Desensitization to Reduce Oral Hypersensitivity and Improve Intake for Children With Feeding Disorders

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.

Inclusion Criteria:

- Behavior problems (i.e., spitting, crying, head turning, gagging, physical aggression)
are interfering with feeding

- Medical causes of feeding disorder have been treated or are well-controlled without
resolution of the feeding problem

- Normal feeding milestones have not been met or regression has occurred

- Enteral feeding dependence as defined by the participant relying on Nasal Gastric or
gastrostomy-tube feedings in order to receive appropriate nutrition and gain weight

- Accepts a limited number of foods and limited volume of foods by mouth (i.e., not
enough variety or volume to maintain growth and/or good nutritional status)

Exclusion Criteria:

- Children who had anatomical/active medical problems that prohibit safe oral intake
will be excluded