Non-organic failure to thrive: growth failure secondary to feeding-skills disorder

Neophobia—A Natural Developmental Stage or Feeding Difficulties for Children?

Food neophobia is the tendency to reject or be reluctant to try new and unfamiliar foods. Due to the period of its occurrence, which falls in the years of early childhood, it can significantly affect the child’s food choices, shape taste preferences, and significantly influence the quality of the child’s diet. The neophobic attitude has an important evolutionary significance because it protects the individual from ingesting potentially dangerous substances. On the other hand, it fosters avoidance behaviors that can also relate to the beneficial aspects of obtaining and consuming food. Currently, the strong emphasis placed on food safety means that neophobia may be less adaptive; nevertheless, a conservative attitude toward new foods still prevails. There is a strong association between food neophobia and the diversity of a person’s diet and previous exposure to different foods. This review describes behaviors associated with food neophobia and analyzes other feeding and eating difficulties in children that should be differentiated from food neophobia. Management approaches affecting the reduction in food neophobia in children through various dietary and psychological interventions are also proposed.

Outcomes for Feeding Tube-Dependent Children With Oral Aversion in an Intensive Interdisciplinary Treatment Program

Purpose Feeding challenges in children are common, at times reaching a severity that requires the placement and long-term use of enteral feedings. A significant barrier to advancing the oral eating of some tube-dependent children is the presence of oral aversion. Although some research exists regarding the treatment of tube-dependent children who are averse to food or the process of eating, specifically, there has yet to be an examination of children who are truly "orally" averse-resisting not just the presentation of food or liquid but also nonnutritive stimuli presented extra- or intra-orally. Method Using a retrospective chart review, the current study aimed to examine the treatment outcomes of 18 feeding tube-dependent children with significant oral aversion (nine boys, nine girls; M _age = 46.7 months, SD = 20.0 months, range: 11.4-89.3 months) as compared to 29 tube-dependent, but nonorally averse, clinical controls. Children completed approximately 6-8 weeks of intensive interdisciplinary feeding treatment. Results Analyses revealed significant improvements in all measured treatment outcomes for both patient groups, including children's rates of acceptance and maladaptive mealtime behavior. Significant reductions in tube use were also observed across both groups, with tube utilization decreasing, on average, by 76.2% for orally averse and by 64.3% for nonorally averse children by program discharge. Conclusion Results demonstrate the therapeutic benefits of intensive interdisciplinary intervention for both groups of tube-dependent children, highlighting that orally averse children, believed to be an especially challenging subset of pediatric feeding patients, demonstrate similarly positive treatment responses. Interestingly, in this preliminary examination, orally averse children demonstrated significantly greater reductions in tube utilization following discharge when compared with their nonorally averse clinical peers.

Pediatric Feeding Disorder: Consensus Definition and Conceptual Framework

Pediatric feeding disorders (PFDs) lack a universally accepted definition. Feeding disorders require comprehensive assessment and treatment of 4 closely related, complementary domains (medical, psychosocial, and feeding skill-based systems and associated nutritional complications). Previous diagnostic paradigms have, however, typically defined feeding disorders using the lens of a single professional discipline and fail to characterize associated functional limitations that are critical to plan appropriate interventions and improve quality of life. Using the framework of the World Health Organization International Classification of Functioning, Disability, and Health, a unifying diagnostic term is proposed: "Pediatric Feeding Disorder" (PFD), defined as impaired oral intake that is not age-appropriate, and is associated with medical, nutritional, feeding skill, and/or psychosocial dysfunction. By incorporating associated functional limitations, the proposed diagnostic criteria for PFD should enable practitioners and researchers to better characterize the needs of heterogeneous patient populations, facilitate inclusion of all relevant disciplines in treatment planning, and promote the use of common, precise, terminology necessary to advance clinical practice, research, and health-care policy.

Failure to Thrive: An Expanded Differential Diagnosis

The patient is a term 6-month-old male, who presented with failure to thrive since birth. History was remarkable for suspected milk and soy protein allergy, gastroesophageal reflux, constipation, and abdominal distension that was present since birth. He was losing weight despite oral intake of over 100 kcal/kg per day. Prior workup including laboratory studies, abdominal X-ray, upper gastrointestinal series with fluoroscopy, barium enema, and abdominal ultrasound were all within normal limits. The patient's history, diagnostic evaluation, and final diagnosis are revealed. This case highlights a rare condition presenting as failure to thrive, a common problem with a wide differential diagnosis.

Dysphagia in children with repaired oesophageal atresia

Dysphagia is a common problem in children with repaired oesophageal atresia (OA). Abnormalities in the oropharyngeal and oesophageal phase have hardly been studied. The aims of this study were to assess the prevalence of dysphagia in children with repaired OA and to identify and differentiate oral and pharyngeal dysphagia based on videofluoroscopic swallow study (VFSS) findings in a limited number of children in this cohort. Medical records of 111 patients, born between January 1996 and July 2013 and treated at the Radboudumc Amalia Children's Hospital, were retrospectively reviewed. The prevalence of dysphagia was determined by the objective and modified Functional Oral Intake Scale (FOIS) in four age groups. The first performed VFSS of 12 children was structurally assessed. The prevalence of dysphagia was 61 of 111 patients (55 %) in age group <1 year. In age group 1-4, 5-11 and 12-18 years, the prevalence of dysphagia decreased from 54 of 106 (51 %) patients to 11 of 64 (17 %) and 5 of 24 (21 %) patients. The 12 VFSS's reviews revealed oral dysphagia in 36 % and pharyngeal dysphagia in 75 %.

CONCLUSIONS

This study highlights dysphagia as an important problem in different age groups of children with repaired OA. Furthermore, our study shows the presence of oropharyngeal dysphagia in this population. This study emphasizes the need to standardize the use of objective dysphagia scales, like the modified FOIS, to provide a careful follow-up of children with repaired OA.

WHAT IS KNOWN

• Prevalence of dysphagia in children with repaired oesophageal atresia varies widely (ranges from 45 to 70 %) in literature. • Oral, pharyngeal and oesophageal dysphagia require different treatment approaches. What is New: • We determined dysphagia based on functional oral intake and provide an overview of change in dysphagia prevalence and severity over time in children with repaired OA. • Our study shows that dysphagia, including oropharyngeal dysphagia, is highly prevalent in young children with repaired OA and improves with time.

Clinical Characteristics of 2 Groups of Children With Feeding Difficulties

OBJECTIVES

The primary aim of this study was to describe and compare the clinical characteristics of 2 groups of children presenting to a feeding clinic: children with autism spectrum disorder (ASD) and children with a nonmedically complex history (NMC). A secondary aim was to compare participants according to the degree of oral motor impairment, presence of oral hypersensitivity, and clinically significant parent stress.

METHODS

Children with feeding difficulties ages between 2 and 6 years were recruited. Prospective data were collected on dietary intake, general development, mealtime behaviors, oral motor skills, oral sensory processing, and parental stress via parent questionnaire and clinical assessment.

RESULTS

In total, 68 children (ASD = 33 and NMC  = 35) participated in the study. Both groups presented with a large number of difficult mealtime behaviors. Although stress was elevated in both groups, parents of children in the ASD group reported significantly higher stress levels than those with children in the NMC group (mean difference 27.3 on a percentile scale, 95% confidence interval [CI] 15.5-39.2, P < 0.01). Across both groups, the majority of children presented with mild-to-moderate oral motor impairments (ASD = 28, 85%; NMC = 28, 80%). Children with heightened oral sensory sensitivity consumed significantly fewer unprocessed fruits and vegetables (mean difference 3.3 foods, 95% CI 1.3-5.3, P < 0.01), and their parents reported a significantly greater frequency of difficult mealtime behaviors (mean difference 5.8 behaviors, 95% CI 3.4-8.1, P < 0.01).

CONCLUSIONS

Features of feeding difficulty presented similarly across the ASD and NMC groups in this study. Oral motor impairment, oral sensory sensitivity, and parental stress should not be overlooked in the management of children with feeding difficulties, regardless of etiology.

Multidisciplinary intervention for childhood feeding difficulties

OBJECTIVE

The aim of the study was to determine whether operant conditioning (OC) or systematic desensitization (SysD) intervention resulted in more improvements in dietary variety/intake, and more reductions in difficult mealtime behaviors.

METHODS

Children 2 to 6 years with autism spectrum disorder or with a nonmedically complex history were recruited. Feeding difficulties were confirmed based on clinical assessment. Participants were randomized to receive 10 OC or SysD sessions (parents could opt for intervention once per week, or intensively within a week). Immersive parent education was delivered across both arms. A 3-month review was provided to measure outcomes postintervention.

RESULTS

In total, 68 participants (87%) completed the study. There were no significant differences in outcome measures between the OC and SysD intervention groups from baseline to 3-month review. When the data were combined across both groups, however, significant improvements in primary outcome measures were observed (P < 0.05). Although not statistically significant, it was considered clinically significant that participants in the OC arm demonstrated more increases in dietary variety (mean difference 3.3 foods, 95% confidence interval -0.1 to 6.8, P = 0.06) compared with the SysD arm. There were limited differences in response observed between the autism spectrum disorder and nonmedically complex history groups, and the intensive and weekly arms.

CONCLUSIONS

Favorable results were observed regardless of intervention, intensity, or etiological group. Results suggest that, when delivered to a protocol by experienced therapists and coupled with parent education, these 2 intervention approaches are effective. Further research is required in exploring these interventions across other subgroups, and examining outcomes for longer periods.

A pilot investigation of feeding problems in children with esophageal atresia

While many long-term complications of esophageal atresia (EA) have been well investigated, little is known about feeding difficulties in children after surgical correction of EA and its impact on caregivers. This study investigates the feeding behaviors of children with EA through a validated feeding questionnaire. The Montreal Children's Hospital Feeding Scale (MCH-FS) was filled out by the primary caregiver during patient follow-up visits in the multidisciplinary EA clinic. Demographic information, EA subtype, associated anomalies and outcomes were recorded. Results were compared between groups and to a normative sample. Thirty caregivers have completed the MCH-FS; 26 patients had type C atresia (86.7%). In comparison to controls, 17.5% of EA cases are one standard deviation above the mean feeding difficulty score, while 6.7% (n = 2) cases are greater than two standard deviations above normative values. Typical EA patients (type C who were not born <30 weeks) had mean MCH-FS scores in the subclinical range, whereas one extremely premature child and the patients with non-type C EA (n = 4) all had scores in the severe range. Feeding difficulties of patients with typical EA appear mild. Likely explanations include the use of early protocolized care and intensive multidisciplinary care in follow up. Nonetheless, patients with complicated EA (non-type C) and their caregivers tend to experience significant feeding difficulties. Early targeted care may be required for this patient subset, and additional cases will be investigated to confirm these preliminary findings and explore further risk factors of feeding problem in this cohort.

Role reversal method for treatment of food refusal associated with infantile feeding disorders

OBJECTIVES

Infantile feeding disorders (IFDs) are common causes of food refusal and failure to thrive, and are frequently encountered by primary care physicians and specialists. We have published the Wolfson criteria for IFD, which have eased the approach to the diagnosis of IFDs. Along with and complementary to the Wolfson criteria, we have also developed the role reversal treatment method for IFD, which has been briefly described earlier. The aim of this study was to validate the role reversal treatment method on a cohort of infants diagnosed as having IFD and to present a detailed description of this method for the first time.

METHODS

Parents of infants and children diagnosed as having IFD were invited to participate in the study; they were handed over a questionnaire comprising 6 categories of questions related to patient and parents behaviors, attitudes, and perceptions, which was completed at initiation and at the end of treatment. Full response was defined as improved normative feeding, cessation of abnormal parental feeding, and improved or normal growth patterns. A partial response was defined as success with two-third categories.

RESULTS

We enrolled 38 patients, and 32 patients completed the study. Improved feeding occurred in 78%, full recovery was documented in 53% of infants by 6 months, and partial response was observed in another 25%. All forms of pathological feeding improved significantly (mechanistic, nocturnal, persecutory, forced feeding, and distraction).

CONCLUSIONS

The role reversal treatment method is a simple and effective approach to the treatment of food refusal associated with IFD.

Self-Assessment of Pediatric Feeding Therapists in the State of Illinois

Introduction:

The care of infants and children with feeding and swallowing disorders requires specialized skills and strategies. Therapist certification is often available for hospital-based feeding, yet due to increasing demand, more non-certified, state-provided therapists are providing treatment. However, their skill set is uncertain and has yet to be explored. This investigation provides insight into therapist skill level and self-perceived proficiency.

Methods:

Feeding therapists throughout the state were surveyed for CEU, caseload, and work environment. Individual skill set and self-reliance with clinical vignettes were assessed a by Likert scale.

Results:

Early Intervention: (0 to 3 years of age) outnumbered outpatient, school, and hospital-based therapists. Limited training and caseload were prevalent and associated with poorer clinical skills. Both early intervention and hospital-based therapists reported proficiency in managing infants with dysphagia, however hospital-based therapists were most self-reliant.

Conclusion:

A certification process and associated clinical pathway is recommended for feeding therapists to provide standardized services throughout state.

Pediatric dysphagia

Feeding and swallowing disorders in the pediatric population are becoming more common, particularly in infants born prematurely and in children with chronic medical conditions. The normal swallowing mechanism is divided into 4 stages: the preparatory, the oral, the pharyngeal, and the esophageal phases. Feeding disorders have multiple causes: medical, nutritional, behavioral, psychological, and environmental factors can all contribute. Pathologic conditions involving any of the anatomic sites associated with the phases of swallowing can negatively impact the coordination of these phases and lead to symptoms of dysphagia and feeding intolerance.

Congenital feeding and swallowing disorders

Although poorly recognized and studied, congenital sucking, swallowing, and/or feeding disorders are common. They can be the symptoms that reveal a neuromuscular disease, or that complicate a neuromuscular disease. It is essential to know feeding physiology during fetal and infant development in order to understand the variety of its disorders and to direct correctly diagnostic and therapeutic processes. A good semiological analysis will identify the symptoms. Several investigations help to determine the mechanism of the trouble (fiber endoscopy, videofluoroscopy, facial and swallowing electromyography, esophageal manometry, etc.). Other investigations, in addition to clinical assessments, help to identify the cause of the whole picture (peripheral electromyography, brain MRI, genetic or metabolic investigations, etc.). The main causes of sucking, swallowing, and feeding disorders are lesions of the brainstem (malformations of the posterior fossa, neonatal brainstem tumors, agenesis of cranial nerves, clastic lesion of the posterior brain, craniovertebral anomalies, syndromes that involve the rhombencephalic development such as Pierre Robin sequence, CHARGE syndrome, etc.). Suprabulbar lesions, neuromuscular disorders, peripheral esophageal, digestive, and laryngeal anomalies and dysfunctions can also be involved. The main principles of the management of congenital sucking, swallowing, and feeding disorders are the following: cure the cause if possible, facilitate the sucking reflex, preventing deleterious consequences of aspiration, preventing malnutrition, and preventing posttraumatic anorexia. Advice can be given to caregivers and physiotherapists who take charge of these children.

The Montreal Children's Hospital Feeding Scale: A brief bilingual screening tool for identifying feeding problems

OBJECTIVE

To establish the psychometric characteristics of a newly developed, brief bilingual 14-item parent report tool (The Montreal Children's Hospital Feeding Scale [MCH-Feeding Scale]) designed to identify feeding problems in children six months to six years of age.

METHODS

To establish construct validity, 198 mothers of children visiting community paediatrician's offices (normative sample) and 174 mothers of children referred to a feeding clinic (clinical sample) completed the scale. Test-retest reliability was obtained by the re-administration of the MCH-Feeding Scale to 25 children in each sample.

RESULTS

Excellent construct validity was confirmed when the mean [± SD] scores of the normative and clinical samples were compared (32.65±12.73 versus 60.48±13.04, respectively; P<0.01). Test-retest reliabilities were high for both groups (normative r=0.845, clinical r=0.92).

CONCLUSION

The MCH-Feeding Scale can be used by paediatricians and other health care professionals for quick identification of feeding problems.

Elevated circulating acylated and total ghrelin concentrations along with reduced appetite scores in infants with failure to thrive

Failure to thrive (FTT) is a term used to describe inadequate growth in infants. The immediate cause is undernutrition. Ghrelin is a potent orexigenic hormone that induces a positive energy balance and enhances appetite. There is no information regarding the possible role of ghrelin in infants with FTT. The aim of this study was 2-fold: 1) to examine circulating ghrelin levels in FTT infants, compared with those of normally growing infants; and 2) to evaluate appetitive behaviors in the two groups. Plasma acylated and total ghrelin concentrations were measured in nine FTT and five normally growing infants (age range, 9-18 mo). Appetite was assessed using three novel appetite measures. Both acylated and total ghrelin levels were significantly elevated in FTT infants compared with controls (p = 0.03 or less). Infants with FTT scored significantly lower than control infants on all appetite measures (p = 0.002 or less). Ghrelin levels were inversely related to appetite, weight velocity, weight/length z-scores, and weight z-score. These findings provide the first evidence that infants with FTT have higher circulating ghrelin concentrations but paradoxically lower appetite scores. Increased ghrelin secretion may reflect an adaptive mechanism attempting to increase appetite and preserve energy balance in response to poor nutritional state.

Delayed introduction of lumpy foods to children during the complementary feeding period affects child's food acceptance and feeding at 7 years of age

The study aimed to follow up children who had been introduced to lumpy solids (chewy foods) at different ages, and to assess their dietary intake and feeding difficulties at seven years of age. Information was collected from a geographically defined population of 7821 mothers of children born in 1991/92, part of the Avon Longitudinal Study of Parents and Children (ALSPAC). Self-report questionnaires were completed by the mother about her child at 6 months, 15 months, and 7 years postpartum about food foods eaten and feeding difficulties. Children were divided into three groups based on the age at which they were first introduced to 'lumpy' solids: 12.1% were introduced before 6 months of age, 69.8% were introduced between 6 and 9 months of age and 18.1% were introduced after 9 months. Children introduced to lumpy solids after the age of 9 months ate less of many of the food groups at seven years, including all 10 categories of fruit and vegetables, than those introduced to lumpy foods between 6-9 months (P < 0.05-0.001). In addition they were reported as having significantly more feeding problems at seven years (P < 0.05-0.001). The long-term feeding problems and reduced consumption of important food groups such as fruit and vegetables in children who are introduced to lumpy foods after the age of 9 months is a cause for concern. Health professionals must encourage the progression from purees and exposure to important food groups.

In-depth mental health evaluation of a community sample of nonreferred infants with feeding difficulties

OBJECTIVE

Evaluate the clinical characteristics of feeding difficulties in 30 community (i.e., nonreferred) infants in the first 2 years of life, and their correlation with mother/child interactions.

METHOD

An "in depth" mental health evaluation of feeding difficulties, and the psychosocial functioning of the child in other areas. The mother-infant relationship and the feeding interactions were also assessed.

RESULTS

Four "groups" were identified. (1) Young infant with difficulties in regulating states and sucking. (2) Older infant with difficulties in self-regulation, focusing, hyper-alert, and with aversion to feeding. (3) Older infants hypersensitive to stimuli (taste, odor) and with difficulties in chewing. (4) Group of with varied and unique feeding problems (pica, rumination).

CONCLUSION

Feeding problems tend to have patterns according to the age of the baby in a nonreferred sample. They are not associated with an altered parent-infant relationship nor poor feeding technique. Parents often adapt successfully to the uniqueness of the baby to maintain weight gain.

The Importance of a Multifaceted Approach in the Assessment and Treatment of Childhood Feeding Disorders

The objective of this article is to describe the use of a multifaceted approach in the assessment and treatment of a child with a severe feeding disorder in an inpatient setting. Family and ward-staff interviews, video observations, and behavioral measures were used in the assessment and treatment of a 2-year-old girl admitted to a pediatric ward with failure to thrive and was being tube fed. Causal and maintaining factors were identified and the subsequent intervention (the feeding program) combined a behavioral treatment (learning principles applied at mealtimes) and family-centered work (systematic parent training procedures). By the time of the psychological intervention, the majority of developmentally and age-appropriate feeding behavior appeared to be absent and the child only fed through a naso-gastric tube. The number and variety of feeding behaviors and the amount and variety of foods taken increased during treatment. These behaviors were maintained during the follow-up and generalized into the home environment. There was also an observed increase in the child's capacity for emotional expression. Successful outcomes can be achieved with complex feeding problems by using a multifaceted approach that places emphasis on effective transdisciplinary collaboration and the inclusion of the family in all stages of the process.

Optimizing the introduction of complementary foods in the infant's diet: a unique challenge in developing countries

Being one of a series of technical support papers pertaining to the South African paediatric food-based dietary guidelines, this paper specifically deals with two of the guidelines proposed for the age group 6-12 months regarding the introduction of complementary foods in the infant's diet. Studies have shown that most of South African infants receive solid foods at the age of 4 months or earlier while only a small percentage are breastfed exclusively until 6 months. The untimely and inappropriate introduction of complementary foods have been shown to be risk factors for both under- and over-nutrition with resultant under- or overweight, stunting and micronutrient deficiencies. Optimal timing for the introduction of complementary foods will depend on the infant's physiological and developmental status. Small, frequent meals of easily digestable, smooth, semisolid nutrient- and energy-dense complementary foods should initially be offered while gradually increasing variety in both the type and texture of food. Protein and carbohydrate intake should increase with the infant's age while preference should be given to foods rich in micronutrients. It should be observed that certain foods, such as fresh cow's milk and egg white, because of their allergenic properties, as well as fat-free and high-fibre foods, excessive fruit juice and low nutrient value drinks such as tea are not recommended. Timely introduction of appropriate complementary foods is vital for the immediate and long-term health of the infant and caregivers should be accordingly advised on feeding at this age.

Weight faltering in infancy and IQ levels at 8 years in the Avon Longitudinal Study of Parents and Children

OBJECTIVE

Our goal was to investigate the association between failure to thrive (defined as weight faltering in the first 9 months of life) and IQ levels 8 years later.

METHODS

Weight gain (conditional on initial weight) from birth to 8 weeks, 8 weeks to 9 months, and birth to 9 months was measured on term infants from the Avon Longitudinal Study of Parents and Children. Cases of weight faltering were defined as those infants with a conditional weight gain below the 5th centile who were compared with the rest of the cohort as the control group. At the age of 8 years, 5771 infants born at term with no major congenital abnormalities had IQ measured by using the Wechsler Intelligence Scale for Children, Third Revision.

RESULTS

Mean (SD) IQ scores were 104.7 (16.3) (total), 107.6 (16.5) (verbal), and 100.2 (16.9) (performance). Children whose weight faltered from birth to 9 months had a total IQ that was significantly lower by an average of -2.71 points at 8 years, equivalent to 0.17 SD. Weight gain from birth to 8 weeks had a positive linear association with child IQ at 8 years. This remained significant in a multivariate regression despite controlling for correlates of both infant growth and child IQ; 1 SD of weight gain was associated with a difference of 0.84 points in the total IQ score. In contrast to early weight faltering, weight gain from 8 weeks to 9 months was not related to IQ at 8 years.

CONCLUSIONS

Failure to thrive in infancy was associated with persisting deficits in IQ at 8 years; the critical period for growth faltering was birth to 8 weeks. The relationship between infant growth from birth to 8 weeks and later intellectual development was approximately linear over the whole range of weight velocities.

Feeding outcomes of extremely premature infants after neonatal care

Feeding is a primary concern for families of extremely preterm (EP) infants following discharge from neonatal care. An increasing number of EP children are being referred for treatment of feeding problems, including eating only a few types of food or very small portions, difficulty transitioning to textured foods, and refusing food. These issues have the potential for significant consequences for the children's growth and development as well as their family's well-being. An understanding of the kinds of feeding problems faced by families of EP infants can help nurses guide families to be ready for and respond to these issues. In this article, the evidence for and the nature of feeding problems in EP children after discharge from neonatal care are examined.

Postnatal factors associated with failure to thrive in term infants in the Avon Longitudinal Study of Parents and Children

OBJECTIVE

To assess the contribution of postnatal factors to failure to thrive in infancy.

METHODS

11 900 infants from the Avon Longitudinal Study of Parents and Children (ALSPAC), born at 37-41 weeks' gestation, without major malformations and with a complete set of weight measurements in infancy (83% of the original ALSPAC birth cohort) were studied. Conditional weight gain was calculated for the periods from birth to 8 weeks and 8 weeks to 9 months. Cases of growth faltering were defined as those infants with a conditional weight gain below the 5th centile.

RESULTS

Analysis yielded 528 cases of growth faltering from birth to 8 weeks and 495 cases from 8 weeks to 9 months. In multivariable analysis, maternal factors predicting poor infant growth were height <160 cm and age >32 years. Growth faltering between birth and 8 weeks was associated with infant sucking problems regardless of the type of milk, and with infant illness. After 8 weeks of age, the most important postnatal influences on growth were the efficiency of feeding, the ability to successfully take solids and the duration of breast feeding.

CONCLUSIONS

The most important postnatal factors associated with growth faltering are the type and efficiency of feeding: no associations were found with social class or parental education. In the first 8 weeks of life, weak sucking is the most important symptom for both breastfed and bottle-fed babies. After 8 weeks, the duration of breast feeding, the quantity of milk taken and difficulties in weaning are the most important influences.

Failure to thrive as a manifestation of child neglect

Failure to thrive is a common problem in infancy and childhood. It is most often multifactorial in origin. Inadequate nutrition and disturbed social interactions contribute to poor weight gain, delayed development, and abnormal behavior. The syndrome develops in a significant number of children as a consequence of child neglect. This clinical report is intended to focus the pediatrician on the consideration, evaluation, and management of failure to thrive when child neglect may be present. Child protective services agencies should be notified when the evaluation leads to a suspicion of abuse or neglect.

What is the long term outcome for children who fail to thrive? A systematic review

AIMS

To ascertain the long term outcomes in children diagnosed as having failure to thrive (FTT).

METHODS

Systematic review of cohort studies. Medline, Psychinfo, Embase, Cinahl, Web of Science, Cochrane, and DARE databases were searched for potentially relevant studies.

INCLUSION CRITERIA

cohort studies or randomised controlled trials in children <2 years old with failure to thrive defined as weight <10th centile or lower centile and/or weight velocity <10th centile, with growth, development, or behaviour measured at 3 years of age or older.

RESULTS

Thirteen studies met the inclusion criteria; eight included a comparison group, of which five included children identified in community settings. Two were randomised controlled trials. Attrition rates were 10-30%. Data from population based studies with comparison groups and which reported comparable outcomes in an appropriate form were pooled in a random effects meta-analysis. Four studies report IQ scores at follow up and the pooled standardised mean difference was -0.22 (95% CI -0.41 to -0.03). Two studies reported growth data as standard deviation scores. Their pooled weighted mean difference for weight was -1.24 SDS (95% CI -2.00 to -0.48), and for height -0.87 SDS (95% CI -1.47 to -0.28). No studies corrected for parental height, but two reported that parents of index children were shorter.

CONCLUSIONS

The IQ difference (equivalent to approximately 3 IQ points) is of questionable clinical significance. The height and weight differences are larger, but few children were below the 3rd centile at follow up. It is unclear to what extent observed differences reflect causal relations or confounding due to other variables. In the light of these results the aggressive approach to identification and management of failure to thrive needs reassessing.

Effect of Gastrostomy on Growth in Children with Neurodevelopmental Disabilities

Chronic malnutrition and growth failure are frequent consequences of feeding difficulties in neurodevelopmentally disabled children. Gastrostomy feeding has been used successfully to alleviate chronic malnutrition as well as distress and frustration associated with feeding. Unfortunately, caregivers are often resistant to gastrostomy placement. In order to determine the impact of gastrostomies in 20 children with neurodevelopmental disability (NDD), a questionnaire was used to collect caregivers’ perceptions both before and after gastrostomy. The questionnaire assessed caregivers’ retrospective perceptions of quality of life, feeding difficulties, and the burdens and benefits of gastrostomies. To determine impact on growth, height and weight were measured once before and three times after gastrostomy (at six, 12, and 24 months). The number of times a child was fed and the amount of time spent feeding decreased significantly following gastrostomy (p<0.001 and p<0.05, respectively). Growth for all children improved following gastrostomy (p<0.001). Pregastrostomy problems improved significantly following gastrostomy, as did caregivers’ perceptions of quality of life for both themselves and their child (p<0.001). These results indicate that gastrostomy has a positive impact on growth for neurodevelopmentally disabled children, and on quality of life for both children and caregivers. Caregivers may find these results encouraging if they are faced with a decision about gastrostomy placement for their child.

Mealtime energy intake and feeding behaviour in children who fail to thrive: a population-based case-control study

BACKGROUND

The essential link between energy needs and energy intake is feeding behaviour, yet few studies have directly observed feeding behaviour in children who have failed to thrive. A cohort of 961 term infants was screened to identify children with first year weight gain below the 5th centile in order to examine their feeding behaviour and food intake.

METHODS

A nested case-control study was used with direct observation at 13-21 months over two lunchtime meals, one consisting of finger foods and the other of 'spoon foods'. Thirty children who failed to thrive and 57 controls were studied. The video-tapes were coded for feeding behaviour using a behavioural coding inventory which distinguishes between children feeding themselves and responding to being fed by their mother. The main outcome measures were counts of five feeding actions (give, accept, feedself, refuse, reject) and measures of energy intake, the weight of food eaten and meal duration.

RESULTS

There were systematic differences in feeding behaviour between meal types, with mothers feeding their child more often at meals comprising spoon foods and children feeding themselves more often at meals comprising finger foods. By weight, more food was consumed at the spoon food meals, but energy intake was no higher, showing that the children compensated for the differing energy yields of the foods. Children who failed to thrive took in less energy than controls, and were less likely to sit in a highchair throughout the meal, but there were no clear differences in other aspects of feeding behaviour.

CONCLUSIONS

Food type is an important variable when studying childhood feeding behaviour. Children who fail to thrive take in less energy than controls of the same age, despite there being no major differences in mealtime feeding behaviour.

The complexity of feeding problems in 700 infants and young children presenting to a tertiary care institution

BACKGROUND

Feeding problems are common in infants and young children. A multidisciplinary team approach contributes to better patient care. However, few quantitative data on multidisciplinary feeding assessment of children have been published. OBJECTIVES The first aim of this study was to characterize the etiology of feeding difficulties in 700 children referred for assessment of severe feeding difficulty. The authors differentiated medical, oral, and behavioral categories. The second aim was to assess the prevalence of prematurity and dysmaturity in the patients and their relationship to the type of feeding problem.

METHODS

Clinical data from 700 children aged less than 10 years who were examined for severe feeding problems were analyzed.

RESULTS

Close to 50% of the children had a combined medical and oral condition underlying their feeding difficulties. More than half of the children were examined for gastrointestinal conditions, particularly gastroesophageal reflux disease. Behavioral problems were more frequently seen in children aged more than 2 years. The results indicate that oral sensory-based feeding problems are related to past medical intervention. Children with feeding disorders had a significantly lower birthweight for gestational age. Preterm babies were overrepresented in this population.

CONCLUSIONS

A multidisciplinary team approach is essential for assessment and management because combined medical and oral problems are the most frequent cause of pediatric feeding problems. A significant relationship was found between the type of feeding problem and age. Infants born preterm and/or with a birthweight below the tenth percentile for gestational age are at greater risk for developing feeding disorders.

Parent-offspring conflict theory, signaling of need, and weight gain in early life

Human growth in early life has major implications for fitness. During this period, the mother regulates the growth of her offspring through placental nutrition and lactation. However, parent-offspring conflict theory predicts that offspring are selected to demand more resources than the mother is selected to provide. This general issue has prompted the development of begging theory, which attempts to find the optimal levels of offspring demand and parental provisioning. Several models have been proposed to account for begging behavior, whether by biochemical or behavioral pathways, including: (1) blackmail of parents; (2) scramble competition between multiple offspring; (3) honest signaling of nutritional need; and (4) honest signaling of offspring worth. These models are all supported by data from nonhuman animals, with species varying according to which model is relevant. This paper examines the evidence that human suckling and crying signal nutritional demand, need, and worth to the mother. While suckling provides hormonal stimulation of breast milk production and signals hunger, crying fulfills a different role, with evidence suggesting that it signals both worth and need for resources (nutrition and thermoregulation). The role of signaling in nutritional demand is examined in the context of three common health problems that have traditionally been assumed to have physiological rather than behavioral causes: excess weight gain, failure to thrive, and colic. The value of such an evolutionary approach lies in its potential to enhance behavioral management of these conditions.

Feeding disorders in infants and children

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.

Biological vulnerability in infants with failure to thrive: the association with birthweight

The development of failure to thrive (FTT) is hypothesized to be caused by the interaction between biological and environmental factors. Birthweight is one biological variable thought to play a role in the infant's growth failure. In studies that enrolled infants with FTT who were full-term at birth, the reported birthweights of these infants were significantly less than healthy control infants (M = 2959 g vs. M = 3364 g), t(14) = -4.597, P < 0.000. There is growing evidence that there is a subgroup of full-term newborn infants who actually may have experienced some degree of intrauterine growth retardation but their birthweights remain above the traditional cut-off of 2500 g so that they go unrecognized. The question to consider is whether these infants are as behaviourally vulnerable as full-term infants with classic intrauterine growth retardation. It may be that this unrecognized group is at a higher risk of developing FTT. The purpose of this manuscript is to discuss birthweight as a possible precursor to the development of FTT.

Behavioral characteristics of infants with nonorganic failure to thrive during a play interaction

PURPOSE

To examine the behavioral responses of infants with nonorganic failure to thrive (NOFTT) during play interactions with their mothers.

DESIGN

Comparative descriptive.

METHODS

The sample consisted of 31 infants; 17 with nonorganic failure to thrive (NOFTT) and 16 matched healthy controls. The infants were videotaped during a play interaction with their mothers. The behaviors exhibited by the infants were scored with the Parent-Child Early Relational Assessment. The environmental context of the play interaction was also rated for how play was initiated, maternal involvement, and the presence of chaos.

RESULTS

Infants with NOFTT exhibited more difficult behaviors during play such as more negative affect, less vocalizing, and more gaze aversion. Mothers of the infants with NOFTT were less likely to remain involved during the play interaction. The environments of the infants with NOFTT were also found to be more chaotic during play.

CLINICAL IMPLICATIONS

Assessment of the infant-mother interaction during play may provide insight into the interactions that occur during other caretaking activities. Strategies could be developed to assist the mother with interacting with her difficult infant. Future research could lead to interventions that could help improve the dynamics of the infant-mother interaction in infants with NOFTT.

Frequent breastfeeding and food refusal associated with failure to thrive. A manifestation of the vulnerable child syndrome

This paper acquaints pediatricians and health care personnel with the triad of poor weight gain, frequent breastfeeding, and food refusal in infants during the second 6 months of life. The histories of six infants aged 8-11 months, with failure to thrive, food refusal, and frequent breastfeeding, are presented. All the mothers were facing significant stresses, which may have decreased their breast milk supply, and were leading them to use breastfeeding for their comfort and/or the comfort of their infant. The infants responded with continued frequent breastfeeding, refusal of complementary foods, and decreased weight gain. These infants fit the characteristics of the vulerable child syndrome. Treatment of these infants required evaluation and treatment of the mothers' psychosocial issues along with a behavioral feeding program. Even with this multidisciplinary approach, these infants showed very slow catch-up growth. Pediatricians and health care personnel should use and build on this information in the evaluation and treatment of infants with similar problems.

Growth patterns among infants with language deficits: a case-control study

We compared growth parameters in infants with language delay to those in children with global delay and to typical controls. Thirty infants with expressive language delay and 36 with combined expressive and receptive language delay were compared with 27 infants with general development delay and with 124 controls. Data on weight, height, head circumference, and feeding behavior were obtained from birth up to age 78 weeks, and converted to percentiles. Medical and sociodemographic data were also evaluated. The weight curves in the combined expressive and receptive language delay group were significantly lower than in the comparison groups, but no cases of failure to thrive were noted. Height and head circumference curves in the combined expressive and receptive language delay group were also lower than in the typical controls. Infants with combined expressive and receptive language delay were lighter and shorter than controls. However, none of the parameters were more than two standard deviations below the mean. It is possible that this finding is of constitutional origin.

Risk factors for failure to thrive: a population-based survey

AIM

To identify whether differences exist between failure to thrive children and controls in either demographic characteristics or parental rating of their eating and other behaviour.

METHODS

As part of an intervention study, 97 children with failure to thrive were identified by population screening and received a standardized assessment by their health visitor at a median age of 15.1 months. This included standard questions to parents concerning their perception of their child's feeding history and behaviour. Their responses were compared with the parents of 28 normally growing children aged 16-18 months, systematically sampled from the same district.

RESULTS

Cases had fallen through a mean of 1.69 weight standard deviation score and were markedly underweight for height. The case families had similar levels of deprivation, both to controls and city norms, and only four showed evidence of major neglect. Failure to thrive children had significantly more infancy feeding problems and were introduced to solids and finger foods later than controls; they were significantly more often described as variable eaters, undemanding and shy and less often as hungry. Cases liked most foods, but significantly less so than controls.

CONCLUSIONS

This suggests that the role of deprivation and neglect has been overstated and that undemanding behaviour, low appetite and poor feeding skills may contribute to the onset and persistence of failure to thrive.

Interview data on severe behavioural eating difficulties in young children

Interview data from parents of 201 children under age 7 years with severe feeding and eating difficulties were analysed to describe features in the child's and parents' experiences that may have contributed to the development of the eating problem. Prematurity and low birth weight, distress during feeding in the first six months of life, and regular or frequent vomiting were common findings in the histories of the children. Aversive experiences during feeding may be the basis for early childhood eating difficulties.

Changes in psychopathology of parents of NOFT (non-organic failure to thrive) infants during treatment

This clinical case-study of 50 infants suffering from NOFT (non-organic failure to thrive) and their parents supports the idea that the feeding problem is intimately related to parental disorders. We find a high rate (70%) of parental psychopathology (axis I diagnosis applying DSM-III-R) at the time of referral and a significant reduction (to 37%) during treatment of the infants and their parents. After a year only 12% of the parents were diagnosed with psychiatric disorders. In contrast personality disorders (axis II diagnosis applying DSM-III-R) show more stability and can be regarded as a trait variable, whereas the psychiatric disorders are of a more reactive nature. These conclusions may be influenced somewhat by the strictly hospital based design of our pilot study (infants and parents contacted only after clinical referral) and by inclusion only of firstborn infants. Nevertheless, they point to the psychopathology of parents as a main cause for non-organic failure to thrive. Psychopathological traits such as severe attachment behavior problems and primary bonding difficulties may have been latent and only became manifest due to the task of nurturing an infant for the first time.

Neonatal sucking and maternal feeding practices

This study is the first to demonstrate an association between neonatal and later sucking ability, clinical signs of feeding ability and maternal feeding practices. Of 49 infants followed to a mean age of six weeks, 20 had some feeding problems (compensatory group), based on changes in feeding practices by their mothers, and 29 did not (non-compensatory group). Infants in the compensatory group performed less well on initial and follow-up sucking measures than infants in the non-compensatory group, indicating that they were feeding less efficiently from birth. Also, infants in the compensatory group ingested less during follow-up testing and were reported to be fed more frequently at home by their mothers than infants in the non-compensatory group. These findings strongly suggest that even among healthy infants, there may be more with problematic feeding abilities than have been previously recognized and that mothers are a reliable source of information about their infants' feeding abilities.

Oral-motor skills following sensorimotor therapy in two groups of moderately dysphagic children with cerebral palsy: aspiration vs nonaspiration

The purpose of this study was to determine the effect of oral sensorimotor treatment on oral-motor skills and measures of growth in moderately eating impaired children with cerebral palsy who were stratified by state of aspiration/nonaspiration. Twenty-seven children aged 2.5-10.0 years participated in this study (aspiration: n = 7, nonaspiration: n = 20). Weight and skinfold measures were taken. Children were observed at lunch time and six domains of feeding were examined: spoon feeding, biting, chewing, cup drinking, straw drinking, swallowing, and drooling. Children underwent 10 weeks of control and 10 weeks of sensorimotor treatment, 5-7 minutes/day, 5 days/week. Treatment compliance for the entire group was 67%. Children who aspirated had significantly poorer oral-motor skills in spoon feeding, biting, chewing, and swallowing than children who did not aspirate. There was significant improvement in eating: spoon feeding (fewer abnormal behaviors, p < 0.03), chewing (more normal behaviors, p < 0.003), and swallowing (more normal behaviors, p < 0.008). There were no significant changes in drinking skills. Children as a group maintained their pretreatment weight-age percentile but did not show any catch-up growth. Children showed adequate energy reserves as measured by skinfold thicknesses. Improvement in oral-motor skills may help these children to ingest food more competently (i.e., less spillage). However, their weight remains at the lowest level of age norms.

Nutritional management of failure to thrive

Failure to thrive, or failure to grow or gain weight, could have several causes that are reviewed in this article. Infant behaviors are discussed, together with nutritional management, catch-up growth, effects of nutritional rehabilitation on body composition, follow-up, and long-term prognosis.

Effect of oral sensorimotor treatment on measures of growth, eating efficiency and aspiration in the dysphagic child with cerebral palsy

Twenty-seven children (mean age 5.1 years) with cerebral palsy and moderate eating impairment were studied to determine frequency of aspiration and the effect of 10 and 20 weeks of oral sensorimotor therapy on eating efficiency and measures of growth (weight, skinfold thickness). The eating efficiency of the children did not change markedly in response to oral sensorimotor therapy. Children maintained their centile rank in weight-for-age and skinfold-for-age measurements. However, there was no catch-up growth. The findings suggest that eating efficiency is not a good estimator of treatment outcome, but rather a diagnostic indicator of the severity of eating impairment. Monitoring of these children's growth is essential in order to provide nutritional rehabilitation as soon as their eating skills can no longer keep up with growth demands.

Classification of eating impairments based on eating efficiency in children with cerebral palsy

Eating impairments in children with cerebral palsy (CP) may vary widely from mild to severe. Accurate diagnosis of the severity of eating has been hampered by the lack of a classification system which would permit stratification of this wide range of problems into mild, moderate, and severe. We propose such a classification system based on measures of (1) growth: weight, height, and skinfold thickness and (2) eating skills: eating efficiency and oral-motor skills. One hundred children, 54 boys and 46 girls from 2 to 16 years, who had various degrees of CP and eating impairments, were studied. Classification, treatment effectiveness, as well as the implications for growth monitoring, based on this classification system are discussed. system are discussed.