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Pediatric Feeding Disorders Continuum
Kennedy Krieger Institute • 707 North Broadway • Baltimore, MD 21205
Peter A. Girolami, PhD, BCBA
Eric Levey, MD
About Our Program:
Established in 1987, the Pediatric Feeding Disorders Program at the Kennedy Krieger Institute in Baltimore, Maryland, is one of the leading programs in the nation designed to help children participate during daily meals with their parents and caregivers by providing a comprehensive approach to treating feeding disorders.
Our program was one of the first to combine the medical expertise of gastroenterology (the study of the digestive system and its disorders) with the therapeutic techniques of behavioral psychology in the treatment of children with feeding disorders. Our interdisciplinary team of specialists can measurably improve a child's appropriate eating behavior while decreasing inappropriate behavior so that mealtime can become family time again.
Our ongoing commitment to implementing innovative methods to address increasingly complex feeding disorders helps ensure positive outcomes. As a result, our methods have become a national standard in the treatment of feeding disorders.
While a wide spectrum of factors can contribute to feeding disorders, certain medical and psychological conditions may accompany them. We see children with conditions related to one or more of the following:
- Gastroesophageal reflux disease
- Gastrointestinal motility disorders
- Food allergies
- Delayed exposure to a variety of foods
- Behavior management issues
- Oral-motor dysfunction
Our patients range in age from one to 12 years, with an average age of four years old.
Evaluation Clinic: Children receiving services in the program typically begin their assessment through an outpatient feeding and swallowing clinic where representatives from the core disciplines meet with the child and his/her parent/caregivers to conduct an initial evaluation. Based on the information obtained during this evaluation, the team meets and agrees upon general and specific recommendations, and if necessary, a treatment plan for the child. The child is then referred for inpatient, day treatment or outpatient services from the appropriate disciplines as needed. Throughout the child's course of treatment, the team works closely together to provide comprehensive assessment, treatment and follow-up.
Inpatient Program: Inpatient services are recommended for children with severe feeding difficulties (e.g., failure to thrive, vomiting, G-tube dependence, total food refusal) so that close medical assessments, nutritional monitoring, oral motor assessments and intense behavioral interventions can be conducted.
Day Feeding Program: Day treatment services are usually recommended for children whose medical status is stable, but mealtime behavior is sufficiently problematic to warrant more intensive treatment than that offered through outpatient services. Day treatment is typically provided five days per week on-site, with parent/caregivers implementing treatment on the weekends at home. Nutrition and gastroenterology also monitor the child's treatment course during day treatment.
Outpatient Services: Outpatient services recommended for children whose nutritional status is not severely impaired, yet mealtime behavior is problematic. These children are usually seen by behavioral psychology once or twice per week, with the majority of the intervention being implemented by parent/caregivers in the home. For all three-treatment modalities, parent/caregivers are trained to implement the behavioral protocols and should play an active role in decisions concerning the child's treatment course. The level of commitment and involvement of the parent/caregiver largely determine the ultimate success of every child's treatment.
As described above, children with severe feeding difficulties (e.g., failure to thrive, vomiting, G-tube dependence, total food refusal) are usually referred for either inpatient or day treatment services to insure close monitoring by all disciplines. Each discipline conducts a variety of assessments to determine the child's course of treatment. For example, medical work-ups may be required to rule-out or begin medical treatments for possible physiological etiologies of the feeding problem. Behavioral psychology will assess the severity and type of the child's food refusal or selectivity, observe meals and begin to evaluate treatment options based on the information gathered. An occupational therapist or speech pathologist specializing in feeding issues may need to assess the child's oral motor abilities to determine whether or not the feeding difficulty is related to neurological deficits or oral motor dysfunction. A nutritionist may need to evaluate the nutritional and caloric requirements for catch-up growth. Finally, social work may need to assist the family in dealing with psychosocial issues and/or identifying and obtaining other community resources.
During the first week of a child's inpatient admission, a steering meeting is held during which the team discusses each member's evaluation results and discusses potential goals for admission. Immediately following this meeting, a parent/caregiver conference is held with all participating disciplines present to review and finalize goals with the parent/caregivers. Throughout the child's admission, the team and parent/caregivers work together with each discipline coordinating therapies to meet the child's admission goals. Typical admission goals include, but are not limited to:
- Increase weight
- Increase PO intake
- Increase food texture/types of food consumed
- Decrease G-tube/bottle dependence
- Decrease mealtime inappropriate behaviors
- Assessment of and reduction of mealtime emesis (vomiting)
The interdisciplinary team and the caregivers develop measurable goals for each child's feeding behavior. Feeding behaviors are objectively measured and treatment decisions are data-based. Outcomes are assessed regularly throughout the admission. A primary goal is to establish feeding patterns, which can be maintained by the caregivers in the home and in other environments. Thus, caregiver training is an essential component to the success of the program.
Almost all children with feeding disorders display inappropriate mealtime behavior that interferes with food consumption, regardless of the disorder's etiology. Therefore, a major focus of the program for most children is on the behavioral assessment and treatment of feeding problems. The pediatric feeding disorders program has a long and successful history of applying the principles and procedures of applied behavior analysis to the assessment of feeding disorders. Throughout the child's admission, individualized behavioral assessments are conducted for a number of reasons: (a) to identify the appropriate behavioral treatment procedures; (b) to assess the efficacy of ongoing treatment and (c) to determine the components of treatment necessary to maintain treatment gains. Throughout the child's admission, the interdisciplinary team meets regularly to continually review and adjust the child's treatment as necessary to meet admission goals.
Prior to discharge, a parent/caregiver meeting is held to review with the parent/caregiver the outcomes of treatment and plans for follow-up care. Typically, children receiving behavioral treatment during the admission will receive follow-up services from behavioral psychology for two years post-treatment, with continued adjustment and monitoring of home treatment protocols to ensure the child's continued improvement at home. Other disciplines will also provide follow-up services, usually through Feeding and Swallowing Clinic visits, or in conjunction with the behavioral psychology follow-up.
Hours of Operation:
Inpatient: Monday - Sunday, 8:30 a.m. - 5:00 p.m.
Day Treatment: Monday - Friday, 8:30 a.m. – 5:00 p.m.
Oupatient: Determined by family and therapist
For more information, please call the Care Management Office:
Toll-free Referral: (888) 554-2080
Baltimore Metropolitan area: (443) 923-2969
Referral specialists are available from 8:30 a.m. to 5:00 p.m., Eastern Standard Time (EST), Monday through Friday, and will gladly answer your questions. If you reach voice mail, please leave a message and a referral specialist will promptly return your call.