Paediatric feeding disorder: nutritional and gastrointestinal management — structured clinical encounter

Station brief (candidate)

You are the paediatric registrar in a gastroenterology and nutrition clinic. A three-year-old with cerebral palsy has refused most foods for six months, accepting only smooth yoghurt and milk. Her weight has fallen from the tenth to below the third centile. Her reflux has been poorly controlled and she is constipated, and her food refusal has been labelled behavioural. The team asks you to define her condition, to carry out the four-domain assessment, to explain why the behavioural label is incomplete, to outline the stepped multidisciplinary management, and to advise on the role of enteral feeding. You have twelve minutes with the team and five minutes for examiner discussion. [4]

Information available on request

• Three years old, cerebral palsy, non-ambulant; food refusal for six months accepting only smooth yoghurt and milk. [4]
• Weight fallen from the tenth to below the third centile over six months; length centile stable. [1]
• Gastro-oesophageal reflux poorly controlled on current therapy; constipated, opening bowels every four to five days. [4]
• No reported coughing or choking with feeds; some wetness to the voice noted with thin liquids. [1]
• Full blood count shows microcytic anaemia with low ferritin; other micronutrients not yet screened. [4]

Tasks

1. Give the consensus definition of her condition and explain why the behavioural label is incomplete. [1]
2. Outline the four-domain assessment that should precede the management plan. [1]
3. Explain the stepped multidisciplinary management, including the first lever and the role of structured behavioural intervention. [5]
4. Advise on the role of enteral feeding and the tube-weaning principle, distinguishing the approach from avoidant/restrictive food intake disorder. [12] [9]
5. Counsel the family on the outlook, the carer burden, and preserving safe oral feeding for pleasure. [11]

Marking anchors

Must-hit

• Defines paediatric feeding disorder using the 2019 Goday consensus as impaired oral intake that is not age-appropriate, associated with medical, nutritional, feeding skill and/or psychosocial dysfunction, and explains that the behavioural label is incomplete because this child has clear medical (reflux, constipation), nutritional (faltering growth, iron deficiency) and likely feeding-skill and psychosocial components that require assessment across all four domains. [1] [4]
• Identifies treating the reflux and constipation as the first management lever, because feeding will not improve while the gut is uncomfortable, and explains that the conditioned aversion will also need structured behavioural intervention so treating the gut alone may not resolve the refusal. [4]
• Outlines the stepped plan: treat the medical driver, build feeding skill, apply structured behavioural intervention, support nutrition with fortification and oral supplements and correct the iron deficiency, and escalate to enteral feeding with the ESPGHAN guidance and an active tube-weaning plan when intake is unsafe or insufficient. [5] [12]

Merit

• Distinguishes paediatric feeding disorder (organ-based) from avoidant/restrictive food intake disorder (DSM-5 psychiatric eating disorder), notes that the two can coexist, and screens for an unsafe swallow before pushing oral intake given the wet voice; addresses the substantial carer burden shown in the qualitative evidence and offers carer support and respite. [9] [11]

Fail

• Accepts the behavioural label and refers to psychology alone without treating the reflux and constipation or completing the four-domain assessment. [4]
• Pushes oral intake or moves straight to a gastrostomy without an instrumental swallow study to exclude aspiration and without a tube-weaning plan. [12]