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Diagnosis and Treatment of Feeding Disorders in Children With

Developmental Disabilities

Steven M. Schwarz, MD*‡; Julissa Corredor, MD*; Julie Fisher-Medina, MS‡; Jennifer Cohen, MD*; and
Simon Rabinowitz, MD, PhD*

ABSTRACT. Objectives. To determine the results of these problems, and we propose a diagnostic and treat-
diagnostic evaluation and the effects of nutritional inter- ment algorithm for children with developmental dis-
vention on energy consumption, weight gain, growth, abilities and suspected feeding disorders. Pediatrics
and clinical status of children with neurodevelopmental 2001;108:671– 676; children, developmental disabilities,
disabilities and suspected feeding disorders. fundoplication, gastroesophageal reflux, gastrostomy,
Methods. We studied 79 children with moderate to hospitalization, nutrition.
severe motor or cognitive dysfunction (male:female, 38:
41; age, 5.8 ⴞ 3.7 years) who were referred for diagnosis
and treatment of feeding or nutritional problems. Initial ABBREVIATIONS. GER, gastroesophageal reflux; RDA, recom-
mended daily allowance; VFSS, videofluoroscopic swallowing
assessments included a 3-day calorie intake record,
study; GT, gastrostomy tube.
videofluoroscopic swallowing study (VFSS), 24-hour in-
traesophageal pH monitoring, milk scintigraphy, and

C
esophagogastroduodenoscopy. hildren with developmental disabilities are at
Results. These studies demonstrated gastroesopha- increased risk for developing feeding-related
geal reflux (GER) with or without aspiration in 44 of 79 difficulties, including gastroesophageal reflux
patients (56%), oropharyngeal dysphagia in 21 (27%), and
aversive feeding behaviors in 14 (18%). Diagnosis-spe-
(GER), oral motor dysfunction, pharyngoesophageal
cific approaches included medical GER therapy in 20 dyskinesia, and aversive feeding behavior.1–3 Protein
patients (25%), fundoplication plus gastrostomy tube energy intake and nutritional status often are com-
(GT) in 18 (23%), oral supplements in 17 (22%), feeding promised as a consequence of feeding impairment,
therapy only in 14 (18%), and GT only in 10 (13%). After particularly among the most severely disabled pa-
24.6 ⴞ 3.0 months, relative calorie intake, expressed as tients.4 – 6 If not adequately treated, feeding disorders
intake (kcal/d)/recommended daily allowance (RDA, may result in additional complications including
kcal/d), improved significantly (initial:final ⴝ 0.78 ⴞ esophagitis, reactive airway disease, aspiration
0.36:1.23 ⴞ 0.27). The z scores increased significantly for pneumonia, and bedsores.7,8 Previous reports indi-
both weight (initial:final ⴝ ⴚ2.80 ⴞ 1.33:ⴚ0.81 ⴞ 0.69) cate that enteral feeding regimens for nutrition sup-
and height (ⴚ3.14 ⴞ 0.98:ⴚ2.00 ⴞ 0.67). Improved subcu-
taneous tissue stores were demonstrated by increased
port in developmentally disabled children improve
thickness of both subscapular skinfolds (change ⴝ 71% overall nutritional status.6 –9 To date, however, few
ⴞ 26%) and triceps skinfolds (38% ⴞ 17%). After nutri- investigations have evaluated the effects of diagno-
tional intervention, the acute care hospitalization rate, sis-specific nutritional therapies on clinical outcomes
compared with the 2-year period before intervention, with respect to the frequency of feeding disorder–
decreased from 0.4 ⴞ 0.18 to 0.15 ⴞ 0.06 admissions per related complications and rates of acute care hospi-
patient-year and included only 3 admissions (0.02 per talization. Accordingly, the objectives of the present
patient-year) related to feeding problems. study were to assess feeding problems in a large
Conclusions. In children with developmental disabil- group of children with developmental disabilities
ities, diagnosis-specific treatment of feeding disorders and to determine the effects of nutritional manage-
results in significantly improved energy consumption
and nutritional status. These data also indicate that de-
ment on growth, weight gain, and feeding-associated
creased morbidity (reflected by a lower acute care hospi- morbidity.
talization rate) may be related, at least in part, to success-
ful management of feeding problems. Our results METHODS
emphasize the importance of a structured approach to We evaluated 79 children who were referred to the Feeding and
Nutrition Clinic at the Stanley S. Lamm Institute for Developmen-
tal Medicine and Child Neurology, Long Island College Hospital,
From the *Department of Pediatrics and the ‡Stanley S. Lamm Institute for State University of New York Downstate Medical Center. Patients
Developmental Medicine and Child Neurology, Long Island College Hos- ranged in age from 0.2 to 17.5 years (mean ⫾ standard deviation ⫽
pital, State University of New York Downstate Medical Center, Brooklyn, 5.8 ⫾ 3.7 years) and were equally divided between males and
New York. females (38 male:41 female; P ⫽ NS). All patients had documented
This work was presented in part at the annual meeting of the North weight loss or had failed to gain weight appropriately during the
American Society for Pediatric Gastroenterology and Nutrition; October 23, 6 months before our evaluation. All participants initially were
1999; Denver, CO. seen on an ambulatory basis, all were receiving care at home (none
Received for publication Nov 7, 2000; accepted Jan 19, 2001. were institutionalized), and all manifested moderate to severe
Reprint requests to (S.M.S.) Department of Pediatrics, Long Island College cognitive or motor impairment. A variety of neurodevelopmental
Hospital, 339 Hicks St, Brooklyn, NY 11201. E-mail: sschwarz@bethisraelny.org disorders were represented (Table 1), and idiopathic cerebral pal-
PEDIATRICS (ISSN 0031 4005). Copyright © 2001 by the American Acad- sy–mental retardation was the most common primary diagnosis
emy of Pediatrics. (39/79, 49%). Prematurity with or without intraventricular hem-

PEDIATRICS Vol. 108 No. 3 September 2001 671


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TABLE 1. Primary Diagnoses in 79 Children with Develop- Protection of Human Subjects) of Long Island College Hospital,
mental Disabilities State University of New York Downstate Medical Center.
Diagnosis n (%)
Statistical Analysis
Cerebral palsy with mental retardation 39 (49) Each value is expressed as the mean ⫾ standard deviation.
Prematurity with or without intraventricular 11 (14) Student’s t tests for paired samples were used to compare anthro-
hemorrhage pometric data and nutritional intakes at the time of study entry
Chromosomal abnormality 8 (10) and at the conclusion of the monitoring period. Acute care hospi-
Central nervous system malformation 6 (8) talizations before and after nutritional intervention were also com-
Congenital infection 6 (8) pared using paired t tests. In all cases, a significant difference was
Pervasive developmental delay 4 (5) indicated by a P value ⬍.05. Statistical analyses were performed
Perinatal asphyxia 3 (4) using a prepackaged computer software program (Instat, Graph-
Fetal alcohol syndrome 2 (3) pad Software, Inc, San Diego, CA).

RESULTS
orrhage was characterized by similar clinical findings to those of Nutritional and Feeding Evaluations
cerebral palsy group. Any participant with a history of significant Dietary records at the time of study entry demon-
cardiac or pulmonary problems was excluded from study. With
the exception of patients manifesting pervasive developmental strated a mean 3-day energy intake:RDA ratio of
delay and fetal alcohol syndrome, who demonstrated no or only 0.78 ⫾ 0.36 (kcal/d) in this group of children with
mild gross motor deficits, physical findings in this population moderate to severe developmental disabilities, sug-
were characterized by moderate to severe spasticity and diplegia gesting that energy consumption was compromised
or quadriplegia. During the initial ambulatory visit, a detailed
dietary history was obtained. Subsequently, 3-day dietary records by feeding difficulties. Evaluations of swallowing
were collected for all patients by prospective recording of esti- function, as described under Methods, showed a di-
mated food consumption, and an investigator calculated all calorie verse group of feeding disorders (Table 2). The most
intakes. Energy consumption data were compiled at study entry common diagnosis was GER (with or without aspi-
and were consistent with historical dietary intakes reported by ration), affecting 44 of 79 patients (56%). In this
parents or caregivers. Dietary evaluations were subsequently con-
ducted at 3-month intervals throughout the study period. For group with significant GER (determined by 24-hour
comparison purposes and because of wide variations in the nu- pH monitoring), 31 had histologically confirmed
tritional needs in our patients, energy consumption was expressed esophagitis. Aversive feeding behaviors were identi-
as intake (kcal/d)/recommended daily allowance (RDA, kcal/d). fied in 14 patients (18%) who otherwise had unre-
Here, RDA is the recommended daily allowance for total energy
intake. In each case, the appropriate RDA reflects either age- markable feeding evaluations. In most cases, these
dependent values provided by the National Research Council (for patients manifested oral hypersensitivity, with dis-
children without disabling motor impairments)10 or corrected es- tinct patterns of food textural preferences and refus-
timates published for children with developmental disabili- als. After speech-language assessment, the VFSS was
ties.11,12 The latter method includes factors for muscle tone and
level of activity and was used to estimate nutritional needs for
used to identify oral motor and swallowing function
nonambulatory children. Anthropometrics included calculations for thin and thick liquids. Oral motor or pharyngeal
of z scores for height and weight. The z scores were determined dysfunction was demonstrated in 21 of 79 patients
using National Center for Health Statistics reference values,12 (27%), and these children made up the oropharyn-
according to the formula z ⫽ (patient value ⫺ median reference geal dysphagia group, whose characteristics were
value)/standard deviaiton of the reference population. Because
reference values for patients with diverse developmental disabil- recently described by Lefton-Greif et al.13
ities were not available, our findings were compared with norma- All 79 children with developmental disabilities
tive National Center for Health Statistics scores. In addition to z were selected for treatment of feeding disorders, as
scores, triceps and subscapular skinfold thicknesses were mea- shown in Table 3. In children with GER, 20 received
sured using a standard Lange caliper. Feeding evaluations in- medical therapy only, including ranitidine (6 mg/
volved assessment by a speech-language pathologist, videofluo-
roscopic swallowing study (VFSS), 24-hour intraesophageal pH kg/d) with or without cisapride (1.2 mg/kg/d), and
monitoring, and 99technetium-sulfur colloid milk scintigraphy (to 10 patients underwent gastrostomy tube (GT) place-
detect aspiration at 1 and 24 hours postprandially). Each VFSS was ment along with medical therapy for GER. (Note: For
performed jointly by a pediatric radiologist and a speech-language the duration of this study, cisapride was available in
pathologist.13 GER was determined by 24-hour pH monitoring
using standard methods.14 Briefly, single-channel recordings were the United States for the routine treatment of symp-
made with the tip of the pH probe placed 15% above the calcu- tomatic GER; see “Discussion.”) A Nissen fundopli-
lated lower esophageal–to-nares distance (probe placement was cation and GT placement were performed in 18 chil-
confirmed by a single chest radiograph). During the monitoring dren (41% of patients with documented GER).
period, 3 feedings of 300 mL/m2 of unsweetened apple juice:water
(1:1; pH ⫽ 3.5– 4.0) were offered at 5-hour intervals. Significant
Patients selected for this surgical intervention dem-
GER was defined by the following criteria: pH ⬍4 for ⬎12 minutes onstrated either histologically moderate to severe
during the first 2 hours after apple juice feeding, pH ⬍4 for ⬎30 esophagitis (grade II–IV) or gross tracheal aspiration
seconds during the third postprandial hour, and, pH ⬍4 for ⬎4 on scintigraphy. In 5 children with GER scintigra-
minutes during sleep. All pH monitoring studies were performed phies were equivocal, but none had a clinical history
and interpreted by the same investigator (S.M.S.). In patients with
significant GER, esophagogastroduodenoscopies were conducted
to detect esophagitis, and esophagitis was scored histologically as TABLE 2. Feeding Disorders in 79 Children with Develop-
grade I–IV (Hill’s criteria) by a single pathologist.15 In addition to mental Disabilities
nutritional and anthropometric data, we also examined acute care
(ie, nonelective) hospitalization rates (expressed as mean admis- Feeding Disorder n (%)
sions per patient-year) for the 24 months before study entry and
GER without aspiration 27 (34)
after the initiation of nutritional management. Informed consents
Oropharyngeal dysphagia 21 (27)
for all invasive diagnostic and therapeutic procedures were ob-
GER with aspiration 17 (22)
tained from parents or legal guardians, and this study was ap-
Aversive feeding behavior 14 (18)
proved by the Institutional Review Board (Committee for the

672 FEEDING DISORDERS IN DEVELOPMENTAL DISABILITIES


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TABLE 3. Medical and Surgical Management of Feeding Dis- .05). Significant improvements in energy consump-
orders tion and nutritional status were observed in all pa-
Intervention Number (%) tient groups. To determine whether nutritional inter-
Medical therapy for GER* 20 (25)
vention affected the clinical (other than nutritional)
GT with fundoplication 18 (23) course of these patients, acute care (ie, nonelective)
Feeding therapy and oral dietary supplements 17 (22) hospitalizations were compared before and after the
Feeding therapy only 14 (18) onset of treatment. Over the 2-year period before
GT without fundoplication† 10 (13) study entry, these 79 children with moderate to se-
* H2 blockers with or without prokinetics. vere developmental disabilities experienced a hospi-
† Including medical therapy for GER. talization rate of 0.40 ⫾ 0.18 hospital admissions per
patient-year. After initiation of nutritional manage-
suggesting aspiration. These patients did not un- ment and throughout the 24-month study, the hos-
dergo fundoplication as primary therapy. Children pitalization rate was 0.15 ⫾ 0.06 admissions per pa-
with oropharyngeal dysphagia and without aspira- tient-year (P ⬍ .01). Review of postintervention
tion received feeding therapy and oral nutritional hospitalizations demonstrated that only 3 nonelec-
supplements using proprietary, age-appropriate for- tive admissions (⬃0.02 per patient-year) were related
mulas with energy densities of 1.0 kcal/mL. If nec- to feeding or nutritional problems. These 3 hospital-
essary, formulas were thickened with rice cereal, 2 izations were all secondary to presumed aspiration
tablespoons per 4 ounces, to increase calorie density pneumonia in GT-fed children with swallowing dys-
or facilitate swallowing (as per VFSS results). GT function who were fed orally. No deaths occurred in
insertions were performed in all patients manifesting this series of patients during the study period.
tracheal aspiration during VFSS. After GT place-
ment, patients were also treated medically for GER. DISCUSSION
Those with significant GER, documented by pH This study examined feeding disorders in a large
monitoring during the initial evaluation, received group of children with moderate to severe develop-
acid reduction and prokinetic medications, whereas mental disabilities and evaluated the nutritional and
participants without reflux received only ranitidine clinical responses to diagnosis-specific management.
after GT. The 14 participants with aversive feeding Our findings demonstrate that over a 24-month pe-
behaviors and without suspected GER underwent riod, treatment of feeding problems was associated
feeding therapy conducted by a speech-language pa- with significant improvement in nutritional status,
thologist. assessed using z scores for weight and height as well
as skinfold thickness measurements. Clinical out-
Nutritional and Clinical Responses comes also suggest that successful treatment of feed-
After institution of medical or surgical manage- ing difficulties resulted in decreased morbidity, as
ment for feeding disorders, patients were followed indicated by a significant reduction in the acute care
for 24.6 ⫾ 3.0 months. Nutritional data are summa- hospitalization rate. This result was, at least in part,
rized in Table 4. By the end of the study period, a consequence of amelioration in swallowing and
overall mean energy consumption increased signifi- GER-related complications including inanition, aspi-
cantly, as indicated by an intake:RDA ratio of 1.23 ⫾ ration pneumonia, and upper gastrointestinal tract
0.44 (P ⬍ .01, compared with the intake:RDA ratio at bleeding.
study entry). To assess the nutritional response to Because all patients in this cohort were referred
therapy, z scores were calculated. Significant in- because of feeding difficulties, we cannot comment
creases in z scores were demonstrated for both on the overall incidence of nutritional problems in
weight (initial:final ⫽ ⫺2.80 ⫾ 1.33:⫺0.81 ⫾ 0.69; P ⬍ children with neurodevelopmental abnormalities.
.01) and height (⫺3.14 ⫾ 0.98:⫺2.00 ⫾ 0.67; P ⬍ .05), However, previous studies have reported feeding
demonstrating improvement in overall nutritional disorders in up to 90% of disabled children.1,2 Se-
status during the 2-year follow-up period. Subscap- verely disabled individuals have the greatest risk of
ular and triceps skinfold thickness measurements malnutrition.1 GER (with or without aspiration) was
were used to assess changes in subcutaneous tissue. the most prevalent feeding-related problem in our
At study conclusion, the mean subscapular skinfold patients, affecting 56% of study participants. This
thickness increased by 71% ⫾ 26% (P ⬍ .05), and the finding is consistent with earlier investigations in
mean triceps skinfold increased by 38% ⫾ 17% (P ⬍ both pediatric and adult patients with cognitive and

TABLE 4. Nutritional Variables in 79 Children with Developmental Disabilities at Study Entry


(Initial) and After 24.6 ⫾ 3.0 Months (Final)
Time of Study P
(Mean ⫾ Standard Deviation) Value
Initial Final
Intake (kcal/d):RDA (kcal/d) 0.78 ⫾ 0.36 1.23 ⫾ 0.44 ⬍.01
z Score, weight ⫺2.80 ⫾ 1.33 ⫺0.81 ⫾ 0.69 ⬍.01
z Score, height ⫺3.14 ⫾ 0.98 ⫺2.00 ⫾ 0.67 ⬍.05
Triceps skinfold (% change) — 38 ⫾ 17 ⬍.05
Subscapular skinfold (% change) — 71 ⫾ 26 ⬍.05

ARTICLES 673
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motor dysfunction, where rates of pathologic GER as vestigations, including a report by one of the present
high as 70% have been reported.7,16 In addition to authors (S.M.S.), reported a significant incidence of
GER, our patients manifested a significant degree of latent GER after GT insertion.16,20 –22 Thus, in 3 com-
oropharyngeal dysphagia.13 These problems were bined cohorts of 255 children with cerebral palsy and
associated with prolonged or inefficient feeding feeding difficulties, 188 (74%) underwent fundopli-
times, reduced energy intake, and malnutrition. cations at the time of GT placement.16,20,22 One of
Overall, 21 of 79 children (26%) manifested abnormal these groups of disabled children manifested early
swallowing kinetics during the oral or pharyngeal and late postsurgical complication rates of 33% and
phases on VFSS. Evidence of tracheal aspiration dur- 39%, respectively.20 By contrast, more recent data
ing this study was an absolute indication for GT demonstrate that gastrostomies (either surgically or
placement. Finally, we followed 14 children whose endoscopically placed) are well tolerated in children
clinical course was marked by aversive feeding be- with neurologic disorders, and GTs may not be a
haviors. None of these patients had a clinical history significant risk factor for development or worsening
suggesting GER, and affected children (the most of GER.23,24 The reasons for these discrepant out-
common single diagnosis was pervasive develop- comes are not entirely clear but may include im-
mental delay) typically demonstrated marked abnor- provements in surgical technique for GT insertion,23
malities in cognitive development, without disabling increased use of endoscopic GT placement,24 or other
motor impairment. factors. The most recent findings therefore suggest
Our observations of significant malnutrition and that antireflux procedures are not needed at the time
growth retardation in children with developmental of tube placement for patients without pathologic
disabilities are consistent with previous reports. One GER. In our study, GER per se was not an indication
study found evidence of undernutrition in 90% of for antireflux surgery. Indeed, we elected to include
severely disabled children with cerebral palsy.5 Fur- fundoplications at the time of GT insertions in only
thermore, although gastrostomy feedings improved 18 of 44 children (41%) with GER, and antireflux
weight percentiles in many patients in that cohort, procedures were performed only in patients with
linear growth remained depressed. Timing of inter- GER whose initial evaluations demonstrated moder-
vention clearly is an important determining factor ate to severe esophagitis or aspiration. Nevertheless,
with respect to nutritional outcomes in these chil- all children undergoing GT placement were given
acid suppressive therapy. No patient who received a
dren. In a group of 51 children with cerebral palsy,
GT alone needed a fundoplication during the fol-
growth responses to enteral feedings were maximal
low-up period. Feeding-related hospitalizations
when supplementation began within 6 months of the
were limited to presumed oropharyngeal aspiration
primary central nervous system insult.6 When nutri-
in children with oral motor dysfunction who were
tional intervention was delayed beyond 8 years,
fed by mouth after GT insertion.
weight gain was still achieved, but linear growth was
Based on both these data and our previous expe-
limited. The problem of undernutrition in children rience in treating developmentally disabled children,
with cerebral palsy occurs despite the fact that we propose an algorithm for evaluating and manag-
nonambulatory patients demonstrate significantly ing feeding problems in these patients (Fig 1). A
lower mean resting energy expenditure than pre- detailed nutritional and feeding history should be
dicted on the basis of conventional methods (ie, Har- included in the routine clinical assessment of all chil-
ris-Benedict, World Health Organization formu- dren with moderate to severe neurodevelopmental
las).17 Dietary and nondietary factors, including disorders. For children with suspected aversive feed-
inadequate energy intake and immobility, probably ing behaviors and without suspected GER, evalua-
contribute to both lower resting energy expenditure tion by a trained speech-language pathologist will
and specific nutritional deficits in these pa- determine whether additional diagnostic evaluation
tients.4,17,18 Findings of improved clinical and nutri- for oral or pharyngeal motor dysfunction is war-
tional status after intervention in these children are ranted before commencing intensive feeding ther-
not surprising. Previous studies have demonstrated apy. If indicated, a VFSS will determine whether the
that an aggressive approach to managing feeding airway is protected from aspiration, and it will assist
abnormalities in children with cerebral palsy re- the therapist in evaluating swallowing of thick ver-
verses specific nutritional deficits.5,6,9 Additionally, sus thin liquids. Primary GT placement is performed
although we did not examine parental or caregiver in children who demonstrate oropharyngeal aspira-
attitudes toward these interventions in our patients, tion. As follow-up of these children suggests, an
one study reported that quality-of-life measures sig- antireflux procedure at the time of GER diagnosis or
nificantly improved for 90% of patients and their GT insertion is not necessary, although all children
families in response to nutritional rehabilitation.19 with gastrostomies received acid suppression ther-
This study extends earlier observations by evalu- apy with H2-receptor antagonists. Oral nutritional
ating responses to tailored approaches to feeding supplements alone often are sufficient to achieve
management. Specific therapies were selected on the nutritional adequacy for patients without evidence
basis of a thorough evaluation of swallowing and of aspiration. For children with a history consistent
gastroesophageal function. Although tube feedings with GER, including patients with swallowing dys-
have been widely used to manage these problems, function and those with aversive feeding behaviors
the importance of gastrostomies as etiologic or exac- that may be secondary to subclinical GER, standard
erbating factors for GER is controversial. Earlier in- evaluations including 24-hour pH monitoring, scin-

674 FEEDING DISORDERS IN DEVELOPMENTAL DISABILITIES


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Fig 1. Algorithm for diagnosis and treatment of
children with developmental disabilities and
feeding or nutritional difficulties.

tigraphy, and endoscopy will identify candidates for define the ideal medical therapy for GER, to evaluate
additional medical therapy or surgery. Fundoplica- responses to nonsurgical treatment after the with-
tions are absolutely indicated only for patients who drawal of cisapride from the US market, and to de-
manifest reflux-associated aspiration. At present, as termine whether antireflux procedures ultimately
shown in the algorithm, we recommend antireflux will be needed in patients with GER but without
procedures for patients with moderate to severe secondary complications.
esophagitis (Hill’s grade II–IV).15 Nevertheless, ad-
ditional investigations are needed to determine
whether GT feedings plus prolonged medical antire- CONCLUSION
flux therapy may also represent sufficient interven- We have demonstrated the efficacy of a structured
tion in this group. However first-line medical antire- approach to managing feeding disorders in children
flux therapy for patients with symptomatic GER with developmental disabilities. These data indicate
remains controversial. As stated recently in a posi- that diagnosis-specific treatments achieve significant
tion paper by the European Society of Pediatric Gas- improvements in overall nutritional status. Although
troenterology, Hepatology and Nutrition, cisapride factors other than improved nutrition (eg, closer fol-
is the most effective prokinetic agent studied to date low-up, fewer hospitalizations with increasing age)
for GER management, with available evidence indi- may affect clinical outcomes, our results suggest that
cating that the drug is both safe and efficacious in all nutritional interventions are associated with a reduc-
age groups.25 Nevertheless, because of concerns tion in the acute care hospitalization rate. Therefore,
about its potential cardiotoxicity, cisapride is un- effective management of feeding disorders may sig-
available in the United States except for compassion- nificantly decrease morbidity for this challenging
ate use. Additional studies are therefore needed to group of patients.

ARTICLES 675
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WHY ISNⴕT MONEY WORKING?

The latest [federal] National Assessment of Educational Progress report shows


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After spending $125 billion . . . over 25 years, we have virtually nothing to show for
it . . . “The education industry suffers from a severe productivity crisis,” says Jay
Green, a senior fellow at the Manhattan Institute. “We’ve tripled input during the
same time that we’ve had no change in output. Any education reform has to
involve increasing productivity. What that means is paying attention to the incen-
tives offered to schools to use their resources effectively.”

Wall Street Journal. April 10, 2001. Editorial

Submitted by Avrum L. Katcher, MD


Flemington, NJ

676 FEEDING DISORDERS IN DEVELOPMENTAL DISABILITIES


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Diagnosis and Treatment of Feeding Disorders in Children With Developmental
Disabilities
Steven M. Schwarz, Julissa Corredor, Julie Fisher-Medina, Jennifer Cohen and Simon
Rabinowitz
Pediatrics 2001;108;671
DOI: 10.1542/peds.108.3.671

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Pediatrics is the official journal of the American Academy of Pediatrics. A monthly publication, it
has been published continuously since . Pediatrics is owned, published, and trademarked by the
American Academy of Pediatrics, 141 Northwest Point Boulevard, Elk Grove Village, Illinois,
60007. Copyright © 2001 by the American Academy of Pediatrics. All rights reserved. Print ISSN:
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Downloaded from http://pediatrics.aappublications.org/ by guest on December 9, 2017


Diagnosis and Treatment of Feeding Disorders in Children With Developmental
Disabilities
Steven M. Schwarz, Julissa Corredor, Julie Fisher-Medina, Jennifer Cohen and Simon
Rabinowitz
Pediatrics 2001;108;671
DOI: 10.1542/peds.108.3.671

The online version of this article, along with updated information and services, is
located on the World Wide Web at:
http://pediatrics.aappublications.org/content/108/3/671

Pediatrics is the official journal of the American Academy of Pediatrics. A monthly publication, it
has been published continuously since . Pediatrics is owned, published, and trademarked by the
American Academy of Pediatrics, 141 Northwest Point Boulevard, Elk Grove Village, Illinois,
60007. Copyright © 2001 by the American Academy of Pediatrics. All rights reserved. Print ISSN:
.

Downloaded from http://pediatrics.aappublications.org/ by guest on December 9, 2017

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