferritin rechecked. However, providers should recall that ferritin is an acute-phase reactant and may be artifactually elevated by inflammation or infection.

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