Paediatric feeding disorder: nutritional and gastrointestinal management — branching viva

Station opening

Examiner: "Define paediatric feeding disorder and outline the principles of its nutritional and gastrointestinal management." [1]

Strong candidate (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, on the WHO International Classification of Functioning, Disability and Health framework; frames the management as a stepped multidisciplinary plan that treats the medical driver first (reflux, constipation, eosinophilic oesophagitis, allergy), builds feeding skill, applies structured behavioural intervention, supports nutrition with fortification or oral supplements, and escalates to enteral feeding with an active tube-weaning plan; states that assessing all four domains in parallel is the single most important principle. [1] [4]

Weak candidate

• "Feeding disorder is when a child won't eat, and I would refer them to a dietitian and a psychologist." [1]

Branch A — The child with food refusal, faltering growth and reflux

Examiner: "A three-year-old with cerebral palsy has refused most foods for six months, her weight has fallen below the third centile, her reflux is poorly controlled and she is constipated. Her refusal has been labelled behavioural. What is your assessment and your first management step?" [4]

Strong

• Explains that this is a paediatric feeding disorder with medical (reflux, constipation), nutritional (faltering growth) and likely psychosocial (conditioned aversion) components, and that the behavioural label is incomplete because the consensus framework requires assessment across all four domains; the first management step is to treat the medical driver by optimising reflux and clearing constipation, because feeding will not improve while the gut is uncomfortable, and then to address the conditioned aversion with structured behavioural intervention. [4] [1]

Weak

• "It is behavioural, so I would refer to psychology and fortify her food." [4]

Branch B — The tube-dependent former premature infant

Examiner: "An eighteen-month-old born at twenty-seven weeks has been nasogastrically fed since the neonatal unit and refuses all oral intake. She grows adequately on the tube. Does she need a gastrostomy?" [10]

Strong

• Explains that this is feeding tube dependency: tube feeding suppressed the hunger cue and removed oral-motor practice so oral feeding was never established; recommends a structured multidisciplinary tube-weaning program (hunger induction, behavioural intervention, oromotor therapy) before a gastrostomy, citing the systematic review that intensive multidisciplinary intervention is the effective standard of care; would place a gastrostomy, per the ESPGHAN guidance, only if long-term non-oral feeding is anticipated, and always with an active weaning plan because dependency is easier to prevent than to treat. [10] [5]

Weak

• "She is growing on the tube, so I would convert to a gastrostomy for convenience." [10]

Branch C — The autistic child with food selectivity

Examiner: "A five-year-old with autism eats only three branded foods of a specific texture. His iron studies show deficiency. What is the evidence-based intervention, and what is your nutritional priority?" [7]

Strong

• Explains that this is sensory-based food selectivity in the psychosocial and nutritional domains; the evidence-based intervention is structured behavioural intervention, and the randomised comparison found the applied behaviour-analytic approach superior to a modified sequential oral sensory approach for expanding food acceptance in children with autism; the nutritional priority is to correct the iron deficiency and screen for other consequences of the narrow diet while the behavioural program works to expand the accepted foods into the everyday mealtime. [7] [4]

Weak

• "I would start an appetite stimulant and a multivitamin." [7]

Branch D — Does this child have an eating disorder?

Examiner: "A family asks whether their food-refusing child has an eating disorder. How do you distinguish paediatric feeding disorder from avoidant/restrictive food intake disorder?" [9]

Strong

• Explains that paediatric feeding disorder is an organ-based, biopsychosocial condition owned by paediatrics and driven by medical, nutritional, feeding-skill and psychosocial factors, while avoidant/restrictive food intake disorder is a DSM-5 psychiatric eating disorder driven by lack of interest, sensory-based avoidance or fear of aversive consequences in the absence of a primary medical cause; the assessment asks what came first and what is sustaining the restriction, because the two can coexist and a child with eosinophilic oesophagitis may develop a genuine ARFID-pattern sensory avoidance, but the diagnostic home and the first treatment lever differ. [9] [1]

Weak

• "They are the same thing and I would refer to eating-disorder services." [9]

Close

Examiner: "Summarise your approach to the nutritional and gastrointestinal management of paediatric feeding disorder in one sentence." [1]

Strong

• "Paediatric feeding disorder is impaired oral intake with dysfunction in one or more of four domains, and I manage it with a multidisciplinary team that treats the medical driver first, builds feeding skill and applies structured behavioural intervention, supports nutrition with fortification and oral supplements, and escalates to enteral feeding only when intake is unsafe or insufficient, with an active tube-weaning plan throughout, while distinguishing it from avoidant/restrictive food intake disorder." [1] [4]