PURPOSE A school-based treatment program for tube-fed children with medically complex conditions and food refusal was implemented to facilitate the children's transition to oral feeding and advance their eating skills. METHOD The program combined educational and therapeutic goals. It was implemented in a regional public school for children with hearing impairments. A team approach was used. Collaboration with the student's families, medical care providers, personal assistants, and classroom staff was maintained. RESULTS Detailed case reviews are provided for 2 of the children who completed the program at age 8;1 (years;months) and 7;8 after 29 and 26 months of treatment, respectively. At the end of the program, tube feeding was discontinued; the children were feeding themselves and taking medications orally. One child was using mature eating skills to eat an unrestricted diet; the other was eating a modified diet consisting of a full nutrient drink and limited smooth and lightly textured solids. CONCLUSION Successful transition to oral feeding and advancement of developmental eating skills were accomplished in a school setting for long-term tube-fed children with medically complex conditions. The program included collaboration with family and medical personnel as well as integrated therapeutic and educational goals.

Feeding disorders are common in infants and children. Multiple interacting behavioral, anatomic, and functional factors all can impact on the feeding process, making the evaluation and treatment of pediatric disorders complex and challenging. Knowledge of the normal process of feeding and swallowing, a careful history, observation of the patient during a feeding session, and selected tests usually provide an understanding of the underlying cause of feeding difficulties. Treatment of underlying pathology and careful balancing of the risks and benefits of oral feeding underlie the selection of an optimal management strategy.

OBJECTIVES To delineate diagnostic criteria for posttraumatic feeding disorder (PTFD) of infancy and to differentiate PTFD from infantile anorexia (IA) via observation of feeding interactions. METHOD Three groups of infants (aged 6-32 months) participated: PTFD (n = 30), IA (n = 30), and healthy eater controls (n = 30). The three groups were matched with regard to age, gender, ethnicity, and socioeconomic status. Child psychiatrists used infants' medical and feeding histories and observed 20-minute mother-infant feeding interactions to determine diagnoses and group placement. Feeding interactions were also videotaped, and two raters assessed infants' resistance to feeding situations and to swallowing, as well as specific qualities of mother-infant feeding interactions. RESULTS Overall, the clinical groups (PTFD and IA) demonstrated more problematic feeding interactions than did the control group. However, the PTFD group exhibited more resistance during feeding interactions than did the other two groups. In particular, the PTFD group displayed the most resistance to swallowing food. CONCLUSIONS Infants' medical and feeding histories, as well as observations of feeding, are important to making the diagnosis of PTFD and differentiating it from other feeding disorders. Implications for treatment of PTFD are discussed.

Many of the symptoms characteristic of the functional gastrointestinal disorders (FGID) are consistent with dysfunction of the motor and/or sensory apparatus of the digestive tract. Those aspects of sensorimotor dysfunction most relevant to the FGID include alterations in: gut contractile activity; myoelectrical activity; tone and compliance; and transit, as well as an enhanced sensitivity to distension, in each region of the gastrointestinal tract. Assessment of these phenomena involves a number of techniques, some well established and others requiring further validation. Using such techniques, researchers have reported a wide range of alterations in sensory and in motor function in the FGID. Importantly, however, relationships between such dysfunction and symptoms have been relatively weak, and so the clinical relevance of the former remains unclear. Moreover, the proportions of patients in the various symptom subgroups who display dysfunction, and the extent and severity of their symptoms, require better characterization. On a positive note, progress is occurring on several fronts, especially in relation to functional dyspepsia and irritable bowel syndrome, and based on the data gathered to date, a number of areas where further advances are required can be highlighted.

OBJECTIVE Gastro-oesophageal reflux disease (GORD) in infants is commonly associated with feeding problems but has not been subject to systematic controlled study. We evaluated feeding, dietary, behavioural data obtained from systematic objective studies of six-month old infants with and without GORD. METHODS Infants with GORD (defined by 24-h pH monitoring, n = 20), and age, gender, gestation, and socio-economic matched healthy infants (n = 20) had standardised assessments of dietary intake, oromotor function by videoanalysis (Feeding Assessment Schedule, FAS), and infant feeding behaviour by Testers and Maternal Ratings (TRIB and MRIB). Videofluoroscopic analyses of swallowing was undertaken in 11/20 GORD infants and analysed by standardised paediatric check list. RESULTS Compared with control data: GORD infants had significantly lower energy intakes; the FAS showed GORD infants to have significantly fewer adaptive skills and readiness behaviour for solids, significantly more food refusal and food loss; the TRIB showed GORD infants to be significantly more demanding and difficult with feeds; and the MRIB revealed that mothers of GORD infants had significantly more negative feelings, significantly less enjoyment of feeds, and reported significantly more crying behaviour. On videofluoroscopy, oral-preparatory and oral phase problems predominated, particularly with solids, silent aspiration occurred during the pharyngeal phase in 2/11, and delayed oesophageal transit occurred in 4/11. CONCLUSIONS Feeding problems affecting behaviour, swallowing, food intake, and mother-child interaction occur in infants with GORD, who displayed a lack of development of age-appropriate feeding skills. The contribution of feeding problems to morbidity in GORD in infants has been underestimated in the past.

Buspirone is a nonbenzodiazepine anxiolytic that has been effective in uncontrolled trials for treating childhood anxiety disorders. A 4-year-old boy with a history of laryngomalacia (congenital structural abnormality with airway collapse and obstruction on inhalation), pharyngeal dysphagia (difficulty in swallowing), poor weight gain, delayed self-feeding skills, and anxiety symptoms is described. An open trial of buspirone, increased gradually to 12.5 mg daily in divided doses over a period of 22 weeks, was associated with decreased anxiety, improved self-feeding skills, and weight gain. Based on parental reports, buspirone appeared to decrease separation and social anxiety, as well as anxiety associated with eating. Drug discontinuation was associated with symptom relapse, whereas drug readministration lead to the same clinical benefits that had been observed previously. The medication was well tolerated, and its benefits have persisted for over 1 year. No new recommendations can be made regarding the use of buspirone in preschool children or in the treatment of anxious behaviors adversely affecting medical conditions in children and adolescents.

A nonorganic pattern of maladaptive eating behavior was identified and diagnosed as conditioned dysphagia in a group of 28 children who had successfully completed pharyngeal flap surgery for correction of hypernasality. The physically intrusive diagnostic and surgical procedures are thought to contribute to the acquisition of a conditioned avoidance response to deglutition that is resistant to extinction but reversible after deconditioning therapy. Comparison with 22 matched normal siblings and 25 normal control children identified conditioned dysphagia as occurring in about 40% of the cleft palate children within 1 year after surgery. Characteristic eating problems included slowness, requiring assistance, eating only small pieces of solid foods, and not finishing meals. Early detection, treatment, and preventive measures are suggested at or about the time of surgery to avoid consequent nutritional deficits and, in some severe cases, a threat to survival if untreated.

The effect of chronic tracheotomy on the acquisition of voice, speech, and language skills was studied. Children with chronological ages of 16 months to 41 months were evaluated for Receptive Communication Age (RCA) and Expressive Communication Age (ECA). Results indicate a consistent deviation of (on the average) 4.8 months delay in RCA and 9 months delay in ECA. An habilitation program for early intervention in voice, speech and language stimulation is described, with follow-up data on 3 children. A progression from non-meaningful, non-vocal communication to more meaningful and functional communication is noted. The evidence indicates that, without therapeutic intervention, children with tracheotomies are at risk for delays in receptive and expressive language development, as well as deficits in oral/vocal speech and voice production.

A nonorganic pattern of maladaptive eating behavior was identified and diagnosed as conditioned dysphagia in a group of 28 children who had successfully completed pharyngeal flap surgery for correction of hypernasality. The physically intrusive diagnostic and surgical procedures are thought to contribute to the acquisition of a conditioned avoidance response to deglutition that is resistant to extinction but reversible after deconditioning therapy. Comparison with 22 matched normal siblings and 25 normal control children identified conditioned dysphagia as occurring in about 40% of the cleft palate children within 1 year after surgery. Characteristic eating problems included slowness, requiring assistance, eating only small pieces of solid foods, and not finishing meals. Early detection, treatment, and preventive measures are suggested at or about the time of surgery to avoid consequent nutritional deficits and, in some severe cases, a threat to survival if untreated.

Cisplatin (cis-diamminedichloroplatinum(II)(CDDP)) is a widely used, highly effective, oncolytic agent that has serious ototoxic side-effects. To test the effectiveness of local delivery, of L-methionine (L-Met) as an otoprotective agent against CDDP ototoxicity, we used a rat model of a highly metastatic breast cancer tumor, i.e. Fisher 344 rats implanted with MTLn3 breast cancer cells. Four experimental groups were evaluated--I: untreated; II: CDDP-treated (three dosages); III: systemically-delivered L-Met + CDDP-treated; IV: locally delivered L-Met + CDDP-treated. The integrity of the outer hair cells (OHCs) was determined using scanning electron microscopy (SEM); hearing was assessed by recording auditory brainstem responses (ABRs) at multiple frequencies. The chemotherapeutic effectiveness of CDDP was quantified by measuring changes in tumor mass and the presence of tumor metastasis. L-Met provided otoprotection of the OHCs against CDDP toxicity in the cochleae of rats following either systemic (III) or local (IV) administration. The ABRs were unchanged in each of the L-Met protection Groups (III and IV) and in the untreated animals of Group I. Treatment with CDDP only (II) induced significant hearing losses at both 16 and 18 kHz when compared to ABRs of untreated rats(I). CDDP was effective in controlling the MTLn3 initiated breast cancer tumors in the CDDP-treated (II) and the local L-Met protection, CDDP-treated (IV) Groups. In contrast, the tumors in the systemic L-Met protection, CDDP-treated Group (III) were not controlled by the CDDP treatment regime. This study demonstrates that local delivery of L-Met to the scala tympani of the cochlea via the round window membrane (IV) provides effective protection against CDDP ototoxicity without compromising its ability to control a highly metastatic form of cancer.

Recent investigations of children with specific language impairment (SLI) have found deviant anatomical asymmetry of the perisylvian cortex. These studies argue that this deviant anatomical asymmetry is linked to the language disorders of SLI children. To date no studies have examined whether deviant functional asymmetry underlies the processing of spoken language in these children. In the current study, brain-electrical activity was recorded from 31 scalp sites while children with SLI listened to auditorally presented stories and two different nonsense contexts. Electrical activity was time-locked to the grammatical word "the" in these contexts. The SLI children showed reversed asymmetry compared to control children from 200 ms to 400 ms in processing "the" in all contexts. More specifically, they showed depressed processing at the left temporal scalp site (T7) and enhanced processing at the right temporal site (T8). The second spatial derivative (the Laplacian) of the voltage activity was calculated to remove constant voltage potential and uniform changes in voltage potential across the scalp. The Laplacian analysis indicated that the sources of the positive electrical activity seen at the temporal electrode sites T7 and T8 are the lateral surfaces of the temporal cortices. A comparison of the scalp topography of the voltage potentials and Laplacian also suggests that children with SLI lack some contribution from a deep neural generator, possibly in the hippocampus or basal ganglia. This investigation is the first to demonstrate a direct link between deviant neurophysiological asymmetry and the processing of spoken language in children with SLI.

Ofloxacin otic is as effective in curing otitis externa in children (<12 years of age) as is the preparation combining polymyxin/neomycin plus hydrocortisone and as ciprofloxacin otic. Furthermore ofloxacin otic, as it requires less frequent dosing, is likely to encourage greater patient adherence and consequently to achieve a better cure rate than both of these treatment options. Because a number of cases of otitis externa are complicated by an undiagnosed tympanic membrane perforation, the lack of ototoxicity associated with ofloxacin otic makes it a particularly safe option for use in these patients.