Desensitization to Reduce Oral Hypersensitivity and Improve Intake for Children With Feeding Disorders
Condition: Feeding Disorder
MeSH terms: Hypersensitivity; Feeding and Eating Disorders
Study type: Interventional

Summary: 
      Many children with feeding disorders frequently gag, vomit, spit out their food, and/or hold
      food in their cheeks. These behaviors make it difficult for children to eat enough food to
      grow. The purpose of this study is to evaluate if a specific behavioral feeding intervention
      called desensitization is an effective intervention to improve oral intake in children with
      feeding disorders by decreasing gagging, vomiting, spitting, and holding food in the cheeks.
      The study will enroll eligible children (6) and their caretakers (6) in the study and they
      will receive behavioral feeding treatment. All treatment sessions will be videotaped and the
      study will last a maximum 8 weeks after the first treatment visit, or until treatment goals
      have been met.
    

Detailed description: 
      Children with complex medical histories may have limited, delayed, or no early oral feeding
      experiences, which decreases the likelihood of independently developing appropriate oral
      motor skills required for eating. Children who are introduced to solid foods after 6-7 months
      of age frequently gag, choke, or vomit due to inefficient oral-motor skills. In typically
      developing children, gagging weakens as a child learns to chew around 7-months of age.
      However, children with feeding disorders do not have the same opportunities to weaken the
      natural gag reflex due to limited experience with oral feedings. As a result, they often
      become hypersensitive to any tactile stimulation and averse to foods and utensils touching
      specific parts of the mouth. There is a gap in the behavioral feeding literature addressing
      oral hypersensitivity and behaviors that interfere with swallowing (i.e., packing, expelling,
      gagging, vomiting). Some work surrounding desensitization of the oral cavity has already been
      done within other disciplines (i.e., occupational therapists and speech and language
      pathologists); however, desensitization has not been well-defined, nor has it been
      empirically studied.

      (1) Specific Aims: The proposed study is designed to assess the following aims:

        1. Define an oral-desensitization protocol to improve oral intake and decrease gags and
           emesis in children with feeding disorders.

        2. Evaluate the efficacy of the brief implementation of an oral-desensitization protocol
           alone and in combination with the antecedent-based procedure, flipped spoon.

        3. To explore the relationship between behavioral feeding intervention and child oral and
           motor proficiency.

        4. To explore the relationship between behavioral feeding intervention and parent and child
           outcomes including parenting stress, mealtime feeding behaviors, and general child
           behavioral functioning.

      (2) Research Hypotheses: The proposed study is designed to test the following hypotheses:

        -  Effect of flipped spoon versus flipped spoon + desensitization. It is hypothesized that
           there will be a faster decrease in (1) gags, (2) latency to clean mouth, (3) packs, (4)
           emesis, and (5) CI's with those participants who receive oral desensitization prior to
           the flipped spoon intervention. It is also hypothesized that children who receive
           desensitization prior to flipped spoon will be able to transition back to an upright
           spoon more quickly when compared to children who did not receive desensitization.

        -  Effect of behavioral feeding intervention on child oral and motor proficiency.
           Exploratory analyses will be conducted to examine pre-test and post-test ratings of
           child oral and motor proficiency. It is anticipated that the oral-motor coordination of
           the participants will significantly improve.

        -  The relationship between behavioral feeding intervention and parent/child outcomes.
           Exploratory analyses will be conducted to examine pre-test and post-test ratings of
           parenting stress, mealtime feeding behaviors, and general child behavioral and emotional
           functioning. It is anticipated that parent-reported ratings in these areas will improve
           from pre-test to post-test.

      Treatment:

      Participants will be randomly assigned to one of two treatment groups: desensitization +
      traditional behavioral intervention or traditional behavioral intervention alone. All
      participants will be treated for a maximum of 40 treatment days, or until treatment goals
      have been met. A total of 3, 45-minute meals will be held each day for a total of 120 meals
      throughout treatment. Trained feeding therapists from the Interdisciplinary Pediatric Feeding
      Program at Mott Children's Hospital will conduct sessions in treatment rooms with one-way
      mirrors. Caregivers will be given the option to observe through the one-way mirror or stay in
      the treatment room with the participant. The behavioral intervention will involve a
      combination of escape extinction and antecedent manipulation of the food (e.g., limiting bite
      size, using a flipped spoon to deposit the bolus). The behavioral intervention plus
      desensitization will include the above in addition to desensitization of the oral cavity.
      Desensitization will occur for the first 3 meals. This involves systematically stimulating
      different areas of the oral cavity (cheeks, palate, tongue, sides of tongue) to provoke and
      ultimately decrease the gag response allowing eating to be easier for participants. Data will
      be collected throughout each meal. All feeding sessions will be recorded to ensure protocol
      fidelity and for the purposes of collecting reliability data.
    

Intervention name(s): Desensitization with flipped spoon; flipped spoon
Intervention type(s): Behavioral; Behavioral
Intervention description(s): Both groups will begin with a baseline phase: escape extinction (non-removal of an upright small maroon spoon) plus continuous access to reinforcement. The baseline phase will take place for 3, 5-bite sessions or until the data become stable. The baseline phase will be followed by desensitization. Desensitization will be conducted for 3, 45-minute treatment meals. Puree will be presented on a flipped EZ spoon after the desensitization sessions are completed. Bite size will be gradually increased. Acceptance of an upright EZ spoon and eventually an upright maroon spoon will be probed based on stability of the data.; Both groups will begin with a baseline phase: escape extinction (non-removal of an upright small maroon spoon) plus continuous access to reinforcement. The baseline phase will take place for 3, 5-bite sessions or until the data become stable. The baseline phase will be followed by puree being presented from a flipped EZ spoon. Bite size will be gradually increased. Acceptance of an upright EZ spoon and eventually an upright maroon spoon will be probed based on stability of the data.
Allocation: Randomized
Intervention model: Parallel Assignment
Masking: None (Open Label)
Primary purpose: Treatment
Keywords: Children with feeding disorders