Prospective study of antecedents for nonorganic failure to thrive

Behavioural Parent Training Versus Dietary Education in the Treatment of Children with Persistent Feeding Difficulties

This controlled treatment-outcome study compared the effects of behavioural parent training (BPT) and standard dietary education (SDE) on the mealtime interaction, feeding behaviour, nutritional status, and adjustment of children with feeding disorders. Participants were 20 children (aged between 18 months and five years) with persistent feeding difficulties, and their families. Children underwent initial screening (involving medical assessment, behavioural observation of mealtime interaction, nutritional intake analysis, and self-report measures of parent and child adjustment) and were randomly assigned to BPT or SDE. Results indicated that children in both treatment conditions showed improvement on the child behaviour measures (e.g. food refusal, disruptive behaviour during mealtimes) at home and in mealtime observations in the clinic. Children in both conditions also showed an increase in the variety of foods sampled by follow-up. Following treatment, mothers who received BPT showed more positive mother–child interaction during mealtimes, and both parents were more satisfied with treatment than parents in SDE. Mothers in both conditions showed slight elevations in mood at posttest and follow-up, and increased marital satisfaction at posttest (which decreased by follow-up). All other treatment effects were maintained at a three- to four-month follow-up assessment.

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.

Risk factors for failure to thrive in infancy depend on the anthropometric definitions used: the Copenhagen County Child Cohort

Failure to thrive (FTT) is the term widely used to describe poor weight gain in infancy, a condition associated with cognitive deficiency in later childhood. FTT has been investigated in earlier population studies, but little is known about risk factors for FTT or the sequence of events as this requires data to be collected prospectively within the first year of life. Furthermore, several different anthropometric criteria have been used to define FTT, and it is not known whether children identified by the different criteria are comparable. In the present population study we compared risk factors for FTT in a general infant population using different definitions of FTT. Three different criteria of FTT mirroring those used in previous population studies were applied to a birth cohort of 6090 infants. Sociodemographic data and prospectively collected information concerning physical and mental development of the children were obtained from National registries and standardised public health nurse records. Risk factors preceding each of the three 'types' of FTT were compared. The three criteria for FTT identified children with very different profiles and a prevalence of FTT ranging from around 2% to 21% in this affluent population. The criterion of slow weight gain conditional on birthweight (conditional weight gain) was associated with lower birthweight, small-for-gestational-age and deviant overall development. Adding low body mass index did not change this profile. In contrast, the commonly used criterion of downward crossing of centiles on an ordinary weight-for-age chart was associated with factors normally linked with low risk of adverse physical and mental development. Slow conditional weight gain, irrespective of additional thinness, seemed to identify infants with prenatal growth retardation and early developmental delays. In contrast, simple downward crossing of centiles seemed mainly to identify healthy low-risk infants, and thus, seems a poor screening measure of FTT in this affluent infant population. Thus, conditional weight gain appears to be the most sensible measure of FTT at present. However, only longitudinal studies including different anthropometric measures and different outcomes can unravel the discriminating power of the different FTT definitions concerning long-term prognosis.

Psychosocial predictors of being an underweight infant differ by racial group: a prospective study of Louisiana WIC program participants

OBJECTIVES

In order to prospectively identify psychosocial predictors of infants being underweight, we followed 3,302 low-income infants. These infants received well-baby care in health departments and were enrolled in the Women, Infants, and Children (WIC) Supplemental Food Program from the newborn period to 12 months of age.

METHODS

We linked risk factor data collected from newborn medical history records to anthropometric data from a WIC database. The unadjusted relative risk of being underweight at 12 months of age, defined as weight for recumbent length below the 5th percentile, according to current Centers for Disease Control and Prevention growth charts, for each group was calculated for the study population and for black and white racial groups. Using logistic regression, we calculated odds ratios measuring the effect of the newborn risk factors on underweight status at 12 months of age.

RESULTS

There were no psychosocial risk factors that were significantly associated with being underweight simultaneously in both racial groups. Among black infants, those whose mothers had an eighth grade education or lower were at greater risk of being underweight at 12 months of age (OR=3.7, CI=1.5-4.8), as were those whose mothers were married (OR=2.7, CI=1.5-4.8). Among white infants, those whose mothers initiated prenatal care in the third trimester were significantly more likely to have underweight infants at 12 months of age (OR=4.5, CI=1.6-12.4).

CONCLUSIONS

Predictors of being underweight at 12 months of age in a low-income population differ by racial group. Further research of public health interventions targeting families of infants with the significant psychosocial risk factors is needed.

The influence of maternal socioeconomic and emotional factors on infant weight gain and weight faltering (failure to thrive): data from a prospective birth cohort

AIMS

To study the influence of maternal socioeconomic and emotional factors on infant weight gain and weight faltering (failure to thrive) in the first year of life.

METHODS

The Gateshead Millennium Baby Study is a population birth cohort in northeast England studied prospectively from birth, via parental questionnaires and a health check aged 13 months. Data were collected on maternal education, deprivation, eating attitudes, and depression, using the Edinburgh Post Natal Depression Scale (EPDS) at 3 months. Weight gain was assessed using change in weight SD score, conditional on birth weight (Thrive Index); weight faltering was defined as conditional weight gain below the 5th centile.

RESULTS

Of 923 eligible infants born at term, 774 (84%) had both weight and questionnaire data. Replicating a previous finding, both the highest and the lowest levels of deprivation were associated with weight faltering; this was independent of the type of milk feeding. No relation was found with maternal educational status. Maternal eating restraint was unrelated to weight gain. Infants of mothers with high depression symptom scores (EPDS >12) had significantly slower weight gain and increased rates of weight faltering up to 4 months (relative risk 2.5), especially if they came from deprived families, but by 12 months they were no different from the remainder of the cohort.

CONCLUSIONS

In this setting, social and maternal characteristics had little influence on infants' weight gain, apart from a strong, but transient effect of postnatal depression.

Physical health outcomes of childhood exposure to intimate partner violence: a systematic review

BACKGROUND

Children exposed to intimate partner violence (IPV) are at increased risk for adverse mental and behavioral health sequelae, as has been documented by both systematic reviews and meta-analyses. Studies addressing the physical health impact of childhood IPV exposure, however, have not been summarized in a manner that might facilitate additional hypothesis-driven research and accelerate the development of targeted interventions.

METHODS

To identify a comprehensive set of articles examining the association between childhood IPV exposure and physical health, we searched online bibliographic databases including Medline, CINAHL, PsychInfo, and Sociological Abstracts using the keywords "domestic" or "intimate partner violence" and "infant," "child," or "pediatric." From >2000 articles retrieved in the initial search, we used online abstract and bibliographic information to identify 94 articles potentially meeting the inclusion criteria of studies that (1) examined a postnatal physical health outcome related to IPV exposure and (2) had a contemporaneous control group. Thorough review of these 94 published studies yielded 22 that met these inclusion criteria. The data then were abstracted independently by 2 of the authors, and differences were settled with the assistance of a third author.

RESULTS

Childhood exposure to IPV increases the likelihood of risk-taking behaviors during adolescence and adulthood and is likely associated with underimmunization. Minimal data and study limitations preclude establishing a clear connection between IPV exposure and general health and use of health services, breastfeeding, or weight gain.

CONCLUSIONS

The impact on physical health from exposure to IPV during childhood is still uncertain. Future studies should be grounded in a theoretical model that specifies how IPV exposure can affect child health, should adjust for confounders adequately, should include a community-based sample, and should be of larger scale.

Salutogenesis as a framework for child protection: literature review

AIM

The aim of this paper is to demonstrate the usefulness of salutogenesis in work relating to child protection.

METHODS

A systematic review to explore the links between parenting, social factors and failure to thrive was carried out using 17 CD ROM and online databases using keywords in appropriate medical subject headings (MeSH terms) and Boolean operators refined for the studies. The salutogenic framework was then used as a way of clarifying what benefit particular research findings may have in identifying and using factors which can be associated with protection, safety and well being of children. Cross-referencing the evidence from the systematic review against Antonovsky's generalized resistance resources created a salutogenic matrix.

FINDINGS

Four factors in the systematic review were found crucially important: parent factors; parenting factors; child factors; and social factors. However, it is probable that these are useful within all child protection research and the evidence gathered in particular cases (here failure to thrive) could be plotted against each factor. Application of a salutogenic framework to the results was further illuminating and has utility for both systematic review methodology and other child protection explorations. The matrix created a warp and weft effect that identified gaps in current evidence and practice and was able to disentangle some of the complexities inherent within failure to thrive situations. By beginning to shed understanding on such processes, the concept of salutogenesis added further depth and rigour to the analysis.

CONCLUSIONS

The concept of salutogenesis is widely used in some areas of nursing practice and research, and can also be regarded as a theoretical tool that has potential in child care and protection research, development and practice. The paper also illustrates the importance of a sound theoretical framework in ensuring depth and rigour in analyses of literature review findings.

Failure to thrive in the term and preterm infants of mothers depressed in the postnatal period: a population-based birth cohort study

AIMS

To examine the relationship between failure to thrive in preterm and term infants and postnatal depression in their mothers.

METHOD

In a whole population birth cohort of 12,391 infants (excluding those born after term or with major congenital abnormalities) failure to thrive over the first nine months was identified using a conditional weight gain criterion which identified the slowest-gaining 5%. Depression symptoms were recorded using the Edinburgh Postnatal Depression Scale (EPDS) at 18 and 32 weeks of pregnancy and at 8 weeks and 8 months after delivery.

RESULTS

After the birth, high depression scores were significantly more common in the mothers of infants born preterm, and controlling for depression scores in pregnancy did not eliminate this association after the birth. Failure to thrive was identified in 4.5% of the children born at term (531/11718) and in 8.3% of those born preterm (56/673). The difference was highly significant (chi2 = 20.25 with 1 df, p < .0001). Using a conventional cut-off on the EPDS (score > 12) to identify mothers as 'depressed', the prevalence of failure to thrive in the term infants of mothers depressed at 8 weeks postpartum was 5.0%; in the remainder of the population (controls) it was 4.3%. In mothers depressed at 8 months the prevalence was 4.3% in both groups. The prevalence of failure to thrive in the preterm infants of mothers depressed at 8 weeks was 8.8% (7.0% in controls) and in those depressed at 8 months it was 12.3% (6.7% in controls). None of these differences in prevalence was statistically significant, and significant differences did not emerge from further analyses using more stringent criteria for depression.

CONCLUSIONS

Preterm births are specifically associated with high maternal depression scores in the postpartum period, and with a higher prevalence of failure to thrive. High depression scores in the postpartum period are not themselves associated with a higher prevalence of failure to thrive, however, either in infants born at term or in those born preterm.

Feeding behaviour in young children who fail to thrive

One-year-old children who failed to thrive in infancy were identified through a specialist clinical service using a conditional weight gain criterion which identified the slowest gaining 5%. Control children of the same age and sex were recruited from the same local geographical area and had the same primary care physician. The food intake and feeding behaviour of the groups was compared using a detailed observational micro-analysis of a lunchtime meal, using a behavioural coding scheme developed for use over the weaning period. Both food and fluid intake at the test meal were significantly lower in the children who failed to thrive than the controls. There was no significant difference in the energy density of the foods they consumed. As recorded in the behaviour counts at the meal, the mothers of the children who failed to thrive fed them as much as or more than the control mothers fed their children. The children who failed to thrive tended to refuse or reject the offered food more, and also fed themselves significantly less often than the controls. These behavioural differences during the meal accounted for about one third of the difference in energy intake between the groups.

Energy compensation in young children who fail to thrive

BACKGROUND

Failure to thrive is generally attributed to undernutrition, but little is known about the appetite or eating behaviour of children with the condition. The hypothesis that young children who fail to thrive lack a normal sensitivity to internal hunger or satiation cues was tested in this study using an energy compensation procedure.

METHOD

Twenty-seven children under assessment by a community-based service for failure to thrive, with weight gain in the lowest 5% for their age, were studied at one year of age with 26 controls of the same age and sex with normal weight gain, resident in the same local geographical area. Test meals were given in the child's own home on two separate days. The test meals were preceded by either a high energy (402 kJ) drink, or by a low energy (1 kJ) drink on a control day. The order was randomised, and the study conducted double blind, without the experimenter or the mother knowing which drink was which. Energy intake at the test meal was measured.

RESULTS

There was no significant difference in the birth weight of the children in the two groups but by the time of the test the cases weighed significantly less than controls, with mean (SD) weight 9.06 (1.05) kg and 11.59 (1.59) kg respectively. In relation to the British Growth Reference for weight this is a difference of 2.2 SD. Mean (SD) energy intake at the meal on the control day was significantly lower in the case children than the controls (FTT 687.5 (334.3) kJ; controls 1065.9 (431.8) kJ; p < .001). After the high energy drink, controls reduced their energy intake at the meal by a mean (SD) -257.3 (383.3) kJ while the cases showed a slight average increase of +78.1 (365.9) kJ; t = 3.26, df 51, p < .001. Per kJ of the pre-load, the average change was -1.18 kJ in controls and +0.80 kJ in cases.

CONCLUSIONS

The controls compensated as expected for their high energy load at the subsequent meal, but the case children did not, showing that they lack the normal responses to internal hunger/satiation cues. High energy snacks may improve the nutritional status of children who fail to thrive.

Eating behaviour and its variability in 1-year-old children

As part of a longitudinal study of the development of eating behaviour, the naturally occurring meals of 30 12 month old children were videotaped on four occasions, all in their own homes. Their mealtime behaviour was coded using a scheme developed for the analysis of feeding behaviour over the weaning period, and summarised as counts of coded actions. Thirty of these meals were coded independently by a second observer. With one exception, the reliability of the counts was high (r> 0.9). The median duration of the meals was 17 min (range 1-50) and the median number of times the mother directly gave the child food was 42 (0-172). The median number of food refusals by the child was 11 (0-89), and self feeding actions, 12 (0-101). Counts of eating behaviour for the main and sweet courses during the same meal were only modestly correlated. Between subject variance for different behaviour counts comprised 41% to 54% of the total variance. These results show that 1 year old children are relatively variable in their eating behaviour from meal to meal, so measures taken from a single meal will not reliably summarise children's feeding characteristics. Food refusal is a common feature of eating behaviour in normal children at this age.

Reversing growth deficiency in children: the effect of a community-based intervention

INTRODUCTION

The effect of a community health nursing intervention on children with growth deficiency (also called nonorganic failure to thrive or growth failure) was examined in a pretest and post-test experimental study. This study evaluated the impact of the intervention on growth quotients, children's diets, parent-child interaction, home environment, and mothers' perceived stress.

METHODS

The sample consisted of 39 children (ages 3 months to 3 years) with growth deficiency in weight or height for age, weight for height, or a decrease in growth across two percentiles. The children were enrolled in Special Supplemental Feeding Program for Women, Infants and Children (WIC) clinics in county health departments and were randomly assigned to experimental or control groups. After preliminary data were collected for the entire sample, a community-based intervention was administered to the experimental group during home visits. The intervention included education about nutrition and about parenting and community skills.

RESULTS

Data collected after the intervention by a research assistant blind to group assignment indicated positive changes (P < or = .05) in the experimental group's growth quotients, home environments, and their mothers' perceived stress.

DISCUSSION

This study supports the community health nursing practice of teaching nutrition and child care during home visits to families of children with growth deficiency.

Nonorganic failure to thrive: a theoretical approach

Nonorganic failure to thrive (NOFTT) is a significant health problem of infancy. Although NOFTT is thought to be a result of multiple factors, exactly what these factors are is unclear. Explaining the development of NOFTT has been hindered by a lack of a theoretical approach. The purpose of this article is to provide a review of the literature and the discussion of a theoretical framework to guide future research in the area of NOFTT.

Does a fall down a centile chart matter? The growth and developmental sequelae of mild failure to thrive

Fifty-two children aged 18 months who had fallen across two weight centile lines were compared to 52 controls. Five years after the initial study, 89% of these children were traced. At follow-up, four of the cases but none of the controls had been placed in care and cases were significantly shorter and lighter than controls. Reanalysis of the early weight data revealed that the screening criterion had been over-inclusive, identifying a majority with only borderline failure to thrive (FTT). Although the mean IQ was lower in the cases than in controls, the difference was not statistically significant. However, a significant association was found within the cases between severity of FTT and IQ. There was no difference in the number of behaviour problems reported. The use of a simple centile shift-based definition of FTT, while proving to be over-sensitive, has identified a subgroup of children who suffered adverse long-term cognitive outcomes.

A community based study of failure to thrive in Israel

OBJECTIVE

To examine the characteristics of infants suffering from failure to thrive in a community based cohort in Israel and to ascertain the effect of failure to thrive on their cognitive development.

METHODS

By review of records maintained at maternal and child health clinics in Jerusalem and the two of Beit Shemesh, epidemiological data were obtained at age 15 months on a cohort of all babies born in 1991. For each case of failure to thrive, a matched control was selected from the same maternal and child health clinic. At age 20 months, cognitive development was measured, and at 25 months a home visit was carried out to assess maternal psychiatric status by questionnaire, and the HOME assessment was performed to assess the home environment.

RESULTS

3.9% of infants were found to have fallen below the third centile in weight for at least three months during the first year of life. Infants with failure to thrive did not differ from the general population in terms of obstetric or neonatal complications, birth order, or parents' ethnic origin, age, or years of education. The infants with failure to thrive did have lower birthweights and marginally smaller head circumferences at birth. Developmental assessment at 20 months of age showed a DQ of 99.7 v 107.2 in the matched controls, with 11.5% having a DQ below 80, as opposed to only 4.6% of the controls. No differences were found in maternal psychiatric problems as measured by a self report questionnaire. There were, however, significant differences in subscales of the HOME scale.

CONCLUSIONS

(1) Infants who suffered from failure to thrive had some physiological predispositions that put them at risk; (2) failure to thrive may be an early marker of families providing suboptimal developmental stimulation.

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.

A clinical tool for nonorganic failure-to-thrive feeding interactions

An interdisciplinary team of professionals developed and piloted a clinical tool, the Feeding Checklist, for assisting observations of feeding interactions with nonorganic failure-to-thrive (NOFTT) clients. The piloting process involved two phases. During the development phase, content validity and reliability were established with three NOFTT experts. The tool was compared with a standardized feeding interaction assessment instrument to determine concurrent validity. Both tools revealed similar behavior patterns significantly differentiating between NOFTT and Thriving dyads. The results also concurred with NOFTT literature findings. During the second phase of the study, pediatric nursing staff significantly improved the nursing documentation of NOFTT feeding interactions when using the Feeding Checklist.

The use of human ecology and epidemiology in nonorganic failure to thrive

Children with nonorganic failure to thrive (NOFTT) comprise a population at risk for small stature, poor growth, slower development, and lower intellectual outcomes. These children are often seen in the Women, Infants, and Children Supplemental Nutrition Program (WIC) and child health clinics and in caseloads of high-risk families. Public health nurses may not be sure how to intervene in the problem of NOFTT because of its multifactorial etiology. A model of nursing care that addresses the many factors that affect the development of NOFTT can enable the public health nurse to appropriately care for the child with NOFTT. The Eco-Epi model, a combination of human ecology and epidemiology, is a conceptual model that can provide a framework for the public health nurse to plan interventions. Even though children with NOFTT are the target population for this model, it can be applied to other public health nursing populations at risk for multifactorial problems. In the Eco-Epi model, the epidemiological concepts of agent (food), host (child), and environment (home) are examined in the context of the microsystem (parent-child interaction, daily activities of the family), the mesosystem (interactions between different environments), and the exosystem (the child's community). The concepts of microsystem, mesosystem, and exosystem are from the theory of human ecology. Examples of how the model works to assess a family and design interventions are provided.

A prospective study of secondary prevention of child maltreatment

This study sought (1) to retest an approach to the prediction of risk of child maltreatment and (2) to test the effect of a comprehensive prenatal and pediatric health services program on the rate of maltreatment. Of 2585 women screened at their first prenatal visit, 1154 qualified for the study. Risk assignment was determined by a structured interview. High-risk women (n = 314) were assigned to receive standard (high-risk control group; n = 154) or intervention (high-risk intervention group; n = 160) services throughout the prenatal period and during the first 2 years of their infants' life. A third group (low-risk control group; n = 295) was selected among low-risk women and received standard care without intervention services. State records were searched for substantive reports of child maltreatment up to 36 months after birth. Physical abuse was found for 5.1% of the study population; neglect was substantiated for 5.9%. Prediction efforts were effective in identifying risk of physical abuse but not of neglect. Comprehensive health services did not alter the reported abuse rate for high-risk parents and was associated with an increased number of neglect reports. Intervention reduced subject attrition and appeared to serve as a bias for detection of maltreatment. Thus this long-term, prospective approach was ineffective for child abuse prevention, perhaps because of detection biases and societal changes.

Antecedents of child neglect in the first two years of life

To determine the prenatal antecedents of child neglect by low-income women, data from a prospective study of child maltreatment were reviewed. Mothers determined to be at high risk prenatally for maltreatment were more likely to be identified as neglectful within 24 months of the interview. Neglectful mothers were less likely to have completed high school, had more children younger than 6 years of age, and had more aberrant responses on parenting skills and support systems scales. Neglected children were lower in birth weight, were rated more difficult temperamentally, and had poorer mental and motor developmental scores.

Oral-motor dysfunction and failure to thrive among inner-city infants

Non-organic failure to thrive among socio-economically deprived inner-city infants may be associated with abnormal oral-motor functioning and aspects of social adversity, such as disorganised meal-times. A Feeding Assessment Schedule was devised to rate oral-motor behaviour objectively and was used to test nine pairs of case and comparison children while they were being fed at home. Video-recordings were made for later analysis. The case infants had immature and abnormal oral-motor development that made them less able to be fed successfully. Temperamentally they were more 'difficult' than the comparison infants, and they were less adept at signalling their needs during meal-times. The case infants also were fed in inappropriate positions for their age, with more distractions and less suitable utensils.

A profile of abuse

Of 260 children considered to have been the victims of child abuse or neglect, or both, 149 suffered non-accidental injury, 71 had evidence of growth problems, 87 had developmental and speech delay, and 63 showed evidence of appreciable behaviour disturbance. While the overall prevalence of development and behaviour problems in the series was high there were particular associations noted between growth problems and developmental delay, between increasing age and behaviour disturbance, and between evidence of emotional deprivation and both behaviour disturbance and developmental delay. Children with non-accidental injury but without growth problems or emotional deprivation were least likely to show behaviour or developmental problems.

Psychosocial growth retardation in adolescence. A reversible condition secondary to severe stress

Two cases of psychosocial growth retardation in adolescents are presented, along with a brief review of the literature. Both cases were females, aged 12-13 years, who showed marked deceleration of growth and development when placed in an emotionally stressful situation. A normal pattern of growth and development ensued when the stressful situation was at least partially alleviated. To facilitate proper management, it is important to recognize those adolescents with psychosocial growth retardation. The increased availability of human growth hormone (hGH) may place more pressure on physicians to use exogenous hGH in adolescents who exhibit growth retardation. It appears that the administration of exogenous hGH is not indicated in the treatment of children with psychosocial growth retardation.

Family interactions surrounding feedings of infants with nonorganic failure to thrive

Family interactional processes surrounding infant feedings in 34 consecutive cases of nonorganic failure to thrive (NFT) admitted to a university teaching hospital are reported. Observations of family interactions for 90 minutes, including one feeding, yielded clinically useful information not readily available from other sources. Behaviors that supported inadequate feedings were reliably identified in 79 percent of the families. Failure of mothers to appropriately respond to their infants' cues, coupled with few signs of emotional attachment, were present in only 26 percent of cases, and inadequate child-care knowledge and skills in only 6 percent. Thus, widely held conceptual models explained perpetuation of inadequate feedings in only 32 percent of cases. Instead, sibling rivalry, displaced maternal anger, and undermined mother were among the problems found. Assessments of family members' interactions surrounding feedings have the potential to enhance the current management of NFT.

Preventing common feeding problems in infants and young children

Feeding is one of many important ways that parents nurture their infants and children. When parents are overly concerned about feeding, they can exacerbate temporary feeding difficulties and misbehaviors by their inappropriate responses to the child's behavior. Child health supervision visits provide opportunities for the early detection of feeding problems, for education about early feeding experiences and typical child behavior at mealtimes, and for suggestions about the prevention of feeding problems. Handouts and printed materials can provide useful guidelines for introducing solid foods and for managing children's mealtime behavior. Early detection might reduce the likelihood that minor feeding disturbances will develop into severe feeding problems. Behavior management strategies and a pleasant social context for mealtimes can improve children's eating and mealtime behavior. Impairments in the parent-infant relationship may lead to serious feeding problems and referrals to appropriate support services are necessary. Prevention and early treatment of feeding problems can be facilitated by health education about early food experiences and the common developmental behaviors that occur as children grow and develop.