Feeding problems in infancy and early childhood: evolutionary concept analysis

Experiences of Allied Health Clinicians Accessing a Pilot Project ECHO® Program to Support Learning in Pediatric Feeding

INTRODUCTION

Pediatric feeding disorder is increasing in prevalence, yet low clinician confidence regarding its management is a barrier to care. Targeted clinician training is needed as traditional didactic training programs are limited in both their accessibility and capacity to provide opportunities for the application of theory-based learning.

METHODS

This study examined the experiences of a group of clinicians involved in a multidisciplinary PedFeed ECHO® network, a virtual community of practice established to support speech pathologists, occupational therapists, dieticians, and psychologists in Queensland, Australia, working with children with pediatric feeding disorder. Sixteen clinicians (34% of the total PedFeed ECHO network) from different professional backgrounds, clinical settings, and locations participated in semistructured interviews three months post completion of eight ECHO sessions.

RESULTS

Inductive thematic analysis revealed three themes: (1) broad-ranging outcomes of PedFeed ECHO, (2) participant experiences of PedFeed ECHO, and (3) facilitators for future success. PedFeed ECHO was viewed very positively and provided participants with a valuable opportunity for information sharing and collaboration as a multidisciplinary team. Participants described impacts on their professional practice, knowledge, confidence, and professional isolation, as well as service and patient-level impacts. Several facilitators for the success of future PedFeed ECHO cohorts were provided.

DISCUSSION

Insights from participants will serve to improve the design and delivery of ECHO training for future cohorts. Monitoring clinical skill development over a longer period of time and exploring clinician perceptions regarding direct impact on patient care are needed to further validate the impact of ECHO.

Feeding Characteristics in Children With Food Allergies: A Scoping Review

BACKGROUND

Food allergy (FA) affects approximately 8% of children and may be immunoglobulin E (IgE)-mediated or non-IgE-mediated. It is recognized clinically that children with both subtypes of FA may present with features of pediatric feeding disorder (PFD); however, there is currently a limited detail of presenting characteristics.

OBJECTIVE

The objective of this study was to synthesize the current evidence regarding the feeding characteristics of children with FA, with a focus on the feeding skills and psychosocial domains of PFD.

METHOD

This study followed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses Extension for Scoping Reviews guidelines. Papers published between 2001 and 2022 describing feeding characteristics in the feeding skills and psychosocial domains in children with FA/history of FA were included. Papers that focused solely on characteristics from the medical or nutritional domains were excluded. Descriptive information regarding demographics, methodology, allergy profile and history, and the characteristics of PFD observed was extracted using a preconceived data extraction form.

RESULTS

Overall, 40 papers contained descriptions of feeding characteristics of children with non-IgE-mediated FA (n = 22) and IgE-mediated FA (n = 11), while four were nonspecific. In the psychosocial domain, food refusal/aversion, anxiety with eating, and poor intake were the most frequently reported, regardless of FA subtype. Less information was reported regarding feeding skills, although slowness in eating, immature diet, and delays in oral sensory-motor skills were described.

CONCLUSIONS

Children with FA/history of FA may present with a range of characteristics that map across the feeding skill and psychosocial domains of PFD. Systematic research is needed to fully describe the feeding characteristics of children with FA.

SUPPLEMENTAL MATERIAL

https://doi.org/10.23641/asha.24562732.

Assessing the US treatment landscape for paediatric feeding disorder: A survey of multidisciplinary providers

BACKGROUND

Paediatric feeding disorder (PFD) is a common childhood condition, estimated to impact one in 37 American children under the age of five. Such high prevalence occurs against a backdrop of limited understanding of the community treatment landscape in the United States.

METHOD

To better understand the community treatment landscape for PFD in the United States and identify provider and treatment delivery characteristics, we collected primary data through a web-based survey targeting providers from all four PFD domains (i.e., medical, nutritional, feeding skill, and/or psychosocial) between January 2022 and March 2022. The 71-item cross sectional survey focussed on patient, provider and treatment characteristics. We distributed the survey using an electronic survey tool through Feeding Matters listserv followed by solicitation to discipline specific listservs and professional networks. The analytic approach involved descriptive statistics compared across settings and provider types, focussing on respondents within the United States.

RESULTS

Eighty-three percent of respondents reported practicing in the United States. Most of the US sample (74.3%) involved providers from the feeding skill domain (speech-language pathologist - SLP, occupational therapist - OT) who reported delivering care through early intervention or outpatient settings using responsive and sensory based approaches. These approaches lack rigorous empirical evaluation.

CONCLUSIONS

Survey results suggest a need to support community providers in engagement with research activity to promote a better understanding of treatment approaches and outcomes associated with a large cohort of providers delivering care (i.e. SLPs, OTs) to patients with PFD.

Disparities in the Diagnosis and Management of Infants Hospitalized With Inadequate Weight Gain

OBJECTIVES

To evaluate the association between race and the named etiology for inadequate weight gain among hospitalized infants and assess the differences in management.

METHODS

This single-center retrospective cohort study of infants hospitalized for the workup and management of inadequate weight gain used infant race and neighborhood-level socioeconomic deprivation as exposures. The etiology of inadequate weight gain was categorized as nonorganic, subjective organic (ie, gastroesophageal reflux and cow's milk protein intolerance), or objective organic (eg, hypothyroidism). The management of inadequate weight gain was examined in secondary outcomes.

RESULTS

Among 380 infants, most were white and had a nonorganic etiology of inadequate weight gain. Black infants had 2.3 times higher unadjusted odds (95% credible interval [CI] 1.17-4.76) of a nonorganic etiology of inadequate weight gain compared with white infants. After adjustment, there was no association between race and etiology (adjusted odds ratio 0.8, 95% CI [0.44-2.08]); however, each 0.1 increase in neighborhood-level deprivation was associated with 80% increased adjusted odds of a nonorganic etiology of inadequate weight gain (95% CI [1.37-2.4]). Infants with a nonorganic etiology of inadequate weight gain were more likely to have social work and child protective service involvement and less likely to have nasogastric tube placement, gastroenterology consults, and speech therapy consults.

CONCLUSIONS

Infants from neighborhoods with greater socioeconomic deprivation were more likely to have nonorganic causes of inadequate weight gain, disproportionately affecting infants of Black race. A nonorganic etiology was associated with a higher likelihood of social interventions and a lower likelihood of medical interventions.

Parents' experiences of living with a child with Paediatric Feeding Disorder: An interview study in Sweden

INTRODUCTION

Children affected by Paediatric Feeding Disorder (PFD) cannot consume enough nourishment by mouth. PFD is highly prevalent and can affect the child's growth and development as well as family life.

AIM

To illuminate Swedish parents' experiences of living with a child with PFD.

METHOD

Semi-structured interviews via telephone or video calls were conducted with 14 purposefully recruited mothers and six fathers. The interviews were analysed using content analysis. Ethics approval was obtained, and the parents all gave informed consent.

RESULTS

Four overarching themes emerged: Living with stress; Advocating for the child; Adapting family life; and Gaining hope. Parents described fearing for their child's life and health, feeling pressure over meals and being emotionally affected. They told of experiencing a lack of understanding from healthcare professionals, friends and family. Parents expressed a struggle for help, the need for early interventions and more effective treatment, and developed strategies for coping with the demands of feeding and caring for their child, accepting their living reality. Finding support from a network helped, but the adaptation of daily life affected their family relations. They felt gratitude towards helpful professionals and relief and joy when their child was doing better.

CONCLUSIONS

A more cohesive chain of care is important for children with PFD, and guidelines and educational support for healthcare providers are needed. Parental experiences provide a base for knowledge for further development of early detection and intervention for children with PFD.

[Sensory food aversion in the context of a modern approach to eating disorders in early childhood]

Sensory food aversion, an early childhood eating disorder, is a serious, permanent form of picky eating, in which the infant or the child consistently and persistently refuses certain foods based on specific characteristics, following one or more previous aversive experiences. Biological (sensory processing disorder, taste sensitivity) and environmental factors contribute to its development. Due to limited diet, specific dietary deficiencies may occur but weight gain is usually normal. Behavioral problems, anxiety disorder, autism spectrum disorder are often associated. Diagnosis can usually be made based on a detailed history, but further assessment may include pediatric examination, nutritionist consultation, and psychologic and occupational therapy assessment. Treatment is based on parent education and support in order to minimize mealtime battles and anxiety and to think together about strategies for expanding the child's diet and to help them to accept new foods. As part of the interdisciplinary team, the pediatrician's role is to monitor appropriate growth and development, exclude dietary deficiencies or prescribe supplementation if necessary. In our article, the screening and treatment of sensory processing disorder as part of the assessment of eating problems are introduced as an example of good clinical practice at the Early Childhood Eating and Sleep Disorder Outpatient Clinic at the Heim Pál National Institute of Pediatrics. Orv Hetil. 2023; 164(45): 1767-1777.

How parents' feeding styles, attitudes, and multifactorial aspects are associated with feeding difficulties in children

BACKGROUND

Parental complaints about feeding difficulties (FD) during childhood are frequent in pediatrics. Behavioral factors about children's feeding and parental aspects are fundamental in solving these problems, but research in this area lacks information considering the joint presence of fathers and mothers. Thus, this study aimed to investigate the features of children, parents and mealtime practices related to FD reported by fathers and mothers and to identify parenting styles, mealtime actions, practices and factors associated with FD in children.

METHODS

323 parents (226 mothers and 97 fathers) of children aged 1 to 7 years were recruited in the emergency waiting room at Sabará Hospital Infantil, in São Paulo, Brazil, and self-completed electronic questionnaires on parenting style (Caregiver's Feeding Styles Questionnaire), parents' mealtime actions (Parent Mealtime Action Scale), socioeconomic information, personal and children's health data and routine meal practices.

RESULTS

The prevalence of FD in children was 26.6%. Indulgent parenting style was the most frequent (44.2%), followed by authoritarian (25.1%), authoritative (23.8%), and uninvolved (6.9%) styles. Most parents (75.8%) reported presence during meals, and 83.6% used distractions. Regression analyses after adjustments showed, as factors associated with FD, female children (OR: 2.06; 95%CI: 1.19-3.58), parents' FD history (OR: 3.16; 95%CI: 1.77-5.64), and greater frequency of parents' behavior of offering many food options (OR: 2.69; 95%CI: 1.18-6.14). Parents with indulgent styles had decreased chances of reporting FD in their children (OR: 0.13; 95%CI: 0.06-0.27). Furthermore, the practice of children sharing the family menu (OR: 0.43; 95%CI: 0.18-0.99) and higher frequency of parents' behavior of setting snack limits (OR: 0.44; 95%CI: 0.23-0.85) were inversely associated with FD.

CONCLUSIONS

This study reinforces the multifactorial aspects involved in the feeding difficulties context. It points out the importance of expanding knowledge of the individual role of fathers and mothers to compose a scenario that can guide future studies and interventions.

TRIAL REGISTRATION

CAAE #99221318.1.0000.5567 with registration number 2,961,598.

Disability Justice and Anti-ableism for the Pediatric Clinician

The impact of ableism on health care, and specifically the health of people with disabilities, is not only underrecognized, but misunderstood at a foundational level due to socially acceptable denial of anti-disability bias. For the pediatrician that seeks to learn about the value of anti-ableist approaches to health care and how it can promote child health, this article reviews the relationship between medical jargon and anti-disability bias, and provides a primer on disability justice, the medical versus social models of disability, and other scholarly concepts related to anti-ableism. The authors provide narrative examples of disability bias in clinical scenarios, and the article concludes with actionable recommendations on anti-ableist language etiquette and clinical best practices. Although ableism is a societal issue, pediatricians have a responsibility to recognize and address ableism as a threat to child health.

Complications of Gastrostomy and Gastrojejunostomy: The Prevalence in Children

Purpose

This study aimed to provide an overview of the prevalence of the complications of a gastrostomy or a gastrojejunostomy with a low-profile gastric tube in children. The study also examined the effect of presence of the gastrostomy tube on the prevalence of complications.

Methods

In this cross-sectional study, parents were invited to complete an online questionnaire. Children aged 0-16 years with a low-profile gastrostomy or gastrojejunostomy tube were included in the study.

Results

A total of 67 complete surveys were conducted. The mean age of the included children was seven years. The most common complications during the past week, were skin irritation (35.8%), abdominal pain (34.3%), and the formation of granulation tissue (29.9%). The most common complications during the past six months were skin irritation (47.8%), vomiting (43.4%), and abdominal pain (38.8%). Most complications occurred within the first year after gastrojejunostomy placement and gradually decreased as the duration since the placement of the gastrojejunostomy tube increased. The prevalence of severe complications was rare. Parental confidence in caring for the gastrostomy positively correlated with increases in the duration of the gastrostomy tube. Even so, parental confidence in the care of the gastrostomy tube was reduced in some parents more than a year after its placement.

Conclusion

The prevalence of gastrojejunostomy complications in children is relatively high. The incidences of severe complications after the placement of a gastrojejunostomy tube were rare in this study. A lack of confidence in the care of the gastrostomy tube was noted in some parents more than a year after its placement.

Intensive Multidisciplinary Feeding Intervention for High-Risk Infants

Infants born premature or other medical complex infants are at high risk for developing long-term feeding problems that extends beyond infancy. Intensive multidisciplinary feeding intervention (IMFI) represents the standard of care for children with chronic and severe feeding issues, with a profession team that should involve, at a minimum, psychology, medicine, nutrition, and feeding skill expertise. IMFI seems to hold benefit for preterm and medically complex infants; however, there remains a need to develop and investigate new therapeutic pathways to reduce the number of patients who likely require this level of care.

Management of nutritional and gastrointestinal issues in RASopathies: A narrative review

Noonan, Costello, and cardio-facio-cutaneous syndrome are neurodevelopmental disorders belonging to the RASopathies, a group of syndromes caused by alterations in the RAS/MAPK pathway. They are characterized by similar clinical features, among which feeding difficulties, growth delay, and gastro-intestinal disorders are frequent, causing pain and discomfort in patients. Hereby, we describe the main nutritional and gastrointestinal issues reported in individuals with RASopathies, specifically in Noonan syndrome, Noonan syndrome-related disorders, Costello, and cardio-facio-cutaneous syndromes. Fifty percent of children with Noonan syndrome may experience feeding difficulties that usually have a spontaneous resolution by the second year of life, especially associated to genes different than PTPN11 and SOS1. More severe manifestations often require artificial enteral nutrition in infancy are observed in Costello syndrome, mostly associated to c.34G>A substitution in the HRAS gene. In cardio-facio-cutaneous syndrome feeding issues are usually present (90-100% of cases), especially in individuals carrying variants in BRAF, MAP2K1, and MAP2K2 genes, and artificial enteral intervention, even after scholar age, may be required. Moreover, disorders associated with gastrointestinal dysmotility as gastro-esophageal reflux and constipation are commonly reported in all the above-mentioned syndromes. Given the impact on growth and on the quality of life of these patients, early evaluation and prompt personalized management plans are fundamental.

Toward Better Understanding of Pediatric Feeding Disorder: A Proposed Framework for Patient Characterization

To establish a foundation for methodologically sound research on the epidemiology, assessment, and treatment of pediatric feeding disorder (PFD), a 28-member multidisciplinary panel with equal representation from medicine, nutrition, feeding skill, and psychology from seven national feeding programs convened to develop a case report form (CRF). This process relied upon recent advances in defining PFD, a review of the extant literature, expert consensus regarding best practices, and review of current patient characterization templates at participating institutions. The resultant PFD CRF involves patient characterization in four domains (ie, medical, nutrition, feeding skill, and psychosocial) and identifies the primary features of a feeding disorder based on PFD diagnostic criteria. A corresponding protocol provides guidance for completing the assessment process across the four domains. The PFD CRF promotes a standard procedure to support patient characterization, enhance methodological rigor, and provide a useful clinical tool for providers and researchers working with these disorders.

Pediatric Dysphagia

Feeding difficulty is common in the pediatric population, particularly in at-risk infants, such as those born prematurely. Appropriate work-up should involve a multidisciplinary team and may commonly use modified barium swallow and flexible endoscopic evaluation of swallow, in addition to history and physical examination. Structural causes of dysphagia may involve surgical management, whereas nonstructural causes may invoke medical therapies. If symptoms do not resolve following intervention, it is important to revisit the interdisciplinary team, because dysphagia is commonly multifactorial in origin. Appropriate identification and early intervention are necessary for successful outcomes in growth and development for children.

Patterns of caregivers' feeding practices and associated characteristics among preschool-age children in the United States

During early childhood, caregiver feeding practices (FP) influence children's diet and eating habits. Inconsistent methods of operationalizing FP have resulted in limited evidence regarding simultaneous FP patterns. This study examined the heterogeneity in FP among caregivers of preschoolers, along with the child, caregiver, and family characteristics associated with FP patterns. Caregivers of preschoolers (n = 437, 90% women) enrolled in 50 childcare centers across Maryland completed the Comprehensive Feeding Practices Questionnaire (CFPQ) and provided demographic information and perceptions of their child's size and temperament. Exploratory Factor Analysis of CFPQ identified 13 factors, and latent profile analysis (LPA) empirically identified three FP classes. Using multinomial structural equation models, we regressed FP classes on child sex, race, age, poverty level, food insecurity education, caregiver perception of child size and temperament. The most common FP pattern (69%) reflected high coercive and control with low autonomy and structural practices (Controlling Class). A second pattern (16%) had high coercive control with moderate structural and autonomy practices (Regulating Class). The third pattern (15%) reflected moderate levels of all practices (Balancing Class). Caregivers who desired their child to be heavier (aOR = 0.40, 95% CI = 0.22-0.72), were more financially secure (aOR = 0.80, 95%CI = 0.65-0.98), and were single (aOR = 0.38, 95% CI = 0.18-0.80) were less likely to be in the Balancing versus Controlling class. For each unit increase in child temperament t-score [higher = difficult], caregivers were more likely to be in the Balancing (aOR = 1.04, 95% CI = 1.01-1.07) or Regulating class (aOR = 1.04, 95% CI = 1.01-1.08) compared to the Controlling class. In this statewide sample, many caregivers endorsed controlling behaviors without endorsing empowering behaviors to help children become healthy eaters. Future studies should examine how caregiver feeding practices evolve and relate to children's eating habits, growth, and development over time.

Mapping the gaps: A scoping review of research on pediatric feeding disorder

BACKGROUND & AIMS

Pediatric feeding disorder (PFD) is defined as impaired oral intake that is not age-appropriate, and is associated with medical, nutritional, feeding skill, and/or psychosocial dysfunction. As PFD is prevalent and increasing, so are publications on the topic; however, the research literature is often disparate in terminology used and siloed by discipline. Greater understanding of the current research concerning PFD will help identify areas in need of further study. The purpose of this scoping review is to examine the extent, range, and nature of research activities concerning PFD and to identify gaps in the empirical literature.

METHODS

Three electronic databases (PubMed/Medline, CINAHL, PsycINFO) were searched using terms related to pediatric feeding disorder, which include, but not limited to, "feeding disorder/problem/difficulty", "avoidant restrictive food intake disorder (ARFID)", "dysphagia", "selective/picky eating", "problematic mealtime behaviors" or "food refusal". The following limits were placed on the search: full text, humans, English, and age limit (up to 18 years old), and publication date (last 10 years). Covidence software was used to facilitate a systematic data management/analysis. Two people in the research team independently reviewed each result (screening titles and abstracts first, then moving to the full texts) to identify studies that met our inclusion/exclusion criteria and conflicts were resolved through a team discussion. Data were charted regarding disciplines of the authors, study purposes, study settings/locations, study methodologies, and study participants. Descriptive statistics and thematic analyses were used to summarize the characteristics of the studies.

RESULTS

The initial search resulted in 5354 articles after removing duplicates between the databases. With a final set of articles (n = 415), data charting was completed. The majority of studies were completed by authors from Psychology (n = 171) and Medicine (n = 123). The most studied aims were to examine attributes of feeding problems (n = 168) and/or factors associated with feeding problems (n = 183). Sample size median was 53. A total of 166 of the 415 studies examined the effect of an intervention, treatment, or program, but dose of the intervention was difficult or impossible to report across studies. Feeding was studied as an outcome in 400 out of the 415 studies. A closer accounting of the systematically developed parent-report tools revealed 50 distinct parent report tools used across the subset of studies utilizing parent report outcomes (n = 123).

CONCLUSIONS

The results of this scoping review highlight the designs and methods used in research on PFD. This reveals critical gaps in knowledge generation and barriers to intervention replication.

Correlation between maternal eating disorder and early infant feeding regulation: a cross -sectional study

Background

The post-partum period is a vulnerable time for mothers in terms of eating disorder symptoms and is critical for the establishment of feeding patterns in infants. This study aimed to investigate the relationships between maternal eating disorder symptoms and objective indices of feeding regulation at 3 months, as well as perceived breastfeeding self-efficacy.

Methods

A sample of n = 73 full-term mother-child dyads (44% female) participated in the study. Mothers self-reported eating disorder symptoms and breastfeeding self-efficacy and objective indices of infant feeding regulation were obtained in the home.

Results

Findings revealed the existence of relationships between higher maternal eating disorder symptoms, and objective indices of infant feeding regulation with substantial gender differences in the patterns emerging. Among mother-daughter dyads, maternal weight and shape concerns were associated with higher infant transfer volume and rate during bottle feeding. In contrast, among mother-son dyads, higher maternal eating disorder symptoms, including weight, shape, and eating concern, were associated with lower infant transfer volume and rate as well as lower levels of proficiency while taking their bottle.

Conclusion

Relationships emerged between higher maternal eating disorder symptoms and feeding regulation with substantial gender differences in these patterns. Additional research clarifying the underlying mechanisms of these associations is warranted and further efforts should be directed towards supporting mothers during the postpartum period.

Factors Associated with Feeding Problems in Young Children with Gastrointestinal Diseases

Feeding problems are associated with the consumption of a limited amount or restricted variety of foods and often occur in children with gastrointestinal diseases. The majority of studies to date do not use valid and reliable measurements to detect feeding problems. The aim of this cross-sectional study was to assess behavioral and skill-based feeding problems in young children with gastrointestinal diseases by using a well-established parent-reported feeding measure and identify demographic, anthropometric, and environmental factors associated with maladaptive feeding behaviors in this pediatric population. Parents completed the Greek version of the Behavioral Pediatrics Feeding Assessment Scale (BPFAS) and self-reported questionnaires assessing mealtime environment and parental feeding practices. It was found that 18.6% of the sample had abnormal Total Frequency Score (TFS) (frequency of problematic feeding behaviors) and 39.5% had abnormal Total Problem Score (TPS) (number of behaviors perceived as problematic by parents). Younger children, with lower body mass index, lower birth weight, and only children were more likely to have feeding problems. The study showed that parent-reported feeding problems are increased in young children with gastrointestinal diseases and are associated with specific aspects of mealtime environment and parental feeding practices.

Feeding Problems in Typically Developing Young Children, a Population-Based Study

Feeding problems have been estimated to occur in approximately 25–45% of normally developing children. The aim of this study was to investigate the prevalence of feeding problems in typically developing young children in Greece. Child feeding behavior, parents’ feelings about their child’s feeding patterns, and parental feeding practices were also explored. Parents completed the Greek version of the Behavioral Pediatrics Feeding Assessment Scale (BPFAS). Data on 742 healthy, typically developing children aged two to seven years are presented. Overall, the majority of children in the sample showed high frequency of desirable mealtime behaviors and low frequency of undesirable mealtime behaviors. However, a significant proportion of the cohort presented with food neophobia and low consumption of vegetables. When applying test cut-off scores, it was found that 8.2% of the sample had abnormal Total Frequency Score (TFS) and 26.6% had abnormal Total Problem Score (TPS). The study showed that parent-reported feeding problems are quite common in children of typical development in Greece. Moreover, while the majority of the sample displayed a high frequency of favorable behaviors, specific child feeding behaviors are amenable to improvement.

Tracing the Use of the Family Management Framework and Measure: A Scoping Review

This article reports the results of a scoping review of research applications of the Family Management Style Framework (FMSF) and the Family Management Measure (FaMM). We identified 32 studies based on the FMSF and 41 studies in which the FaMM was used, 17 of which were based on the FMSF. Both the framework and measure have been used by investigators in multiple countries, with most applications of the FaMM outside the United States. Although the FMSF and FaMM were originally developed for use with families in which there was a child with a chronic physical condition, both have been applied to a broader range of health conditions and to studies focusing on families with an adult member facing a health challenge. Based on our findings, we make recommendations for how researchers can more fully address all aspects of the FMSF.

Correlates and Trajectories of Preterm Infant Sucking Patterns and Sucking Organization at Term Age

BACKGROUND

Premature infants may experience increased difficulty with nutrition and growth. Successful oral feeding is an important factor associated with discharge readiness. Despite the importance of feeding as a growth-fostering process, little empiric evidence exists to guide recommendations for early interventions.

PURPOSE

Evaluate whether specific elements of sucking, during preterm initiation of oral feeding, predict sucking organization at corrected term age.

METHODS

Sucking performance of 88 preterm infants born between 24 and 34 weeks of post-menstrual age was measured at baseline and term (33-35 and 40 ± 1.5 weeks). Participants were divided into 4 groups (quartiles) based on initial measures of performance including number of sucks, number of bursts, sucks per burst, and maximum pressure. Stability in sucking organization was assessed by comparing changes in infant's quartile location from baseline to term.

RESULTS

A correlation between quartile location was observed for mean maximum pressure (PMAX): infants with PMAX in the lowest quartile (poorest performance) were significantly more likely to remain in the lowest quartile at term (P < .000); infants in the highest quartile (best performance) at baseline were significantly more likely to be in the highest quartile at term (P < .000).

IMPLICATION FOR PRACTICE

Infants with the weakest sucking pressures at 34 weeks of post-menstrual age continue to be at risk for less than optimal feeding skills at 40 weeks of post-menstrual age. Early identification of at-risk infants may allow for effective interventions to potentially decrease long-term feeding problems.

IMPLICATIONS FOR RESEARCH

Future research should focus on the development of personalized interventions to address attributes of problematic feeding such as sucking efficiency.

Examining child mealtime behavior as parents are coached to implement the Mealtime PREP intervention in the home: Findings from a pilot study

Introduction

The purpose of this study was to examine parental use of evidence-based mealtime strategies, child mealtime behavior, and parental identification of mealtime problems over time as parents were coached to implement the Promoting Routines of Exploration and Play during Mealtime intervention as part of a pilot study.

Method

This repeated measures study included data collection during three phases: (a) pre-intervention; (b) intervention; (c) post-intervention. Primary outcome measures included a parental strategy use checklist (parental strategy use) and the Behavioral Pediatric Feeding Assessment (problematic child behavior and parental identification of mealtime problems). Linear mixed models were fitted to assess change over time.

Results

We observed significant improvements in parental strategy use ( p < .001), child mealtime behavior ( p < .001), and parental perception of mealtime problems ( p = .002) over time.

Conclusions

The results of these analyses signal that empowering parents to integrate evidence-based strategies into child mealtimes is a promising approach to managing child mealtime behavior. More research is needed to determine the true relationship between parental strategy use and child behavior over time.

A Middle-Range Theory for Nurses to Diagnose Ineffective Infant Feeding Patterns

PURPOSE

To construct a middle-range theory, based on the Roy adaptation model, for nurses can diagnose an ineffective infant feeding pattern.

DATA SOURCE

Scientific findings were used through a literature review and the concepts of the Roy model.

DATA SYNTHESIS

The theory indicated new elements for the diagnosis: 12 etiological factors and 13 clinical indicators. Most of those are not contained in the NANDA taxonomy.

CONCLUSION

The middle-range theory for these diagnoses highlights the need for a review of the components present in the taxonomy.

IMPLICATIONS FOR NURSING PRACTICE

This approach guides research on nursing diagnoses to revise the content of the theory and to expand its concepts and elements for the diagnosis of an ineffective infant feeding pattern.

Effect of nutritional supplement formula on catch-up growth in young children with nonorganic faltering growth: a prospective multicenter study

BACKGROUND/OBJECTIVES

Inadequate nutrition in infants and young children affects physical growth and neurocognitive development. Therefore, early nutritional intervention is important to promote catch-up growth in young children with faltering growth. The aim of this study was to evaluate the effect of nutritional supplementation with a pediatric concentrated and balanced nutritional supplement formula on promoting growth and improving nutritional status in children with nonorganic faltering growth.

SUBJECTS/METHODS

Children aged 12–36 months whose body weight-for-age was < 5^th percentile on the Korean Growth Charts were enrolled. Children born premature or having organic diseases were excluded. Children were instructed to consume 400 mL of formula per day in addition to their regular diet for 6 months. Pediatricians and dietitians educated the parents and examined the subjects every 2 months. Anthropometric parameters were measured at baseline and at 2, 4, and 6 months, and laboratory tests were done at baseline and 6 months. The good consumption group included children who consumed ≥ 60% of the recommended dose of formula.

RESULTS

Total 82 children completed the 6-month intervention. At baseline, there were no significant differences in all variables between the good consumption and poor consumption groups. Weight and weight z-scores were significantly improved in the good consumption group compared to the poor consumption group at the end of the intervention (P = 0.009, respectively). The good consumption group showed a significant trend for gaining weight (P < 0.05) and weight z-score (P < 0.05) compared to the poor consumption group during 6 months of formula intake. The concentration of blood urea nitrogen was significantly increased in the good consumption group (P = 0.001).

CONCLUSIONS

Nutritional supplementation with a concentrated and balanced pediatric nutritional formula along with dietary education might be an effective approach to promote catch-up growth in children with nonorganic faltering growth.

Feeding and developmental outcomes of infants in a South African community

BACKGROUND

Prevalent environmental risk factors place infants in lower-middle-income countries (LMICs) at an increased risk for feeding and developmental difficulties.

AIM

This study aimed to determine the relationship between feeding and developmental outcomes in infants, as early feeding difficulties may have a cascading effect on developmental outcomes and vice versa.

METHODS

Data on 144 infants' feeding and development [mean age (standard deviation) = 8.8 months (2.2)] from a primary health care clinic in Gauteng, South Africa were retrospectively analysed.

RESULTS

Early introduction of cup feeding was found to be a predictor of possible expressive language and articulation difficulties. Gagging, spitting, or vomiting, pocketing, the use of force feeding, and poor sucking and chewing abilities were significantly associated with behavioural and social-emotional difficulties. Breastfeeding was found to be a protective factor for language development. The results emphasise the importance of primary prevention and early identification of risks in late infancy in LMIC.

Pre-emptive Intervention for Autism Spectrum Disorder: Theoretical Foundations and Clinical Translation

Autism spectrum disorders (ASD) are an emergent public health problem, placing significant burden upon the individual, family and health system. ASD are polygenetic spectrum disorders of neural connectome development, in which one or more feedback loops amplify small genetic, structural, or functional variations in the very early development of motor and sensory-motor pathways. These perturbations trigger a 'butterfly effect' of unpredictable cascades of structural and functional imbalances in the global neuronal workspace, resulting in atypical behaviors, social communication, and cognition long-term. The first 100 days post-term are critically neuroplastic and comprise an injury-sensitive developmental window, characterized by a neural biomarker, the persistence of the cortical subplate, and a behavioral biomarker, the crying diathesis. By the time potential diagnostic signs are identified, from 6 months of age, ASD neuropathy is already entrenched. The International Society for Autism Research Special Interest Group has called for pre-emptive intervention, based upon rigorous theoretical frames, and real world translation and evaluation. This paper responds to that call. It synthesizes heterogenous evidence concerning ASD etiologies from both psychosocial and biological research literatures with complexity science and evolutionary biology, to propose a theoretical framework for pre-emptive intervention. This paper hypothesizes that environmental factors resulting from a mismatch between environment of evolutionary adaptedness and culture initiate or perpetuate early motor and sensory-motor lesions, triggering a butterfly effect of multi-directional cascades of atypical developmental in the complex adaptive system of the parent and ASD-susceptible infant. Chronic sympathetic nervous system/hypothalamic-pituitary-adrenal axis hyperarousal and disrupted parent-infant biobehavioral synchrony are the key biologic and behavioral mechanisms perpetuating these atypical developmental cascades. A clinical translation of this evidence is proposed, for application antenatally and in the first 6 months of life, as pre-emptive intervention for ASD.

Improvements in Children's Feeding Behavior after Intensive Interdisciplinary Behavioral Treatment: Comparisons by Developmental and Medical Status

This study examined changes in child mealtime behavior, diet variety, and family mealtime environment after intensive interdisciplinary behavioral treatment (IIBT) for 52 children referred to a day treatment feeding program. Children fell into three developmental status groups including autism spectrum disorder (n = 16), other special needs (n = 19), and no special needs (n = 17), with some having no known medical problems (n = 22) and some having gastrointestinal, cardiopulmonary, and/or endocrine-metabolic problems (n = 28). At pre-intervention and post-intervention, caregivers completed the About Your Child's Eating scale, the Brief Assessment of Mealtime Behavior in Children, and a food preference inventory of 70 common foods (20 fruits, 23 vegetables, 12 proteins, 8 grains, 7 dairy). Mixed-factor 2 × 3 ANOVAs compared each of the 11 feeding outcomes across the two study phases (pre-, post-intervention) for the three developmental status groups. All feeding outcomes except fruit acceptance showed significant improvements from pre- to post-intervention, with no main effects for developmental status, and no interaction effects. Additionally, mixed-factor 2 × 2 ANOVAs compared each of the 11 feeding outcomes across the two study phases (pre-, post-intervention) for children with and without medical problems. All feeding outcomes except fruit acceptance showed significant improvements from pre- to post-intervention, with no main effects for medical status, and no interaction effects. Present results suggest that IIBT is effective for improving a number of children's feeding problems, regardless of their developmental or medical status.

Age-based norm-reference values for the Pediatric Eating Assessment Tool

BACKGROUND AND OBJECTIVES

Differentiating problematic feeding from variations of typical behavior is a challenge for pediatric providers. The Pediatric Eating Assessment Tool (PediEAT) is a parent-report measure of symptoms of problematic feeding in children 6 months to 7 years old with evidence of reliability and validity. This study aimed to determine age-based, norm-referenced values for the PediEAT.

METHODS

Parents of children between 6 months and 7 years old (n = 1110) completed the PediEAT. Descriptive statistics were calculated for subscale and total scores of the PediEAT within 11 age groups.

RESULTS

The PediEAT total scores followed a general downward trajectory with increasing age. Physiologic Symptoms were relatively steady from 6 to 15 months, and then rapidly declined in 15-18 month olds and continued to decline thereafter. Problematic Mealtime Behaviors increased from 6 to 9 months to a peak in 24-30 month olds and then declined with increasing age. Selective/Restrictive Eating increased from 6 to 9 months to a peak at 12-15 months and then decreased over time thereafter. Symptoms of difficulty with Oral Processing were highest in 6-9 month olds and decreased with age.

CONCLUSIONS

The PediEAT now has age-based norm-reference values to guide score interpretation and clinical decision-making.

"It's a Long-Term Process": Description of Daily Family Life When a Child Has a Feeding Disorder

Pediatric feeding problems occur in 25% of the general pediatric population and up to 80% of those who have developmental delays. When feeding problems place the child at nutritional risk, families are typically encouraged to increase their child's intake. Family mealtime can become a battle, which further reinforces problematic feeding behaviors from the child and intensifies well-intentioned but unguided parental mealtime efforts. Family has an essential influence on feeding; however, studies to date neglect to address the family context of feeding difficulty. In this study we describe, in the context of everyday life, family management of feeding when a child had a significant feeding problem. Parents of children with feeding problems were interviewed with the Family Management Style Framework components as a guide. Twelve parents participated, representing nine families of children with feeding disorder. Description of family management of feeding provides a foundation for development of family feeding interventions.

Factor Structure and Psychometric Properties of the Neonatal Eating Assessment Tool-Bottle-Feeding (NeoEAT-Bottle-Feeding)

BACKGROUND

Feeding difficulties are common in infancy. There are currently no valid and reliable parent-report measures to assess bottle-feeding in infants younger than 7 months. The Neonatal Eating Assessment Tool (NeoEAT)-Bottle-feeding has been developed and content validated.

PURPOSE

To determine the factor structure and psychometric properties of the NeoEAT-Bottle-feeding.

METHODS

Parents of bottle-feeding infants younger than 7 months were invited to participate. Exploratory factor analysis was used to determine factor structure. Internal consistency reliability was tested using Cronbach α. Test-retest reliability was tested between scores on the NeoEAT-Bottle-feeding completed 2 weeks apart. Construct validity was tested using correlations between the NeoEAT-Bottle-feeding, the Infant Gastroesophageal Reflux Questionnaire-Revised (I-GERQ-R), and the Infant Gastrointestinal Symptoms Questionnaire (IGSQ). Known-groups validation was tested by comparing scores between healthy infants and infants with feeding problems.

RESULTS

A total of 441 parents participated. Exploratory factor analysis revealed a 64-item scale with 5 factors. Internal consistency reliability (α= .92) and test-retest reliability (r = 0.90; P < .001) were both excellent. The NeoEAT-Bottle-feeding had construct validity with the I-GERQ-R (r = 0.74; P < .001) and IGSQ (r = 0.64; P < .001). Healthy infants scored lower on the NeoEAT-Bottle-feeding than infants with feeding problems (P < .001), supporting known-groups validity.

IMPLICATIONS FOR PRACTICE

The NeoEAT-Bottle-feeding is an available assessment tool for clinical practice.

IMPLICATIONS FOR RESEARCH

The NeoEAT-Bottle-feeding is a valid and reliable measure that can now be used in feeding research.Video Abstract Available at https://journals.lww.com/advancesinneonatalcare/Pages/videogallery.aspx.