CHAPTER 8 Development and Disorders of Feeding, Sleep, and Elimination Marie Reilly, MD Feeding Milestones 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 ▶ Does the infant hold his or her head up while sitting in a supportive chair? ▶ Does he or she watch adults’ eating behavior? ▶ Does he or she reach for food on other people’s plates? ▶ Is he or she opening his or her mouth when food is coming? ▶ Can he or she move food from a spoon to his or her mouth then his or her throat? ▶ Has the child reached twice the birth weight? 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.
Alison Schonwald, MD, FAAP
Development and Disorders of Feeding, Sleep, and Elimination
Marie Reilly, MD
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
▶ Does the infant hold his or her head up while sitting in a supportive chair?
▶ Does he or she watch adults’ eating behavior?
▶ Does he or she reach for food on other people’s plates?
▶ Is he or she opening his or her mouth when food is coming?
▶ Can he or she move food from a spoon to his or her mouth then his or her throat?
▶ Has the child reached twice the birth weight?
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.
Table 8.1. Anticipatory Guidance
Regularly scheduled time-limited meals
Prevents grazing; maintains schedule
Opportunity to develop hunger and satiety and develop preference for healthy eating
Neutral, distraction-free environment
Limits conflict, keeps focus on eating
Allow children to play with food, tolerate mess
Uses typical developmental learning; maintains positive environment
Provide the same food for all family members
Expands variety of food texture, flavor, and parents model healthy food choices
Small portions, easy to bite or grasp
Adapted with permission from Phalen JA. Managing feeding problems and feeding disorders. Pediatr Rev. 2013;34(12):552.
Feeding and Eating Disorders
Feeding disorders occur in only 3% to 5% of children. In contrast to picky eating, true feeding disorders are characterized by significantly impaired physical health or psychosocial function. Feeding disorders are more common (up to 80%) in children with developmental disabilities, such as cerebral palsy, autism spectrum disorder, intellectual disability, and other chronic medical conditions (40% to 70%); they are also associated with gastrointestinal disorders (including gastroesophageal reflux and constipation) and craniofacial abnormalities.
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
Disruptive and stressful mealtimes
Failure to advance textures
Forceful, intrusive feeding
Abrupt cessation after trigger event
Signs and Symptoms
Appearance of pain with feeding
Vomiting and diarrhea
Chronic cardiorespiratory symptoms
Failure to thrive
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.
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.
Quality sleep is important to a child’s overall growth and development. Decreased sleep can negatively impact children’s emotional, behavioral, and cognitive functioning. Disrupted sleep can impact not only the child’s overall functioning, but that of his or her family as well. Primary pediatric health care professionals therefore have the opportunity to have a significant impact on the lives of children and their families by providing age-appropriate anticipatory guidance, as well as screening for and managing common pediatric sleep issues.
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
Exercise and diet
No Electronics in the bedroom or before bed
Independence when falling asleep
Needs of child met during the day
Equal Great Sleep
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.
Table 8.2. Sleep Recommendations and Level of Support
Clinicians Should Ask About
Level of Support
Age-appropriate bedtimes and wake-times with consistency
Timing and regularity
Strong support for ensuring that children nap, go to bed, and wake up at times that allow them to obtain age-appropriate amounts of sleep
Moderate support for bedtimes no later than 9:00 pm
Moderate support for maintaining a regular sleep schedule
Insufficient support that sleep schedules should not vary more than 30-60 minutes
Schedules and routines
Daily routines, Bedtime routines
Strong support for establishing bedtime routines Insufficient support for wake time routines Insufficient support for consistency in daytime routines
Quiet, Comforts, Ambient light
Limited support for children’s rooms needing to be dark
Limited support for quiet bedrooms
Equivocal support for avoiding sounds as children go to sleep
Equivocal support for children needing their own bedroom
Insufficient support for children having a comfortable bed in a familiar bedroom
Exercise and diet
Timing of activity, Amount of activity, Caffeine, Eating before bed, Sugar
Limited support for limiting caffeine consumption
Limited support for maintaining a healthy, balanced diet
Limited support for children not going to bed hungry or not consuming a large meal before bedtime
Equivocal support for engaging in daily physical activity
Insufficient support for not eating too much close to bedtime
Non-support for avoiding exercise within 1-4 hours of bedtime
No electronics in the bedroom or before bed
Strong support for limiting access to electronics during and after bedtime by removing them from children’s bedrooms
Moderate support for establishing a positive atmosphere in the child’s living environment
Limited support for parents maintaining a positive attitude toward sleep
Limited support for children being relaxed and calm before bed
Limited support for children avoiding fun, exciting, or frustrating activities before bed
Independence when falling asleep
Parental presence, Sleep associations
Strong support for children learning to settle in their own bed, without their parents to avoid dependence on parental presence to fall asleep or after night wakings
Needs of child met during the day
Attachment; Emotional needs
Moderate support for ensuring children’s emotional needs are met during the day
Insufficient support for ensuring that children’s physiological needs are met during the day
Adapted from Allen SL, Howlett MD, Coulombe JA, Corkum PV. ABCs of SLEEPING: a review of the evidence behind pediatric sleep recommendations. Sleep Med Rev. 2016;29:1–14, with permission from Elsevier.
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
▶ Place alarms or bells on doors and windows.
▶ Remove potentially dangerous items from the child’s room and common pathways.
▶ Have child sleep on mattress on first floor.
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.
Box 8.4. Criteria for Restless Legs Syndrome
▶ Urge to move the legs; usually accompanied by, or thought to be caused by, uncomfortable and unpleasant sensations in the legs.
▶ Symptoms begin or worsen during periods of rest or inactivity.
▶ Symptoms are partially or totally relieved by movement.
▶ Symptoms occur exclusively or predominantly in the evening or night.