Prediction of intellectual development in young children with early histories of nonorganic failure-to-thrive

Catch-Up Growth in Infants and Young Children With Faltering Growth: Expert Opinion to Guide General Clinicians

Faltering growth (FG) is a problem regularly seen by clinicians in infants and young children (<2 years of age). It can occur due to non-disease-related and disease-related causes and is associated with a wide range of adverse outcomes, including shorter-term effects such as impaired immune responses and increased length of hospital stay, and longer-term consequences, including an impact on schooling and cognitive achievements, short stature, and socioeconomic outcomes. It is essential to detect FG, address underlying causes and support catch-up growth where this is indicated. However, anecdotal reports suggest misplaced fear of promoting accelerated (too rapid) growth may deter some clinicians from adequately addressing FG. An invited international group of experts in pediatric nutrition and growth reviewed the available evidence and guidelines on FG resulting from disease-related and non-disease-related effects on nutritional status in healthy term and small for gestational age infants and children up to the age of 2 years in low-, middle-, and high-income countries. Using a modified Delphi process, we developed practical consensus recommendations to provide clarity and practical recommendations for general clinicians on how FG should be defined in different young child populations at risk, how FG should be assessed and managed, and the role of catch-up growth after a period of FG. We also suggested areas where further research is needed to answer remaining questions on this important issue.

The Neural Processing of Vocal Emotion After Hearing Reconstruction in Prelingual Deaf Children: A Functional Near-Infrared Spectroscopy Brain Imaging Study

As elucidated by prior research, children with hearing loss have impaired vocal emotion recognition compared with their normal-hearing peers. Cochlear implants (CIs) have achieved significant success in facilitating hearing and speech abilities for people with severe-to-profound sensorineural hearing loss. However, due to the current limitations in neuroimaging tools, existing research has been unable to detail the neural processing for perception and the recognition of vocal emotions during early stage CI use in infant and toddler CI users (ITCI). In the present study, functional near-infrared spectroscopy (fNIRS) imaging was employed during preoperative and postoperative tests to describe the early neural processing of perception in prelingual deaf ITCIs and their recognition of four vocal emotions (fear, anger, happiness, and neutral). The results revealed that the cortical response elicited by vocal emotional stimulation on the left pre-motor and supplementary motor area (pre-SMA), right middle temporal gyrus (MTG), and right superior temporal gyrus (STG) were significantly different between preoperative and postoperative tests. These findings indicate differences between the preoperative and postoperative neural processing associated with vocal emotional stimulation. Further results revealed that the recognition of vocal emotional stimuli appeared in the right supramarginal gyrus (SMG) after CI implantation, and the response elicited by fear was significantly greater than the response elicited by anger, indicating a negative bias. These findings indicate that the development of emotional bias and the development of emotional perception and recognition capabilities in ITCIs occur on a different timeline and involve different neural processing from those in normal-hearing peers. To assess the speech perception and production abilities, the Infant-Toddler Meaningful Auditory Integration Scale (IT-MAIS) and Speech Intelligibility Rating (SIR) were used. The results revealed no significant differences between preoperative and postoperative tests. Finally, the correlates of the neurobehavioral results were investigated, and the results demonstrated that the preoperative response of the right SMG to anger stimuli was significantly and positively correlated with the evaluation of postoperative behavioral outcomes. And the postoperative response of the right SMG to anger stimuli was significantly and negatively correlated with the evaluation of postoperative behavioral outcomes.

A meta-analysis of the predictability of LENA™ automated measures for child language development

Early language environment plays a critical role in child language development. The Language ENvironment Analysis (LENA™) system allows researchers and clinicians to collect daylong recordings and obtain automated measures to characterize a child's language environment. This meta-analysis evaluates the predictability of LENA's automated measures for language skills in young children. We systematically searched reports for associations between LENA's automated measures, specifically, adult word count (AWC), conversational turn count (CTC), and child vocalization count (CVC), and language skills in children younger than 48 months. Using robust variance estimation, we calculated weighted mean effect sizes and conducted moderator analyses exploring the factors that might affect this relationship. The results revealed an overall medium effect size for the correlation between LENA's automated measures and language skills. This relationship was largely consistent regardless of child developmental status, publication status, language assessment modality and method, or the age at which the LENA recording was taken; however, the effect was weakly moderated by the gap between LENA recordings and language measures taken. Among the three measures, there were medium associations between CTC and CVC and language, whereas there was a small-to-medium association between AWC and language. These findings extend beyond validation work conducted by the LENA Research Foundation and suggest certain predictive strength of LENA's automated measures for child language. We discussed possible mechanisms underlying the observed associations, as well as the theoretical, methodological, and clinical implications of these findings.

Lexical Repetition Properties of Caregiver Speech and Language Development in Children With Cochlear Implants

Purpose Early language input plays an important role in child language and cognitive development (e.g., Gilkerson et al., 2018; Hart & Risley, 1995). In this study, we examined the effects of child's hearing status on lexical repetition properties of speech produced by their caregivers with normal hearing (NH). In addition, we investigated the relationship between maternal lexical repetition properties and later language skills in English-learning infants with cochlear implants (CIs). Method In a free-play session, 17 mothers and their prelingually deaf infants who received CIs before 2 years of age (CI group) were recorded at two post-CI intervals: 3 and 6 months postactivation; 18 hearing experience-matched infants with NH and their mothers and 14 chronological age-matched infants with NH group and their mothers were matched to the CI group. Maternal speech was transcribed from the recordings, and measures of maternal lexical repetition were obtained. Standardized language assessments were administered on children with CIs approximately two years after CI activation. Results The findings indicated that measures of lexical repetition were similar among the three groups of mothers, regardless of the hearing status of their infants. In addition, lexical repetition measures were correlated with later language skills in infants with CIs. Conclusions Infants with CIs receive the language input that contains similar lexical repetition properties as that in the speech received by their peers with NH, which is likely to play an important role in child speech processing and language development. These findings provide the knowledge for professionals to coach parents to implement specific language intervention strategies to support language development in infants with hearing loss. Supplemental Material https://doi.org/10.23641/asha.11936322.

Infant-Directed Speech Enhances Attention to Speech in Deaf Infants With Cochlear Implants

Purpose

Both theoretical models of infant language acquisition and empirical studies posit important roles for attention to speech in early language development. However, deaf infants with cochlear implants (CIs) show reduced attention to speech as compared with their peers with normal hearing (NH; Horn, Davis, Pisoni, & Miyamoto, 2005; Houston, Pisoni, Kirk, Ying, & Miyamoto, 2003), which may affect their acquisition of spoken language. The main purpose of this study was to determine (a) whether infant-directed speech (IDS) enhances attention to speech in infants with CIs, as compared with adult-directed speech (ADS), and (b) whether the degree to which infants with CIs pay attention to IDS is associated with later language outcomes.

Method

We tested 46 infants-12 prelingually deaf infants who received CIs before 24 months of age and had 12 months of hearing experience (CI group), 22 hearing experience-matched infants with NH (NH-HEM group), and 12 chronological age-matched infants with NH (NH-CAM group)-on their listening preference in 3 randomized blocks: IDS versus silence, ADS versus silence, and IDS versus ADS. We administered the Preschool Language Scale-Fourth Edition (PLS-4; Zimmerman, Steiner, & Pond, 2002) approximately 18 months after implantation to assess receptive and expressive language skills of infants with CIs.

Results

In the IDS versus silence block, all 3 groups looked significantly longer to IDS than to silence. In the ADS versus silence block, both the NH-HEM and NH-CAM groups looked significantly longer to ADS relative to silence; however, the CI group did not show any preference. In the IDS versus ADS block, whereas both the CI and NH-HEM groups preferred IDS over ADS, the NH-CAM group looked equally long to IDS and ADS. IDS preference quotient among infants with CIs in the IDS versus ADS block was associated with PLS-4 Auditory Comprehension and PLS-4 Expressive Communication measures.

Conclusions

Two major findings emerge: (a) IDS enhances attention to speech in deaf infants with CIs; (b) the degree of IDS preference over ADS relates to language development in infants with CIs. These results support a focus on input in developing intervention strategies to mitigate the effects of hearing loss on language development in infants with hearing loss.

Behavioral Management of Feeding Disorders of Childhood

Feeding disorders, characterized by suboptimal intake and/or lack of age-appropriate eating habits, are common and may be seen in up to 45% of children. Feeding disorders are a significant concern to both the affected families and to the providers who treat them. Fortunately, there are well-established behavioral treatments which have been shown to be highly efficacious. This article provides an overview of behavioral assessment and treatment of pediatric feeding disorders, provides guidance in treatment planning, and provides information which may be useful in considering if additional psychological consultation may be beneficial.

Defining pediatric malnutrition: a paradigm shift toward etiology-related definitions

Lack of a uniform definition is responsible for underrecognition of the prevalence of malnutrition and its impact on outcomes in children. A pediatric malnutrition definitions workgroup reviewed existing pediatric age group English-language literature from 1955 to 2011, for relevant references related to 5 domains of the definition of malnutrition that were a priori identified: anthropometric parameters, growth, chronicity of malnutrition, etiology and pathogenesis, and developmental/ functional outcomes. Based on available evidence and an iterative process to arrive at multidisciplinary consensus in the group, these domains were included in the overall construct of a new definition. Pediatric malnutrition (undernutrition) is defined as an imbalance between nutrient requirements and intake that results in cumulative deficits of energy, protein, or micronutrients that may negatively affect growth, development, and other relevant outcomes. A summary of the literature is presented and a new classification scheme is proposed that incorporates chronicity, etiology, mechanisms of nutrient imbalance, severity of malnutrition, and its impact on outcomes. Based on its etiology, malnutrition is either illness related (secondary to 1 or more diseases/injury) or non-illness related, (caused by environmental/behavioral factors), or both. Future research must focus on the relationship between inflammation and illness-related malnutrition. We anticipate that the definition of malnutrition will continue to evolve with improved understanding of the processes that lead to and complicate the treatment of this condition. A uniform definition should permit future research to focus on the impact of pediatric malnutrition on functional outcomes and help solidify the scientific basis for evidence-based nutrition practices.

Failure to thrive in childhood

BACKGROUND

Failure to thrive impairs children's weight gain and growth, their defenses against infection, and their psychomotor and intellectual development.

METHODS

This paper is a review of pertinent articles that were published from 1995 to October 2010 and contained the terms "failure to thrive", "underweight", "malnutrition", "malabsorption", "maldigestion" and "refeeding syndrome". The articles were retrieved by a search in the PubMed and Cochrane Library databases.

RESULTS

In developed countries, failure to thrive is usually due to an underlying disease. The degree of malnutrition is assessed with anthropometric techniques. For each patient, the underlying disease must be identified and the mechanism of failure to thrive understood, so that proper medical and nutritional treatment can be provided. Nutritional treatment involves either giving more food, or else raising the caloric density of the patient's food. Liquid formulas can be given as a supplement to normal meals or as balanced or unbalanced tube feeds; they can be given orally, through a nasogastric tube, or through a gastrostomy tube. Severely malnourished children with poor oral intake should be treated with parenteral nutrition. To avoid refeeding syndrome in severely malnourished children, food intake should be increased slowly at first, and phosphate, magnesium, and potassium supplements should be given.

CONCLUSION

The proper treatment of failure to thrive in childhood consists of treatment of the underlying illness, combined with nutritional treatment that addresses the mechanism of the accompanying failure to thrive.

Early intervention and recovery among children with failure to thrive: follow-up at age 8

OBJECTIVES

We sought to examine the impact of a randomized, controlled trial of home visiting among infants with failure to thrive on growth, academic/cognitive performance, and home/classroom behavior at age 8.

METHODS

Infants with failure to thrive (N = 130) or adequate growth (N = 119) were recruited from pediatric primary care clinics serving low-income, urban communities. Eligibility criteria included age <25 months, gestational age >36 weeks, birth weight >2500 g, and no significant medical conditions. Evaluation included anthropometries, Bayley scales, maternal anthropometries, demographics, negative affect, IQ, and the Home Observation for Measurement of the Environment scale. Infants with failure to thrive were treated in an interdisciplinary growth and nutrition clinic and randomized into clinical-intervention-plus-home-intervention or clinical-care-only groups. The home-visiting curriculum promoted maternal sensitivity, parent-infant relationships, and child development. Follow-up visits were conducted by evaluators who were unaware of the children's growth or intervention history. At age 8, the evaluation included anthropometries, the Wechsler Intelligence Scale for Children III, and the Wide Range Achievement Test, Revised. Mothers completed the Child Behavior Checklist and teachers completed the Teacher Report Form.

ANALYSIS

Multivariate analyses of variance were used to examine differences in growth, cognitive/academic performance, and home/school behavior, adjusted by maternal education, public assistance, and, when appropriate, infant Bayley score, maternal BMI, height, negative affect, IQ, and Home Observation for Measurement of the Environment scores.

RESULTS

Retention was 74% to 78%. Children in the adequate-growth group were significantly taller, heavier, and had better arithmetic scores than the clinical-intervention-only group, with the clinical-intervention-plus-home-intervention group intermediate. There were no group differences in IQ, reading, or mother-reported behavior problems. Children in the clinical-intervention-plus-home-intervention group had fewer teacher-reported internalizing problems and better work habits than the clinical-intervention-only group.

CONCLUSIONS

Early failure to thrive increased children's vulnerability to short stature, poor arithmetic performance, and poor work habits. Home visiting attenuated some of the negative effects of early failure to thrive, possibly by promoting maternal sensitivity and helping children build strong work habits that enabled them to benefit from school. Findings provide evidence for early intervention programs for vulnerable infants.

How does maternal and child feeding behavior relate to weight gain and failure to thrive? Data from a prospective birth cohort

OBJECTIVES

The aim of this study was to study the influences of child and maternal feeding behavior on weight gain and failure to thrive in the first year of life.

METHODS

The Millennium Infant Study recruited a population birth cohort in Northeast England shortly after birth and studied them prospectively to the age of 13 months. Parents completed questionnaires at 6 weeks and 4, 8, and 12 months. Appetite was rated on a 5-point scale at each age, and a core group of questions was used to generate scores of oromotor dysfunction, avoidant eating behavior, maternal feeding anxiety, and response to food refusal. Routinely collected weights were used to assess weight gain using the thrive index (TI); weight faltering was defined as TI below the 5th percentile from birth to age 6 weeks or 4, 8, or 12 months.

RESULTS

Of 923 eligible infants, 75% of the mothers returned at least 1 questionnaire and > or =2 weights. Weight gain to 6 weeks was independently related to appetite and oromotor dysfunction rated at 6 weeks. Appetite rated at 6 weeks and 12 months both independently predicted weight gain to 12 months. Some avoidant eating behavior was seen in most children by 12 months old, but there was no relationship with weight gain or faltering after adjustment for appetite. However, the extent to which caregivers responded to food refusal was a significant inverse predictor of weight gain, even after adjustment for appetite.

CONCLUSIONS

Inherent child appetite characteristics seem to be an important risk factor for weight faltering and failure to thrive, but high maternal promotion of feeding may also have an adverse influence.

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.

Postnatal depression and faltering growth: a community study

OBJECTIVE

To investigate the association between faltering growth in children and maternal postnatal depression.

METHODS

Children aged < or =2 years were identified from community child health surveillance records if their weights fell across 2 centile channels on standardized growth charts or fell below the second centile. Mothers of these index children were invited to complete the Edinburgh Postnatal Depression Scale and the anxiety subscale of the Hospital Anxiety and Depression Scale. Those who scored above threshold values on either scale were interviewed with the revised Clinical Interview Schedule. Matched control children were obtained from health visitor records, and records of their weights were obtained. Mothers of control children completed the same questionnaires.

RESULTS

A total of 196 index children and 567 control children were studied. Significantly more mothers in the index group scored above the threshold for both the Edinburgh Postnatal Depression Scale (33% vs 22%; odds ratio [OR]: 1.71; 95% confidence interval [CI]: 1.16-2.53) and the Hospital Anxiety and Depression Scale (24% vs 13%; OR: 2.08; 95% CI: 1.33-3.25) questionnaires. Furthermore, clinical interviews with these mothers demonstrated that 21% of the index group and 11% of the control group fulfilled criteria for depressive episode (OR: 1.88; 95% CI: 1.21-2.94).

CONCLUSIONS

Depression in mothers of children with faltering growth during the first 2 years of life is significantly greater than in mothers of children who are gaining weight appropriately. In view of the high rates of maternal depression in children with poor weight gain, clinical management at presentation of either problem should focus on both members of the mother-child dyad and on the interaction between mother and child. These findings have implications for all professionals who work in primary and secondary health care.

Failure to thrive and cognitive development in toddlers with infantile anorexia

OBJECTIVE

The goal of this study was to examine the relative contributions of growth deficiency and psychosocial factors to cognitive development in toddlers with infantile anorexia.

METHODS

Eighty-eight toddlers, ranging in age from 12 to 33 months, were enrolled in this study. Toddlers were evaluated by 2 child psychiatrists and placed into 1 of 3 groups: infantile anorexia, picky eater, and healthy eater. All 3 groups were matched for age, race, gender, and socioeconomic status (SES). Toddlers underwent nutritional evaluations and cognitive assessments with the Bayley Scales of Infant Development. Toddlers and their mothers were also videotaped during feeding and play interactions, which later were rated independently by 2 observers.

RESULTS

On average, toddlers with infantile anorexia performed within the normal range of cognitive development. However, the Mental Developmental Index (MDI) scores of the healthy eater group (MDI = 110) were significantly higher than those of the infantile anorexia (MDI = 99) and picky eater (MDI = 96) groups. Within the infantile anorexia group, correlations between MDI scores and the toddlers' percentage of ideal body weight approached statistical significance (r =.32). Across all groups, the toddlers' MDI scores were associated with the quality of mother-child interactions, SES level, and maternal education level. Collectively, these variables explained 22% of the variance in MDI scores.

CONCLUSIONS

This study demonstrated that psychosocial factors, such as mother-toddler interactions, maternal education level, and SES level, are related to the cognitive development of toddlers with feeding problems and explain more unique variance in MDI scores than nutritional status.

To what extent is failure to thrive in infancy associated with poorer cognitive development? A review and meta-analysis

BACKGROUND

Previous empirical studies of the cognitive sequelae of failure to thrive in infancy have led to apparently inconsistent conclusions.

METHODS

Studies of cognitive abilities in failure to thrive were located through published bibliographies, supplemented by a search through MEDLINE. They were classified (a) into those in which the cases were identified in hospital or other specialist clinics, and those in which they were identified in primary care or by whole population screening; (b) into those that were controlled and those that were not controlled; and (c) into those with a cross-sectional and those with a longitudinal design. Effect sizes in controlled studies were summarised using D statistics for the principal cognitive outcome measure, from the last occasion on which the child was tested if the study was longitudinal.

RESULTS

In studies with cases identified in hospital or other specialist clinics (52 cases, 36 controls), the pooled effect size (weighted standardised mean difference) for cognitive outcomes was -.85 (95% CI -.41 to -1.30). In studies with cases identified in primary care (552 cases, 573 controls), it was -.30 (95% CI -.18 to -.42). In each longitudinal study testing the same children at different ages, the effect size was smaller when the children were older. To obtain an overall estimate of the long-term cognitive outcome of failure to thrive in infancy, data from controlled studies in which cases were identified in primary care, and restricted to IQ or McCarthy scale scores in older children (502 cases, 523 controls), were used. The weighted mean difference was -.28 (95% CI -.16 to -.41), equivalent to 4.2 IQ points (95% CI 2 to 6).

CONCLUSIONS

Evidence from reasonably well-controlled studies indicates that failure to thrive in infancy is associated with adverse intellectual outcomes sufficiently large to be of importance at a population level.

Cognitive development of children in poverty with failure to thrive: a prospective study through age 6

BACKGROUND

This study examined the cognitive development of children in poverty with normal growth and those with a history of failure to thrive (FTT) prospectively from infancy through age 6.

METHOD

Participants were 226 low-income infants with normal birthweight and no perinatal complications, congenital problems, or chronic illnesses. One hundred and twenty-eight children experienced FTT and were treated in an interdisciplinary clinic, and 98 had normal growth.

RESULTS

Cognitive development declined in both groups to 1.0-1.5 SD below the norm. Children with FTT had lower cognitive scores than children with adequate growth through age 4, followed by recovery. By ages 5 and 6, there were no differences in cognitive scores based on the children's growth history. Using hierarchical linear modeling, child-centered home environment and small family size were related to better cognitive performance.

CONCLUSIONS

The low scores of both groups point to the need for programs promoting a child-centered home environment.

Clinical implications of household food security: definitions, monitoring, and policy

Poverty-related food insecurity is a reality that many clinicians in nutrition and health care encounter either directly or indirectly. It is associated with both overnutrition and undernutrition, but it is not congruent with malnutrition. Food insecurity affects human development and health throughout the lifecycle, but can be particularly harmful during critical or vulnerable stages early and late in life. Understanding the causes and consequences of food insecurity and knowing how to identify them can improve the quality and effectiveness of clinical care, and facilitate prevention and treatment of many kinds of health problems. Numerous public policies and programs exist to ameliorate and prevent poverty-related food insecurity. However, the resources to support them ebb and flow with the politics of annual state and federal budgetary cycles. Support and need for these social-safety-net programs also vary with business cycles. Unfortunately, need often expands as support shrinks along with employment and government revenues during recessions, and shrinks as support expands along with employment and government revenues during expansions.

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.

An event-related potential study of older children with an early history of failure to thrive

Elementary and junior high school children (n = 13), who were diagnosed with nonorganic failure to thrive (FTT) as infants and toddlers, were compared with a normal control group (n = 14) on visual event-related potentials (ERPs) elicited during a primed lexical decision task. Positive stimuli were real words that were identical to the priming stimuli; negative stimuli were nonpronounceable letter strings. Although the groups did not differ in word-list reading level, the former FTT group had slower reaction (decision) times and did not show ERP evidence of priming in the N400 epoch. Anterior sites yielded better separation of the real words and letter strings than posterior sites. A late anterior component between 500 msec to 650 msec poststimulus onset showed the largest condition effect for both groups. The control group had a larger negative going late anterior component to words than the FTT group. The combined reaction time and ERP findings point to less automatized word recognition in the FTT group.

Fütter- und Gedeihstörungen bei kleinen und/oder behinderten Kindern

Zusammenfassung Behandlungsbedürftige Fütter- und Gedeihstörungen (Prävalenz 2-4%) haben selten eine isolierte Ursache, meist ist ein Bündel von ungünstigen Bedingungen an der Entstehung und vor allem Aufrechterhaltung der Störung beteiligt. Das können organische Ursachen wie chronische Erkrankungen, Auffälligkeiten in der Person oder dem Verhalten des Kindes oder der Bezugsperson oder in der Interaktion sein. Fütter- und Gedeihstörungen können eine längerdauernde Zusatz- oder Vollsondierung erfordern, oder das Kind lehnt altersgemäß grobe Kost ab, hat ein sehr selektives Essverhalten oder es gibt massive Interaktionsstörungen während des Fütterns. Fütter- und Gedeihstörungen können neben den direkten körperlichen Auswirkungen auch längerdauernde ungünstige Einflüsse auf andere Verhaltensbereiche und auf mentale Fähigkeiten haben. Die Diagnostik der Fütter- und Gedeihstörungen umfasst neben der Abklärung einer organischen Grunderkrankung die Klärung der Schluck- und der oralmotorischen Fähigkeiten sowie den Ausschluss eines gastroösophagealen Refluxes. Das differenzierte Fütterprotokoll muss die orale und die Sondenernährung umfassen. Die Verhaltensbeobachtung umfasst die Füttersituation und wenn nötig auch breitere Interaktionsbereiche. Neben einer Therapie der Grunderkankung steht die direkte Anleitung der Bezugspersonen in der Füttersituation im Vordergrund. Daneben können eine Therapie der Oralmotorik sowie der Bezugsperson und Interaktionsanleitungen in verschiedenen Verhaltensbereichen erforderlich sein.

An electrophysiological study of school-aged children with a history of failure to thrive during infancy

Sixty-five subjects, ages 8 to 12, participated in a visual electrophysiological study. Twenty-two of the subjects had received a diagnosis of nonorganic failure-to-thrive (FTT) before the age of three. The remaining 43 subjects had no history of FTT and served as Controls. IQs were obtained with the abbreviated WISC-III, and the Controls were split into two groups, LO IQ and HI IQ, to provide a LO IQ Control group with an average IQ equivalent to the FTT group. Event-related brain potentials (ERPs) were recorded from five scalp locations during a cued continuous performance task (CPT). Subjects had to press a button every time they saw the letter "X" following the letter "A" (50 targets out of 400 stimuli). During the CPT, the FTT subjects made marginally more errors of omission to targets than the LO IQ Control group and significantly more errors of omission than the HI IQ Control subjects. The groups did not differ significantly on errors of commission (false alarms) or reaction times to targets. ERP averages revealed a group difference in amplitude in a late slow wave for the 50 non-X stimuli (false targets) that followed the letter A. This difference was greatest over frontal sites, where the FTT group had a more negative going slow wave than each control group. Late frontal negativity to No Go stimuli has been linked with post-decisional processing, notably in young children. Thus, the FTT subjects may have less efficient inhibitory processes, reflected by additional late frontal activation.

Is infant-directed speech prosody a result of the vocal expression of emotion?

Many studies have found that infant-directed (ID) speech has higher pitch, has more exaggerated pitch contours, has a larger pitch range, has a slower tempo, and is more rhythmic than typical adult-directed (AD) speech. We show that the ID speech style reflects free vocal expression of emotion to infants, in comparison with more inhibited expression of emotion in typical AD speech. When AD speech does express emotion, the same acoustic features are used as in ID speech. We recorded ID and AD samples of speech expressing love-comfort, fear, and surprise. The emotions were equally discriminable in the ID and AD samples. Acoustic analyses showed few differences between the ID and AD samples, but robust differences across the emotions. We conclude that ID prosody itself is not special. What is special is the widespread expression of emotion to infants in comparison with the more inhibited expression of emotion in typical adult interactions.

Failure-to-thrive, maltreatment and the behavior and development of 6-year-old children from low-income, urban families: a cumulative risk model

OBJECTIVE

A cumulative risk model was used to examine the relationship among failure-to-thrive (FTT), maltreatment, and four aspects of children's development: cognitive performance (standardized testing), adaptive functioning at school, and classroom behavior (teacher report), and behavior at home (maternal report).

METHOD

The sample included 193 6-year-old children and their families, recruited from pediatric clinics serving inner-city, low-income, primarily African-American families, who were part of a longitudinal investigation of child development and maltreatment. Four risk groups were formed based on their growth and maltreatment history: neither FTT nor Maltreatment, FTT Only, Maltreatment Only, and both FTT and Maltreatment. FTT was defined as a deceleration in weight gain (weight-for-age below the 5th percentile) prior to 25 months of age among children born at term with birth weight appropriate for gestational age. Maltreatment was defined as having at least one report to CPS for neglect, physical abuse and/or sexual abuse.

RESULTS

Risk status was negatively associated with each of the four developmental outcomes. Children with a history of both FTT and maltreatment had more behavior problems and worse cognitive performance and school functioning than children with neither risk factor. Children with only one risk factor (either FTT or maltreatment) achieved intermediate scores.

CONCLUSIONS

Findings support a cumulative risk model as being more detrimental to children's development than the presence of a single risk factor alone, consistent with theories linking the accumulation of environmental risks to negative consequences. These results underscore the importance of interventions to prevent both FTT and maltreatment during children's early years.

Failure to thrive in a population context: two contrasting studies of feeding and nutritional status

Although failure to thrive (FTT) is generally thought to be a nutritional problem, dietary intake in children with FTT has been little researched. We describe two community-based studies of dietary intake and eating behaviour in FTT. The first study of ninety-seven children with FTT identified by population screening found that only a minority of case children were associated with neglect, organic illness or deprivation, even though dietary information suggested an underlying nutritional cause in the majority. Limited case-control data suggested significantly delayed weaning and less liking for food in general among the case children. The second study found diminished appetite, delayed progression onto solid foods and fewer foods eaten by forty-four children referred with FTT compared with forty-five controls, but was unable to detect a significant difference in energy intake, even allowing for varying body composition and other confounding variables. This study also revealed the bias introduced by recruiting case children by referral rather than screening, and that despite rigorous matching procedures the controls were not representative of the general population. These studies suggest a wide range of differences in eating behaviour and feeding patterns between children with FTT and controls, but suggest that measurements of nutrient totals may not be robust. Studies of FTT based on referred children can be misleading, as can comparison with controls, unless allowance can be made for important confounding social variables.

A randomised controlled trial of specialist health visitor intervention for failure to thrive

AIMS

To determine whether home intervention by a specialist health visitor affects the outcome of children with failure to thrive.

METHODS

Children referred for failure to thrive were randomised to receive conventional care, or conventional care and additional specialist home visiting for 12 months. Outcomes measured were growth, diet, use of health care resources, and Bayley, HAD (hospital anxiety and depression), and behavioural scales.

RESULTS

Eighty three children, aged 4-30 months, were enrolled, 42 received specialist health visitor intervention. Children in both groups showed good weight gain (mean (SD) increase in weight SD score for the specialist health visitor intervention group 0.59 (0.63) v 0.42 (0.62) for the control group). Children < 12 months in the intervention group showed a higher mean (SD) increase in weight SD score than the control group (0.82 (0.86) v 0.42 (0.79)). Both groups improved in developmental score and energy intake. No significant differences were found for the primary outcome measures, but controls had significantly more dietary referrals, social service involvement, and hospital admissions, and were less compliant with appointments.

CONCLUSIONS

The study failed to show that specialist health visitor intervention conferred additional benefits for the child. However, the specialist health visitor did provide a more coordinated approach, with significant savings in terms of health service use. Problems inherent to health service research are discussed.

Effect of community based management in failure to thrive: randomised controlled trial

OBJECTIVE

To evaluate the effectiveness of a health visitor led intervention for failure to thrive in children under 2 years old.

DESIGN

Controlled trial, randomised by primary care practice.

SETTING

Newcastle upon Tyne health district.

INTERVENTION

Structured health visitor management, with dietetic, paediatric, and social work input as required.

SUBJECTS

229 children (120 in intervention practices and 109 in control practices) were identified as failing to thrive by population screening during the first 2 years of life. Follow up was by home visit of a research nurse and review of the childrens' records at age 3 years.

MAIN OUTCOME MEASURES

Follow up weight and height and number of routinely collected weights.

RESULTS

95 of the 97 families offered intervention completed at least the initial assessment. At follow up, 187 (82%) records were reviewed, and these suggested that 15 (16%) controls were lost to follow up immediately after the screening weight was taken compared with only one child in the intervention group. In the 134 (58%) families who consented to home visits, children in the intervention group were significantly heavier and taller and were reported to have better appetites than childen in the control group, although both groups were equally satisfied by the services they had received. When the children were last weighed, 91 (76%) in the intervention group had recovered from their failure to thrive compared with 60 (55%) in the control group (P<0.001).

CONCLUSION

In failure to thrive, health visitor intervention, with limited specialist support, can significantly improve growth compared with conventional management.

Management of pediatric dysphagia

Decisions for management of feeding and swallowing problems in infants and children are likely to be most effective in a professional team approach with caregivers. Optimal management relies on optimal assessment. This article focuses on management strategies that involve "food rules," the position and posture changes, alterations in food and liquid attributes, oral-motor and swallow function, utensil changes, adjustments in feeding schedules and pacing, and behavioral intervention with failure to thrive in the context of global issues for children who are oral and nonoral feeders.

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.

The cumulative effect of neglect and failure to thrive on cognitive functioning

OBJECTIVE

A cumulative risk model was used to examine the relationship among neglect, failure to thrive (FTT), and cognitive functioning in low income children.

METHOD

A sample of 177 children 3 to 30 months old was recruited from a pediatric clinic serving low-income, primarily African American families. Four groups were formed based on neglect and FTT status: Neglect and FTT, Neglect Only, FTT Only, and No Neglect or FTT. FTT was defined as weight-for-age below the 5th percentile on growth charts. To avoid the biases associated with Child Protective Service reports as definitions of neglect, the HOME scale (Caldwell & Bradley, 1984) was used to define neglect.

RESULTS

The cognitive performance of the group with neglect and FTT was significantly below that of the children in the Neglect Only, FTT Only, and No Neglect or FTT groups.

CONCLUSIONS

These findings support a model in which the accumulation of risk factors is detrimental to cognitive functioning. The results also underscore the need for thorough evaluation when one risk factor has been identified. Growth failure may come to the attention of medical personnel, but neglect may not be detected. However, a child experiencing both neglect and FTT may be at risk for significant deficits in cognitive functioning.

Grandmother co-residence, parenting, and child development among low income, urban teen mothers

PURPOSE

To examine the relationships among grandmother co-residence, parenting, and early child development among low income, urban families with teen mothers whose children vary in growth (adequate versus failure to thrive [FTT]).

METHODS

Seventy-nine adolescent mothers of infants and toddlers (42 with adequate growth and 37 with FTT) recruited from a primary care clinic. Data collected during a laboratory evaluation included a videotaped session of mother and child during feeding, developmental assessment (Bayley Scales), and questionnaires on family support, perceived parenting stress, and maternal perception of child's temperament.

ANALYSIS

Multivariate analyses of covariance. Independent variables were growth (adequate/FTT) and grandmother co-residence (present/absent). Dependent variables were maternal warmth during feeding, maternal perception of child's temperament, child's mealtime behavior, and child's cognitive and motor development. Covariates were child's age, maternal age, maternal education, parity, family support, and perceived stress.

RESULTS

Teen mothers living with grandmothers were younger (mean age = 17.4 versus 18.6, p = .03) and had fewer children (mean parity = 1.2 versus 1.7, p = .001). Mothers displayed more warmth when not living with grandmothers (p = .01). Among adequately growing children, grandmother co-residence was associated with better motor skills (106 versus 98, p = .039). In contrast, among children with FTT, grandmother co-residence was associated with lower motor skills (90 versus 100, p = .017).

CONCLUSIONS

Although multigenerational families may be protective for some teen parents and their young children, grandmother co-residence was not associated with maternal warmth. With the added stress of a poorly growing child, grandmother co-residence was associated with less optimal motor development.

Nonorganic failure to thrive: developmental outcomes and psychosocial assessment and intervention issues

Serious growth problems, such as Nonorganic Failure to Thrive (NFTT), place an infant/toddler at significant risk for poor developmental outcomes. Evidently, an NFTT child's malnutrition and subsequent poor growth and development are accentuated by a family context of impoverishment, dysfunctional relationships, inadequate education, and a dearth of developmentally enriching experiences. The purpose of this review is to describe NFTT, to present development outcomes, and to discuss psychosocial assessment and intervention issues relevant to this developmental disability of early childhood. An ideographic approach to case conceptualization, evaluation, and treatment is suggested to achieve successful developmental outcomes and to guide research endeavors.

Effect of deprivation on weight gain in infancy

Weights were retrieved from child health records for an annual cohort of 3418 children, aged 18-30 months, to explore the relationship between deprivation and weight gain. Their level of deprivation was classified, using census data for their area of residence, as affluent (11%), intermediate (69%) or deprived (20%). Children from deprived areas were smaller at all ages with a widening gap: by one year of age, they were three times as likely as affluent children to be below the third centile for weight. The thrive index, a measure of the degree of centile shift, showed a slight gain over the first year in affluent and intermediate children, while in deprived children it decreased (p = 0.001). Deprived children were 2.2 times more likely than intermediate children to have failure to thrive, as manifest by subnormal thrive index values (p = 0.00008). Unexpectedly, children from affluent areas also showed slightly increased rates. We suggest that this may be explained by higher rates of breast feeding in affluent areas.