Neglect: failure to thrive and obesity

Frequency of malnutrition in children and adolescents with child maltreatment

INTRODUCTION

child maltreatment (CM) can have a negative impact on physical and mental health in childhood and throughout life.

OBJECTIVE

to determine the frequency of malnutrition in cases of CM from the Clínica de Atención Integral al Niño Maltratado (CAINM) of the Instituto Nacional de Pediatría (INP), Mexico.

MATERIAL AND METHODS

this was a cross-sectional, retrospective, descriptive study of children with CM. Height/age, weight/height, and body mass index/age were used to determine malnutrition status (undernutrition and overweight or obesity). The frequency of malnutrition by age group and sex were compared using X2 tests. The prevalence of malnutrition at CAINM was compared to that expected in Mexico (ENSANUT-2012), serving as a reference for children without CM, using one-sample Poisson tests.

RESULTS

of the 117 cases, 41 % presented wasting or overweight/obesity, and 25 % were growth-stunted. Neither wasting nor stunting displayed any difference between age groups (p > 0.05). Overweight/obesity was observed more frequently in adolescents than in schoolchildren (p < 0.05). Being overweight or obese was most frequently associated with sexual abuse, and wasting and stunting were most often associated with neglect. Compared to the population without CM, the group under 5 years of age had a higher prevalence of wasting (p < 0.01), and those aged 5 to 11 years had a higher prevalence of both wasting and stunting (p < 0.001).

CONCLUSIONS

CM cases were characterized by acute undernutrition and stunting as well as by adolescents who were overweight or obese. Malnutrition in the pediatric population should be analyzed from a wider perspective, including possible CM.

Parental neglect of feeding in obese individuals. A review of scientific evidence and its application among Saudi population

Human beings encountered malnutrition during the twentieth century and obesity in the very next century. This is how the future will look when the present becomes a slice of history. Obesity is threatening the healthy being of many youngsters throughout the world. Environmental influences have indicated to effect even genetically safe subjects among which parental neglect seems to be most alarming. Two extensively and globally investigated variables, the feeding style and the physical activity, provide some hope in its prevention. Despite the high rise of obesity prevalence in Saudi Arabia, there is scant research on these topics. The purpose of this review is to present a comprehensive assessment of these 2-obesity associated parental variables. The composed literature could provide an insight to the dominant surge of obesity in the Arab nations and stimulate research on current parenting practices in the Kingdom.

Malnutrition and Medical Neglect

Anomalies found during the assessment of nutrition in children are common in pediatric practice, yet few articles address the intersection between malnutrition and medical neglect. The diagnosis of medical neglect requires several components including a) harm, or risk of harm due to lack of recommended health care, b) recommended care provides benefit significantly greater than potential risk, c) caregiver understands the medical recommendations; and d) has access to the recommended care, but fails to utilize it. Through the application of this definition to cases of malnutrition, considerations for diagnosing medical neglect when presented with malnutrition are reviewed. Cases include children with special healthcare needs, children exposed to selective diets, previously well children with severe malnutrition, and treatment-resistant failure to thrive. Obesity is a state of malnutrition, which may also involve neglect; in this instance, the "neglect" involves failure to supervise nutritional intake necessary for optimal functioning. Because many cases involve interactions with medical providers, the subsequent failure to follow medical advice regarding obesity management may also be considered medical neglect. This article reviews the relationship between medical neglect, nutritional deprivation, and over-nutrition to explore when a diagnosis of medical neglect may be applicable.

Failure to Thrive in the Outpatient Clinic: A New Insight

Failure to thrive (FTT) is an abnormal growth pattern determined by inadequate nutrition. It is a common problem in children, representing 5% to 10% of patients seen in an outpatient setting. Many definitions have been proposed based on anthropometric deterioration; however, they show poor concordance. No single definition is sufficiently sensitive in identifying faltering growth whilst a combination of multiple criteria seems more accurate. In light of the recent redefinition of pediatric malnutrition as a disequilibrium between requirements and intakes of energy, and macro- and micronutrients, a wider conception of FTT as an unsatisfactory nutritional status related to poor growth and health is useful. Although the most severe problems of micronutrient malnutrition are found in developing countries, people of all regions of the world can be affected by micronutrient deficiencies (MNDs), a form of undernutrition with relevant effects on growth and health. Changes in diets and lifestyle, elimination diets, food insecurity, and food intake disorders create the conditions at risk of faltering growth and MNDs. This new insight integrates the "classical" anthropometric criteria for definition and treatment, in the aim of warranting both a regular increase in size and an overall adequate development and health status.

The role, yield and cost of paediatric faecal elastase-1 testing

OBJECTIVE

Faecal elastase-1 (FE1) is a sensitive marker for exocrine pancreatic enzyme insufficiency. Pancreatic insufficiency (EPI) leads to maldigestion and subsequent poor weight gain. Thus, FE1 is performed as work-up for children with failure to thrive (FTT). However, EPI in the paediatric population outside of cystic fibrosis (CF) is rare. This study aimed to identify the indications for FE1 testing and their diagnostic yield in children. The secondary aim was to evaluate the cost per case of EPI detected for the various indications.

DESIGN

All FE1 tests performed on children (0-18 years) at a tertiary paediatric hospital in Sydney, Australia between 2010 and 2013 (inclusive) were identified. A retrospective chart audit was performed to identify the indication for testing FE1. The diagnostic yield based on FE1 cut-offs <200 and < 100 μg/g were assessed.

RESULTS

The most common indication for testing FE1 was "FTT only" (71/216, 32.9%), however, in this cohort of patients, FE1 was least likely to be positive with only 2 out of the 71 (2.8%) patients returning a positive result. In comparison, CF was the second most common indication for testing (60/216, 27.8%), but nearly half (48.8%) of tests returned a positive result in this cohort. The cost per case detected (FE1 <200 μg/g) reflected the test yield with an average cost per positive test of $262.50 (AUD2015) for FTT with short-gut syndrome and $420.00 (AUD2015) for CF-related indications.

CONCLUSION

Our study shows that for patients with isolated failure to thrive, FE1 testing is low yield and costly.

Aspects of abuse: recognizing and responding to child maltreatment

Child maltreatment is a public health problem and toxic stress impacting at least 1 in 8 children by the age of 18 years. Maltreatment can take the form of physical and sexual abuse, neglect, and emotional maltreatment. While some children may experience only one form of maltreatment, others may survive multiple forms, and in some cases particularly complex forms of maltreatment such as torture and medical child abuse. When considering maltreatment, providers should be adept at obtaining a thorough history not only from the parent but when appropriate also from the patient. The most common form of child maltreatment is neglect, which encompasses nutritional and medical neglect, as well as other forms such as physical and emotional neglect. Talking with caregivers about stressors and barriers to care may give insight into the etiology for neglect and is an opportunity for the provider to offer or refer for needed assistance. Familiarity with injury patterns and distribution in the context of developmental milestones and injury mechanisms is critical to the recognition of physical abuse. While most anogenital exam results of child victims of sexual abuse are normal, knowing the normal variations for the female genitalia, and thereby recognizing abnormal findings, is important not only forensically but also more importantly for patient care. Pattern recognition does not only apply to specific injuries or constellation of injuries but also applies to patterns of behavior. Harmful patterns of behavior include psychological maltreatment and medical child abuse, both of which cause significant harm to patients. As health professionals serving children and families, pediatric providers are in a unique position to identify suspected maltreatment and intervene through the health care system in order to manage the physical and psychological consequences of maltreatment and to promote the safety and well-being of children and youth by making referrals to child protective services.

Getting my child to eat the right amount. Mothers' considerations when deciding how much food to offer their child at a meal

Feeding young children successfully requires parenting skills, trust that children will eat, and nutrition and child development knowledge to ensure that foods and the amounts offered are developmentally appropriate. Mothers are often responsible for determining how much food is offered to their children; however, the influences on mothers' decisions regarding how much to offer their children--their motivations, goals for feeding and child consumption--have not been investigated. Study aims included gathering qualitative data regarding mothers' decisional processes related to preparing a dinner meal plate for her preschooler. Low income mothers (n = 15 African American and n = 15 Latina mothers) were recruited from preschools in the Denver, CO metropolitan area to participate in semi-structured interviews. Mothers prepared a plate for their preschooler and were asked about influences on their decisions about portion sizes and their expectations for children's eating. Data were coded by 2 independent coders using a consensus coding process and analyzed by investigators. Three themes emerged: (1) portion sizes differ for children who are "good" eaters and "picky" eaters; (2) mothers know the "right amounts" to serve their child; and (3) mothers have emotional investments in their children's eating. Some influencing factors were child-centered (e.g. child's likes and dislikes, "picky" and "good" eaters, and foods previously eaten in the day) and some related to adult expectations and concerns (nutrient content and waste). Interventions focusing on portion size may be more effective if tailored to the mothers' perceptions regarding her child's eating characteristics.