Feeding Dysfunction in Children with Eosinophilic Gastrointestinal Diseases

One of the most pleasurable and normal activities in a child's life is eating food. Certain gastrointestinal dysfunctions, however, can impact the pleasurable aspect of eating and in some circumstances, impair the child's growth.

A team of clinicians and researchers from Children's Hospital Colorado and National Jewish Health recognized this. Specifically, they noticed that eosinophilic gastrointestinal diseases (EGIDs), a group of increasingly common diseases associated with food allergies, can significantly impair the ability of some children to eat.

Dan Atkins, MD, Department of Pediatrics, National Jewish Health, and Allergy Section of Children's, noted that parents of children with EGIDs often reported difficulty feeding their children and voiced concern about growth and the difficulties of providing adequate nutrition. His colleague, Glenn T. Furuta, MD, Children's Digestive Health Institute, likewise noted that feeding problems are often the first symptoms of Eosinophilic Esophagitis (EoE). Drs. Atkins and Furuta serve as Co-Directors of the Gastrointestinal Eosinophilic Diseases Program (GEDP) collaboratively offered by Children's Hospital Colorado and National Jewish Health.

Given this association between EGIDs and feeding disorders (FD), clinician researchers from the GEDP endeavored to learn more about this understudied area. Led by Vince Mukkada, MD, (now assistant professor at Brown University), they performed a retrospective analysis of children with EGIDs. The study aimed to determine the number of children with EGIDs who also had feeding problems as well as further describe the characteristic features of their feeding dysfunction.

Children with intestinal allergies can have problems eating

After reviewing the records of 200 children with EGIDs, they determined that 16 percent had very significant eating problems. In addition, they found that the vast majority of these children exhibited problematic feeding behaviors characterized by food refusal, low volume or variety of intake, spitting food out, grazing, or required prompting to eat.
This is the first study to document the prevalence and describe these specific features of feeding dysfunction in children with EGIDs.

"We hope that this study's results will be far reaching," said Dr. Furuta, who noted that while other diseases (such as gastroesophageal reflux disease, or GERD) are more common, "EoE is on the rise."

"Primary care providers (PCPs) are on the front lines of identifying children at risk for EoE," he said. "If children don't respond to traditional management of GERD, EoE could be a likely cause."

A referral to a gastroenterologist

As such, Dr. Furuta advises PCPs to be aware of EoE as a potential cause of feeding problems and encourages them to initiate an evaluation with a gastroenterologist.

Nancy Maune, occupational therapist and member of the GEDP, adds that feeding issues may be the first sign to a PCP that a toddler, in particular, may have EoE.

"There are lots of maladaptive, learned feeding behaviors in these kids," she said, describing children who refuse food and acquire angst around mealtime. Refusal behaviors may then lead to an "immature diet" despite the fact that the child has typical oral motor skills for their age. This diet may also become restricted in variety and volume, due to learned inflexibility and anxiety.

"This study and our experiences with children with EGIDs demonstrate that even when gastrointestinal inflammation resolves, feeding problems may persist," said Dr. Furuta. He and his colleagues have yet to identify the exact reasons, but he insists that, "ongoing treatment with feeding specialists is key to long-term success."

"It's so important to involve a feeding specialist early, and often, in the course of these diseases," said Angela Haas, MA, CCC-SLP, Feeding Disorders Program specialist, speech pathologist at Children's Hospital Colorado and a member of the GEDP. "Feeding therapists not only work with children to improve oral intake, they also work with caregivers to support an improved mealtime dynamic in the home setting."

Addressing the problem to prevent future issues

"If these problems are not addressed early, children may go on to have long-standing issues with eating, growth and development," added Dr. Furuta. "Early attention to this issue is often critical."

"A feeding specialist may notice that the patient will prefer to drink rather than eat because foods of higher texture cause discomfort when eaten," Haas said. "We would diagnose that as feeding disorder."

Haas works with her patients to discontinue eating foods that irritate them and replaces them with foods they can more easily tolerate.

The GEDP team has planned a prospective study to measure the scope of these problems in children with EGIDs and determine the impact of feeding therapy.

How to test for EoE

"A primary care provider will need more testing to make the diagnosis of EoE," said Kelley Capocelli, MD, Assistant Professor of Pathology and member of the GEDP, who notes that an endoscopic biopsy is required to diagnose EoE. When studying tissue inflamed with mucosa, "The key finding is an overabundance of eosinophils," she said. "If you see more than 15 eosinophils in a high power microscopic field with associated tissue damage, these changes support a diagnosis of EoE."

Dr. Capocelli's research with Dr. Samantha Woodruff and other members of the GEDP has demonstrated the importance of looking for fibrosis in the biopsy (scarring that may relate to trouble swallowing) and recommends looking for this feature when comparing biopsies after treatment to evaluate the patient's response.

"More than other hospitals, the esophageal biopsies at Children's are typically deeper and obtain more tissue for examination," Dr. Capocelli said. "95% of our biopsies are able to examine the lamina propria, the area under the surface where fibrosis develops," she said.  "The GEDP is unique in that all of its participants work together to customize testing and treatment for every child," she added.

Treatment of EoE at Children's Hospital Colorado and National Jewish Health

Dr. Atkins advises PCPs to rely on allergists and nutritionists to help them identify potential food allergies and to develop a complete diet.

Michelle Henry, clinical dietitian and member of the GEDP, further describes the steps necessary to identify a proper diet for patients with EGIDs: "The first step is to take a history," she said. "Then the allergist will perform allergy testing to identify specific food allergies and I build a diet with the remaining foods. Some won't eat what's in the diet so you have to be creative to accommodate other textures."

In a worst-case scenario, Henry advises formula as an extreme alternative. The length of the nutrition guide depends on the child and is customized to each patient. Because of the customized program, Henry explained that she sees some patients weekly and some annually.

The Gastrointestinal Eosinophilic Diseases Program at Children's Hospital Colorado and National Jewish Health

Drs. Atkins and Furuta founded the Gastrointestinal Eosinophilic Diseases Program (GEDP), a multidisciplinary program that cares for children with EGIDs.

Led by Drs. Atkins and Furuta, the GEDP is dedicated to providing outstanding multidisciplinary care for children with EGIDs. This team of medical professionals from two world-class healthcare institutions is the only multidisciplinary program caring for children with EGIDs in the Rocky Mountain region. They gladly accept referrals from across the nation. It is one of the few programs in the country to include feeding specialists and behavioral health professionals in the team approach of treating children with EGIDs.

The mission of the GEDP is to improve the quality of life for patients and families affected by EGIDs. The GEDP offers a comprehensive evaluation for patients suspected of having EGIDs and for children who have a previously established diagnosis. Patients are seen at both National Jewish Health and Children's. Patients referred to the program will receive a thorough review of their medical records including pathology slides, endoscopic procedures and allergy testing. A multidisciplinary evaluation is coordinated by a nurse coordinator and is staffed by board-certified pediatric gastroenterologists and allergists, psychosocial and behavioral clinicians, nutritionists and pediatric feeding specialists. Additional testing may need to be performed including endoscopy, allergy testing and radiographic analysis.

Treatment options are reviewed and discussed in detail with families and their physicians. Appropriate education and support will be provided. Follow up occurs by telephone and during future appointments.

Research protocols that seek to determine the cause of EGIDs, offer novel treatment plans, and improve the quality of care are a significant part of the mission of the GEDP. Interested patients are offered the opportunity to participate in available protocols.

Contact Us

To refer a patient or for information about the GEDP at Children's Hospital Colorado or National Jewish Health, please call (720) 777-7457 or (800) 222-LUNG (5864).

^{Pediatrics. 2010 Aug 9. [Epub ahead of print]
Feeding Dysfunction in Children With Eosinophilic Gastrointestinal Diseases.
Mukkada VA, Haas A, Maune NC, Capocelli KE, Henry M, Gilman N,
Petersburg S, Moore W, Lovell MA, Fleischer DM, Furuta GT, Atkins D.}

Study: Feeding Dysfunction in Children with Eosinophilic Gastrointestinal Diseases

Objectives

Feeding dysfunction (FD) seen in younger children with eosinophilic gastrointestinal disease (EGID) has not been well described. Thus, our aim was to further characterize FD in children with EGIDs.

Methods

A retrospective medical record analysis of 200 children seen over 12 months in a multidisciplinary Gastrointestinal Eosinophilic Diseases Program was performed. The clinical data of 33 children identified as also having FD were examined, including information obtained by history, physical examination, feeding evaluation, review of nutritional data, allergy testing and histologic assessment of mucosal biopsies.

Results

Of 200 children with EGIDs:

• 16.5 percent had significant FD (median age, 34 months with a range: 14-113 months).
• 93.9 percent reported a variety of learned maladaptive feeding behaviors
• Frequent gagging or vomiting occurred in 84.8 percent
• Food sensitivity was documented in 88 percent
• 52 percent had other allergic disease
• 21 percent were diagnosed with failure to thrive
• 69.7 percent required individual or group feeding therapy
• 42 percent had residual eosinophilia of >15 per HPF on esophageal biopsies performed at the time of symptoms

Conclusions

FD is prevalent in children with EGIDs often presenting as maladaptive learned feeding behaviors with altered mealtime dynamics and physical difficulties in eating mechanics. FD can persist even after eosinophilic inflammation is successfully treated. Awareness of the increased prevalence of FD in children with EGIDs will enable earlier recognition of this problem, resulting in a comprehensive, individualized treatment plan with the desired outcome of improving the development, feeding and nutrition of these children.

This study was supported by the Pappas Foundation in Boston, Mass. and the Campaign Urging Research on Eosinophilic Diseases (CUREDfoundation.org). These foundations are committed to fund basic and clinical research studies and improve public awareness of EGIDs.