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Clinical Observations
Food Chaining: A Systematic Approach for the Treatment of
Children With Feeding Aversion
Mark Fishbein, MD*; Sibyl Cox, MS, RD*; Cheryl Swenny, MA*; Chris Mogren, RN*;
Laura Walbert, CCC/SLP†; and Cheri Fraker, CCC/SLP†
*SIU School of Medicine, Department of Pediatrics, Springfield, Illinois; and †Preemietalk,Springfield, Illinois
ABSTRACT: Food chaining has been developed as a
systematic method for the treatment of children with
extreme food selectivity. Food chaining is an individual-
ized, nonthreatening, home-based feeding program
designed to expand food repertoire by emphasizing similar
features between accepted and targeted food items. This
chart review illustrates the efficacy of food chaining in
treating aversive feeding disorders.
An estimated 25%–35% of children have feeding
problems.
1
Toddlers learning to self-feed and
attempting new foods and textures are most often
affected. The spectrum of feeding disorders ranges
from mild to severe. Mild feeding disorders are
characterized by a common tendency to avoid
selected food items according to texture, taste, sight,
or odor. These individuals do not require any inter-
vention, and this condition is often self-limited.
Severe feeding disorders are characterized by inap-
propriate limitation of food acceptance that may
jeopardize nutrition status. Approximately 3%–10%
of children are affected, with a greater prevalence
noted in handicapped individuals (26%–90%).
2
In
these instances, intervention is required to increase
food acceptance.
Behavioral management has been implemented
successfully in the treatment of children with feed-
ing disorders.
3–6
Traditional therapy for severely
affected children has included prolonged hospital-
ization for up to 8 weeks.
7
Mealtimes are directed by
a feeding specialist in an unfamiliar environment
for the child. Though successful, inpatient therapy is
labor intensive, costly, and inconvenient.
At our institution, we have established an alter-
native therapy for aversive feeding disorder that
includes home-based therapy with the advantage of
convenience and familiarity. The intervention,
incorporating sensory integration and behavioral
modification techniques, includes food chaining
(Fraker, Walbert, Cox 2004 copyright) and allows for
expansion of food repertoire by emphasizing similar
features (taste, texture, temperature) between
accepted food items and new/targeted food items. In
this model, the parent or guardian assumes the
primary feeding role.
8,9
Study Population
A retrospective chart review was performed on 10
children referred to our feeding program for evalu-
ation/treatment of feeding aversion from September
2001 to June 2003. Subjects with parents or guard-
ians who appeared incapable or unwilling to imple-
ment behavioral modification according to physical,
psychological, or mental impairment were not can-
didates for food chaining.
Methods
All subjects underwent initial assessment by a
multidisciplinary feeding team including a pediatric
gastroenterologist, dietitian, speech language pathol-
ogist (feeding therapist), and behavioral psycholo-
gist. Each subject was identified with extreme food
selectivity and designated for a feeding program
that included food chaining (Figure 1). The individ-
ualized treatment protocol was designed by the
dietitian, speech language pathologist, and behav-
ioral psychologist. The treatment plan was invoked
by the parent or guardian, child, and speech lan-
guage pathologist. A 10-point food acceptance scale
compiled weekly by parent or child was used to
determine rate and variation of dietary progression
(1, tolerated poorly, to 10, tolerated well). The food
chain originates with an accepted food, an item that
the child eats willingly and reliably. Targeted or goal
food items are established by parent, child, or feed-
ing therapist. During the course of therapy, new food
items, positioned between accepted and targeted
Correspondence: Mark Fishbein, MD, SIU School of Medicine,
Department of Pediatrics, Springfield, IL 62794-9658. Electronic
mail may be sent to mfishbein@siumed.edu.
0884-5336/06/2102-0182$03.00/0
Nutrition in Clinical Practice 21:182–184, April 2006
Copyright © 2006 American Society for Parenteral and Enteral Nutrition
182
food items and that were rejected previously or
never attempted, are introduced. Food chain
branching and expansion allows for the addition of
food targets to meet the child’s current needs. The
endpoint of therapy occurs when parent and child no
longer rely upon the intervention of the feeding
therapist to achieve feeding goals.
Correspondence between study participants and
feeding team members occurred through clinic vis-
its, telephone calls, voice mail, electronic mail, and
videotape. The investigation commenced at the ini-
tiation of the feeding program and was completed 3
months later. Subject demographics included age,
gender, diagnoses other than aversive feeding dis-
orders, nutrition status, gastrostomy/jejunostomy
tube status (present or absent), and intervention
duration per week (correspondence time). The study
was approved by the Springfield Committee for
Research Involving Human Subjects.
Statistical Analysis
A paired t-test involving the number of new/
targeted food items accepted from 0 to 3 months was
used to determine the outcome of the intervention.
Results
Ten children (6 male, 4 female) with age median
of 3 years (range, 1–14 years) were studied. Eight of
10 subjects had experienced prior feeding interven-
tions without sustained improvement. All subjects
were enrolled in the feeding program for at least 3
months. Six of 10 children carried other diagnoses.
Four of 10 children required supplemental gastros-
tomy/jejunostomy feedings. At the onset of feeding
intervention, subject #2 was consuming only animal
crackers and juice, subject #5 was consuming only
water, and subject #9 was consuming only carbon-
ated beverages. The median intervention during the
3-month interval occurred for 1.25 hours/week
(range, 0.5–2 hours/week; Table 1).
All children were able to increase their food
repertoire over 3 months (p⬍.05, paired t-test). The
median number of accepted foods at onset was 5
(range, 1–10). The median number of new/target
foods at 3 months was 20.5 (range, 8–129); see
Figure 2). Supplemental feeding status did not
change after intervention.
Discussion
Behavioral modification techniques are integral
to the treatment of feeding disorders in children. In
this chart review, the efficacy of food chaining, an
intervention designed to expand food repertoire
through behavioral modification, was demonstrated.
The children were nonuniform with regard to nutri-
tion status or medical condition, but all had extreme
food selectivity. A majority of subjects had failed
previous feeding therapy. Despite these prior fail-
ures, all subjects involved in this individual feeding
program that includes food chaining were able to
Figure 1. Example of food chain: French fries to chicken pot pie. Accepted food item: French fries. Targeted food item:
chicken pot pie. New food items: listed in sequence.
April 2006 183FISHBEIN ET AL
expand their diets successfully. The manner of inter-
vention/communication modality also was tailored
to meet subject necessity and convenience. Despite
these variations, all subjects had sufficient access
and time allotment to therapy to achieve adequate
progress with their feeding program. Traditional
feeding programs involve prolonged hospitalization,
with feeding therapy provided primarily by a
trained therapist. In contrast, our program is home
based and allows for an expanded role in feeding
therapy by parents.
The demands of a successful feeding program
have been illustrated in these cases. Prerequisites
include feeding therapist availability (at least 1/2
hour per week for several consecutive months, and
perhaps longer), feeding therapist expertise (thera-
pist must be familiar with behavioral modification
and its role in food chaining), and sufficiently moti-
vated and compliant parent or guardian. The goals
of a feeding program should be realistic and estab-
lished by parent, therapist, and child. If imple-
mented properly and in this manner, food chaining
may be a useful adjunct in the treatment of children
with feeding aversion.
References
1. Linscheid T, Budd K, Rasnake L. Pediatric feeding disorders. In:
Roberts M, ed. Handbook of Pediatric Psychology.2
nd
ed. New
York, NY: Guilford Press; 1995:501–515.
2. Manikam R, Perman JA. Pediatric feeding disorders. J Clin
Gastroenterol. 2000;30:34– 46.
3. Kedesdy J, Budd K. Childhood Feeding Disorders: Biobehavioral
Assessment and Intervention. Baltimore, MD: Paul H. Brooks
Publishing Co; 1998.
4. O’Brien S, Repp A, Williams G, Christophersen E. Pediatric
feeding disorders. Behav Modif. 1991;15:394– 418.
5. Linscheid T, Tarnowski K, Rasnake L, Brams J. Behavioral
treatment of food refusal in a child with short gut syndrome.
J Pediatr Psychol. 1987;12:451–459.
6. Rasnake L, Linscheid T. A behavioral approach to the treatment
of pediatric feeding problems. J Pediatr Perinat Nutr. 1987;1:75–
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7. Babbitt R, Hosch T, Coe D, et al. Behavioral assessment and
treatment of pediatric feeding disorders. J Dev Behav Pediatr.
1994;15:278–291.
8. Fraker C, Walbert L. Evaluation and Treatment of Pediatric
Feeding Disorders: From NICU to Adolescent. Speech Dynamics
Inc; 2003.
9. Fishbein M, Cox S, Walbert L, Fraker C. Feeding disorders in
children: a little taste. Nutrition and the MD. 2003;29:1–5.
Table 1
Patient demographics and length of interventions per week
Subject Age/
gender
Z-score
(weight/height
or BMI/age)
Previous feeding
therapy
Other
diagnoses
Supplemental feedings
(gastrostomy, jejunostomy
Intervention
(hours/week mean)
#1 11/M 1.7 No None No 1.5
#2 3/F ⫺1.29 Yes None No 1.5
#3 3/F ⫺1.07 Yes None No 1.5
#4 2/F ⫺1.93 Yes Cleft palate Yes 0.5
#5 5/M 1.23 Yes Dysphagia, bronchopulmonary
dysplagia
Yes 0.5
#6 1/M ⫺3.27 Yes Dysphagia, renal insufficiency No 1
#7 1/M 0.73 Yes Congenital heart disease No 2
#8 14/M ⫺0.35 No None No 1.5
#9 9/M 1.16 Yes Dysphagia, microgastria Yes 0.5
#10 2/F ⫺1.66 Yes Cleft palate Yes 0.5
BMI, body mass index; F, female; M, male.
Figure 2. Accepted food items at 0 and 3 months after food
chaining.
184 Vol. 21, No. 2FOOD CHAINING FOR FEEDING AVERSION
