Serious food restriction may occur following an allergic reaction. Individuals with a pre-existing feeding/eating disorder, avoidant/restrictive food intake disorder (ARFID), may be at particular risk for detrimental effects. This Clinical Question describes the relationship between reactions and restricted eating, provides practical clinical guidance for intervention, and articulates a call for future research advancing evidence-based care for patients following a reaction.

Pediatric patients with medical/developmental conditions face increased risk for avoidant/restrictive food intake disorder (ARFID). Diet-managed chronic illnesses may heighten risk for disordered eating, with emerging research finding medical symptoms predating disordered eating behaviors. Pediatric-onset immunoglobulin E-mediated food allergy ("food allergy") is on the rise, affecting an astonishing 8% of US children. The relationship between food allergy and ARFID is puzzlingly understudied despite food allergy clearly altering the individual's relationship with food, posing continuous danger, and requiring persistent, fundamental eating changes to maintain safety. Food allergy is managed through strict dietary avoidance of allergen(s) and confers well-documented risk to psychosocial functioning. Dietary restriction exceeding medically required avoidance (as observed in ARFID) further compounds risk for adverse health and psychosocial impacts. In this Spotlight, our team of clinical researchers working at the intersection of ARFID and food allergy proposes a model identifying three areas of food allergy-specific impact that may drive the higher prevalence of ARFID within this population. Failure to successfully regulate these universal drivers to preserve daily functioning may precipitate the development of ARFID. We propose (1) unique characteristics of allergic reactions and medical treatment, (2) the impacts of chronic vigilance and avoidance, and (3) response to learning paradigms and physiological upregulation disrupt the development of feeding/eating for both patients and caregivers. Patients with food allergy + ARFID may also be especially vulnerable to iatrogenic harm from the imprecision of current allergy testing modalities. We outline the sparse literature on food allergy + ARFID comorbidity and call for ARFID-focused research in this area.

Pediatric feeding disorder is a prevalent, impactful diagnosis for children and their families. This diagnosis is heterogenous in presentation and requires the care of a multidisciplinary team of providers. Existing research suggests providers are underprepared to assess and treat pediatric feeding disorder, therefore more information on training and clinical practice is needed. This study conducted focus groups to describe the training journey of providers across all four pediatric feeding disorder domains (medical, nutrition, feeding skill, psychosocial). Seven focus groups (total of 25 providers) were conducted and analyzed using thematic analysis. Four themes were identified: differences in academic preparation, workplace infrastructure and access, desire for comprehensiveness and feasibility, and value of the family perspective. Overall, results point to opportunities to improve provider training and therefore patient care including academic exposure to pediatric feeding disorder and multi-disciplinary collaboration practices, increased access to mentorship, training, and evidenced-based resources, and enrichment of the research to practice pipeline with a focus on family-centered care.

Objective: To produce a consensus statement on the psychological treatment of feeding/eating aversions seen in pediatric feeding disorder (PFD) and avoidant/restrictive food intake disorder (ARFID), diagnoses that share common symptoms and psychological mechanisms but have historically been addressed separately in the literature. Method: To help bridge the gaps between ARFID and PFD treatment and research, we convened a group of experts to clarify and describe the psychological interventions for treating learned food avoidance. The current manuscript summarizes the conclusions of the meeting. Result: The primary outcome of the consensus process was a description of a common core approach to psychological intervention across the two fields: Exposure to food and the feeding/eating experience with the goal of increasing the volume and variety of food and fluid consumed. Although our consensus process identified some differences in the mode of delivery and incorporation of specific treatment elements, the consensus panel agreed that these differences are related to three primary factors: the severity of clinical impairment, age and developmental status of the patient, and the specific feeding and eating behaviors targeted, rather than to the ARFID/PFD diagnostic distinction. Discussion: Building on the consensus statement, we discuss other considerations in preparing for and delivering exposure-based treatment, including multidisciplinary assessment, readiness for treatment, and systemic factors that influence access and engagement.

OBJECTIVE:Evaluate the outcomes of individuals with intellectual and developmental disabilities (IDD) admitted to an intensive behavior treatment program to reduce severe externalizing behavior (e.g., aggression; self-injury). METHODS:The authors conducted a retrospective electronic health record review of 40 consecutive patients aged 6 to 19 years with severe externalizing behavior causing imminent risk of harm to self or others over a 4-year period (January 2020 to December 2023). The intensive outpatient model involved daily intervention (Monday-Friday; 5 hours per day across an approximate 5-month period) that was structured and individualized based on the tenants of applied behavior analysis. Systematic data extraction included participant characteristics, outcomes of behavioral assessments, components of the behavioral intervention, percent reduction of externalizing behavior, and percent of caregiver-directed goals met. RESULTS:All participants had a diagnosis of autism and 80% had a co-occurring intellectual disability. Participants presented with 3 primary types of externalizing behavior-aggression (87.5%), disruption (82.5%), and self-injury (67.5%). At discharge, participants had a 90.74% reduction in externalizing behavior and 82.5% of participants met their primary caregiver-directed goal. CONCLUSION:Findings provide provisional evidence regarding the benefits of intensive behavioral treatment for children with IDD and severe externalizing behavior.

Some significant clinical feeding disorders, such as avoidance restrictive food intake disorder (ARFID), resemble the features of a conditioned taste aversion (CTA) in animals that have learned to avoid a novel taste that has been previously paired with illness. These findings suggest that pharmacological manipulations that effectively facilitate CTA extinction in preclinical studies maybe useful pharmacological adjuncts to exposure therapy in the clinic. The present study investigated the efficacy of d-cycloserine (DCS) in promoting CTA extinction. Male and female rats were given an injection of the gastric discomfort-inducing agent lithium chloride (LiCl) paired with the novel taste of saccharin, which is the gold standard for inducing CTA in preclinical studies. Females needed a higher dose of LiCl to induce a similar reduction to males and DCS did not promote extinction in either sex. A series of experiments in male rats then demonstrate that DCS promotes an aversion to saccharin aversion rather than reducing it. Moreover, the effects of DCS depend on whether the rats have begun to increase intake during extinction trials (i.e., extinction learning). More specifically, DCS did not affect intake in rats who are extinguishing but reduced intake in rats who were not extinguishing, presumably by facilitating the reconsolidation of the original fear memory. These findings highlight the importance of the timing of pharmacological adjuncts to exposure therapy and the need to wait until there are signs that exposure therapy is working before administering a memory facilitating treatment to avoid enhancing memory reconsolidation and exacerbating the feeding disorder.

OBJECTIVE:To examine clinical correlates of insomnia symptoms in children with autism spectrum disorder ascertained from a general outpatient autism clinic. STUDY DESIGN:This analysis included 103 children with autism spectrum disorder (mean age = 5.8 ± 2.2 years; range 2-10, 77.7% male). A multidisciplinary team assessed medical and psychosocial histories using parent ratings from the Pediatric Autism Insomnia Rating Scale (PAIRS), Aberrant Behavior Checklist (ABC), Brief Autism Mealtime Behavior Inventory, and the Parent Health-Related Quality of Life and Family Functioning and Family Functioning Surveys. Height and weight were collected. Children in the current sample with scores on the PAIRS ≥ 22 were compared with those with a mean PAIRS score < 22. Univariable and multivariable logistic regression modeling was used to evaluate clinical correlates with insomnia symptoms ≥ 22. Best subset selection approach identified the most important predictors. RESULTS:The PAIRS mean was 18.39 ± 14.54 (range 0 to 58); 33% scored ≥ 22. After adjusting for confounders, disruptive mealtime behaviors (P < .001), parent health-related quality of life and family functioning (P < .001 to .001), ABC subscales (P < .001 to .022), and dietary supplements (P = .019) were significantly associated with PAIRS ≥ 22. There were no group differences in height, weight, constipation, or demographics. Best subset modeling showed ABC hyperactivity/noncompliance, dietary supplements, and mealtime behaviors as the most significant predictors (receiver operating characteristic = 0.842, χ2(df) = 32.84 (3), χ2Diff. = 4.80,P < .001). CONCLUSIONS:The PAIRS appears useful for characterizing the nature and severity of current insomnia symptoms in autistic children.

Expert consensus previously established a framework for characterizing patients with pediatric feeding disorder (PFD) through a multidisciplinary case report form (CRF) methodology. Field testing of the PFD CRF and creation of a shared patient database represented next steps in the development of this clinical tool. The current study assessed the acceptability and feasibility of the PFD CRF through data collection across three feeding programs involved in the initial development of the CRF. A total of 80 patients completed multidisciplinary team evaluations and contributed data to the current evaluation of clinical implementation. Data analysis and feedback from end users (i.e., multidisciplinary care teams) subsequently guided CRF revisions. Results suggests the PFD CRF represents a feasible and practical method of common data collection across institutions, while also providing important insights into future research and dissemination efforts.

Objectives:To evaluate the long-term follow-up status of patients with a history of feeding tube dependence who completed a multidisciplinary, day treatment program. Method:We conducted a 17-item Qualtrics survey of patients who participated in treatment to improve the volume and variety of solid food intake and replace enteral feeding due to chronic food refusal an average of 6 years following intervention. Results:Of the 81 patients included in the original outcome study, 75 met eligibility criteria; 36 caregivers (48%) completed the survey. Survey respondents and non-respondents were similar in terms of patient demographics and status at discharge. Most patients (80%) who achieved full wean from feeding tube dependence at program discharge maintained their wean at the time of the survey. Most caregivers (89%) described their child's relationship with food as "good" or "neutral". Discussion:Intensive multidisciplinary intervention holds benefits for children with complex feeding problems, including advancing the volume and variety of food consumed during meals and reducing the need for enteral feeding. The durability of these benefits, however, is not well understood. The current follow-up survey of patients who completed an intensive feeding program suggests that treatment gains, such as the reduction of tube dependency, endure for most patients. Conclusion:Our findings provide provisional evidence of the long-term effectiveness of our intensive multidisciplinary model in promoting oral intake and reducing tube dependence among young children with chronic food refusal. Future research should seek to better understand who benefits most from this model of care.

OBJECTIVE:The primary objective of this pilot trial was to determine to what extent hunger provocation, via rapid weaning from enteral feedings, was acceptable and feasible and to evaluate the effect of this intervention when used during intensive multidisciplinary feeding intervention for children dependent on enteral feedings. METHOD:The study was conducted at an Intensive Multidisciplinary Program located in the Southeastern United States from May 2021 to October 2023. Children were randomly assigned 1:1 to standard wean or rapid wean using permuted blocks of 2 and 4 with allocation pattern concealed to investigators resulting in respective cohort sizes of 8 (N = 16 participants, total) for 8 weeks. Feasibility benchmarks and data completeness were summarized using percentages and means. The study also evaluated the effect of intervention on treatment outcomes including weight-for-age z-score, percentage of daily caloric needs met by mouth, percent of patients achieving ≥1 day where 100% of caloric needs were met via oral feeding, and time to effect. RESULTS:Feasibility and acceptability benchmarks were achieved. Preliminary outcome data suggest rapid tube weaning did not influence reaching 100% oral intake or fully weaning from a feeding tube when used as an adjunct to behavioral intervention. CONCLUSION:This study was a prerequisite to support a future efficacy randomized clinical trial to further study how to optimize outcomes to achieve full weaning from tube feeding.

Diagnostic ambiguity has surrounded the two primary diagnoses for dysfunctional feeding and eating in pediatric populations-that is, pediatric feeding disorder (PFD) and avoidant restrictive food intake disorder (ARFID). Recent expert consensus emphasized the need for diagnostic refinement to enhance understanding and improve clinical and research activities for both conditions. With the proposed revision of ARFID, Zickgraf and colleagues provide a research grounded springboard for beginning the revision process. The proposal centers upon a new Criterion A that emphasizes ARFID as a disorder driven by a negative, temporally proximate association with eating/food involving three distinct, yet potentially co-occurring responses of disgust/distaste, anhedonia/uncomfortable fullness, and acute fear/panic. In this commentary, we consider the potential benefits of the proposed framework from the PFD perspective and identify three additional areas-DSM text revisions, benefits of a shared feeding and eating disorder diagnosis, and a call for education and advocacy to complement future revisions-for further consideration during work to improve PFD and ARFID diagnostic systems.

B.K. was a 10-year-old male patient who presented for evaluation and treatment by our multidisciplinary pediatric feeding team located in the Southeast US. He presented with formula dependence and total food refusal. B and his family traveled from a different region of the US to access subspecialty care due to the medical urgency of B's feeding problems. He was receiving 100% of his nutritional needs from a hypoallergenic formula and accepted a limited number of foods (eg, beef jerky, chicken wings) by mouth that he would masticate but spit out before swallowing. He was admitted to our 8-week intensive multidisciplinary intervention program, which treats severe avoidant/ restrictive food intake disorder (ARIFD) and pediatric feeding disorder. His admission was considered medically urgent, as B's sole source of nutrition (one specific hypoallergenic formula) had been discontinued. The family had recently tried introducing a new formula, but B's persistent refusal of alternative means of nutrition had resulted in an inpatient hospitalization due to acute weight loss and malnutrition. At the time of admission to the intensive feeding program, B's family had about 3 weeks' supply of formula remaining.

Doctoral psychology internships play a key role in the development of the competencies of the clinical child and adolescent psychologist workforce needed to serve the increasing behavioral and mental health needs of children. This study surveyed 50 internship training directors regarding workforce needs, the structure of experiential internship components, and the organizational infrastructure and funding of internship programs that provide focused care to children and adolescents within medical settings. Findings suggest that internships most commonly occur within academic medical settings and include clinical child psychology, integrated care, pediatric psychology, neuropsychology, and developmental disabilities tracks. On average, sites had 6 interns, 3 tracks, and 4 major rotations per track. Training directors identified program funding to be the greatest barrier to sustaining internship programs. Currently, internships are funded through clinical revenue, grants, and organizational funds covering an average intern salary of 31,020 plus benefits as well as 0.3 FTE of a training director’s time to administrate the program. The number of internship tracks within a single program was associated with greater administrative time for the training director. Implications for advocacy at the federal, state, profession, and institutional level to increase funding and decrease barriers to training are discussed.

Background:Although intensive multidisciplinary interventions (IMIs) provide benefits for patients with pediatric feeding disorders (PFD), access to these programs is limited and challenges faced by the programs remain unclear. Objective:To better understand the barriers faced by existing day programs that provide IMI, disparities in patient care, and areas for improvement to better inform policy and improve access to treatment for PFD. Methods:Semi-structured interviews were conducted with a leader of outpatient programs providing IMI in the United States. Data regarding leader's perspectives on disparities in patient care, barriers faced by the intensive multidisciplinary feeding day programs, and future goals and directions for their programming were collected. Afterward, a qualitative content analysis was conducted to consolidate and categorize information related to patient care, access, and barriers faced by day programs and patients with PFD. Results:Barriers and challenges were identified at the patient, program, and systems levels. Patient-level barriers included familial resources or socioeconomic status, geographic distance from the program site, and difficulty with the time commitment, whereas program-level barriers included limited site personnel and capacity and long wait times. System-level barriers primarily center on insurance, with inconsistent coverage of services and limited payer knowledge about PFD and IMI. Conclusion:IMIs are effective in managing PFD; however, a variety of patient-level, program-level, and systems-level factors serve as barriers for patient access to care and program success. Further research, improved reimbursement, and consensus statements on effective treatments can help improve access to and coverage for care, allowing for the development and sustainability of more programs.

Background Symptoms related to infant ankyloglossia/tongue-tie may deter mothers from breastfeeding, yet frenotomy is controversial. Methods Databases included PubMed, Embase, CINAHL, PsycINFO, Web of Science, and Google Scholar from 1961-2023. Controlled trials and cohort studies with validated measures of surgical efficacy for breastfeeding outcomes were eligible. Meta-analyses synthesized data with inverse-variance weighting to determine standardized mean differences (SMD) between pre-/postoperative scores. Results Twenty-one of 1568 screened studies were included. Breastfeeding self-efficacy improved significantly post-frenotomy: medium effect after 5–10 days (SMD 0.60 [95% CI: 0.48, 0.71; P < 0.001]), large effect after 1 month (SMD 0.91 [CI: 0.79, 1.04; P < 0.001]). Nipple pain decreased significantly post-frenotomy: large effect after 5–15 days (SMD −1.10 [CI: −1.49, −0.70; P < 0.001]) and 1 month (SMD −1.23 [CI: −1.79, −0.67; P = 0.002]). Frenotomy had a medium effect on infant gastroesophageal reflux severity at 1-week follow-up (SMD −0.63 [CI: −0.95, −0.31; P = 0.008]), with continued improvement at 1 month (SMD −0.41 [CI: −0.78, −0.05; P = 0.04]). From LATCH scores, breastfeeding quality improved after 5–7 days by a large SMD of 1.28 (CI: 0.56, 2.00; P = 0.01). Conclusions Providers should offer frenotomy to improve outcomes in dyads with ankyloglossia-associated breastfeeding difficulties. Protocol registration PROSPERO identifier CRD42022303838 . Impact This systematic review and meta-analysis showed that breastfeeding self-efficacy, maternal pain, infant latch, and infant gastroesophageal reflux significantly improve after frenotomy in mother-infant dyads with breastfeeding difficulties and ankyloglossia. Providers should offer frenotomy to improve breastfeeding outcomes in symptomatic mother-infant dyads who face challenges associated with ankyloglossia.

Pediatric feeding disorder (PFD) is increasingly common and is often treated by speech language pathologists (SLPs) and occupational therapists (OTs) in the community setting. However, the preparedness of these disciplines to effectively address PFD is relatively unknown. A national (US), online survey was disseminated to providers who assess and treat PFD. For the present analysis, the responses of SLPs (N = 418) and OTs (N = 195) related to their clinical background, educational background, post-graduate training, and self-rated clinical effectiveness were statistically analyzed and compared across the two disciplines. Both SLPs and OTs report feeling underprepared to work with PFD clients immediately following their academic training, but time spent in post-graduate training and years of clinical practice both significantly (p < 0.0001) increased feelings of effectiveness in assessing and treating PFD. Most SLPs and OTs pursued self-directed learning activities to increase competence, with the most common activities being article review, podcasts, and peer case review, although SLPs were significantly more likely to use podcasts (p < 0.0001) and peer review (p = 0.0004) than OTs. The most common barriers for providers were financial, time, travel, and institutional support barriers. While PFD is a key practice area of both SLPs and OTs, both provider groups feel unprepared and under-supported in providing competent care to these patients upon graduation. Future research and policy should support advancements in training for current SLPs and OTs related to PFD and address current barriers to a specialized educational pathway.

BACKGROUND:Food allergy (FA) affects around 5.6 million children in the United States, conferring risk for negative impacts on growth and psychosocial functioning. While evidence suggests a higher prevalence of feeding difficulties in children with FA, the link between FA and feeding dysfunction remains unclear. OBJECTIVE:To investigate feeding problems in children with parent-reported IgE-mediated FA and/or pediatric feeding disorder (PFD) compared with healthy children in a community-based sample and explore factors associated with feeding problems in children with FA. METHODS:A matched cross-sectional cohort study used survey data from 352 parents of children aged 6 months to 7 years who reported a diagnosed IgE-mediated FA and/or PFD (50 with FA only, 67 with FA and PFD, and 235 with PFD only). Healthy children were matched based on age, sex, race, and socioeconomic factors. Feeding problems were assessed using the Pediatric Eating Assessment Tool. Matched-pairs generalized linear regressions compared each cohort and explored factors associated with feeding problems in children with FA. RESULTS:Children with FA exhibited significantly higher feeding problems compared with healthy children. Children with a diagnosed PFD had more severe feeding problems, irrespective of comorbid FA. Factors linked with feeding problems in children with FA included older age, non-White race, increased medical comorbidity, and limited dietary variety. CONCLUSIONS:This study adds to evidence indicating a higher prevalence of feeding problems in children with FA. Clinicians treating FA patients should routinely screen for feeding and growth concerns and consider referral to multidisciplinary feeding programs as needed.

OBJECTIVES:Feeding difficulties after congenital heart surgery are a common concern for caregivers of children with CHD. Insight into the intricacies of their experience is lacking. With a better understanding, healthcare providers can continue to optimize the approach and support mechanisms for these families. This study will explore the psychosocial impacts on caregivers, define barriers to care, and identify areas to improve their care.STUDY DESIGN:This mixed-methods study combined semi-structured interviews with surveys. Purposive sampling targeted caregivers of a child who underwent heart surgery and was discharged with alternative enteral feeding access. A hybrid inductive-deductive methodology was used to analyse interview transcripts. Survey scores were compared to interview content for concordance.RESULTS:Fifteen interviews were conducted with socio-demographically diverse caregivers. Feeding difficulties were often identified as their greatest challenge, with the laborious feeding schedule, sleep deprivation, and tube management being common contributors. Most caregivers described feeling overwhelmed and worried. Time-intensive feeding schedules and lack of appropriate childcare options precluded caregivers' ability to work. Barriers to care included imperfect feeding education, proximity of specialist clinics, and issues with medical supply companies. Caregiver proposals for improved care addressed easing the transition home, improving emotional support mechanisms, and intensifying feeding therapy for expedited tube removal.CONCLUSION:This study describes the psychosocial toll on the caregiver, typical barriers to care, and ideas for improved provision of care. These themes and ideas can be used to advance the family-centered approach to feeding difficulties after heart surgery.