The process of parenting in failure to thrive

A quantitative psychometric evaluation of an intervention for poor dietary variety in children with a feeding problem of clinical significance

Few studies have been published that offer a quantitative evaluation of interventions for feeding problems of clinical significance. Twenty-four children referred to the service for clinically significant feeding problems were administered the Behavioral Pediatric Feeding Assessment Scale (BPFAS; W. Crist & A. Napier-Phillips, 2001) and the Child Feeding Assessment Questionnaire (CFAQ; G. Harris & I.W. Booth, 1992) before and after a duel targeted 16-week therapeutic intervention to improve dietary variety. Dietary variety was assessed through a food diary where only items that were accepted on more than one occasion were deemed to be part of the child's habitual diet. Results indicated that all subscales of the BPFAS and the CFAQ were responsive to the intervention, with scores falling from those of clinical significance to those more representative of non-feeding-problem children. Regression analysis indicated that children's problem scores on the BPFAS predicted 15% of the variance in increased dietary variety following the intervention. The outcome of this evaluation indicated that improving dietary variety in children with clinically significant feeding problems is challenging. With the right approach, however, large improvements can be observed relatively quickly.

Early growth faltering in healthy term infants predicts longitudinal growth

BACKGROUND

Early growth monitoring may not identify infants at-risk for later growth faltering because it is difficult for the provider to recognize how large of a negative shift might be problematic.

AIM

The aim of this study was to determine whether a slowing in early weight-for-age could be used to identify children at increased risk of later growth faltering.

METHODS

Longitudinal data for infants aged birth to two years were analyzed for 1978 healthy, term infants born between 1999-2001. Logistic regression techniques were used to determine whether a negative change in weight-for-age, across well-child visit intervals, can identify infants at risk for growth faltering.

RESULTS

The period prevalence of underweight was 24%. The odds ratio (OR) for infants with a negative shift in z-scores>or=-0.85 between four and six months was 2.4 (95% CI 1.5, 3.9) compared to those without this shift, holding birth weight constant. Sensitivity analyses revealed that the model was significant when either the 2000 CDC growth charts (p<0.0001) or the 2006 WHO growth charts (p<0.0001) were used as the reference, although the prevalence of underweight was lower (14.7%) when the 2006 WHO growth charts were the reference.

CONCLUSION

The findings support the hypothesis that a downward shift in weight-for-age of this magnitude during early infancy when well-child visits are most frequent can be used to identify children at risk of later poor growth.

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

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

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.

Maternal core beliefs and children's feeding problems

BACKGROUND

Although maternal mental health problems have been implicated in the exacerbation of childhood feeding difficulties, little research has assessed the contribution of broader maternal cognitions to these problems. The current study examined gender differences in the relationships between mothers' core beliefs and children's feeding problems.

METHODS

One hundred and three mothers of girls and 93 mothers of boys (age range, 7-64 months) completed the Young Schema Questionnaire and the Child Feeding Assessment Questionnaire.

RESULTS

While controlling for child age, a clear link between maternal core beliefs and perceived feeding difficulties emerged for mothers of girls. In particular, abandonment, failure to achieve, dependence and incompetence, enmeshment and defectiveness, and shame beliefs were associated with increased reports of feeding problems in girls. In contrast, emotional deprivation and subjugation beliefs were associated with maternal reports of food fussiness and food refusal in boys.

CONCLUSIONS

There appears to be a clear role for maternal core beliefs in the reporting of feeding difficulties in children, and the specificity of these links differs depending on the gender of the child. Further research is required to establish the direction of causality and the specificity of these relationships.

Mothers of undernourished Jamaican children have poorer psychosocial functioning and this is associated with stimulation provided in the home

OBJECTIVES

To compare mothers of undernourished children with mothers of adequately nourished children on maternal depression, parenting self-esteem, social support and exposure to stressors and to determine if these variables are independently related to undernutrition and stimulation provided in the home after controlling for socio-economic status.

DESIGN

A case control study.

SETTING

Children and their mothers were recruited from 18 government health centres in the Kingston, St Andrew and St Catherine parishes of Jamaica.

SUBJECTS

One hundred and thirty-nine mothers of undernourished children (WAZ< or =-1.5z scores) aged 9 - 30 months and 71 mothers of adequately nourished children (WAZ > -1z scores) matched for sex and age group were enrolled into the study.

RESULTS

Mothers of undernourished children came from poorer homes but had similar social support to mothers of adequately nourished children. They were more depressed, had lower levels of parenting self-esteem (both P<0.01), reported higher levels of economic stress (P<0.001) and provided a less stimulating home environment (P<0.05). However, after controlling for social background variables there was no independent relationship between either psychosocial function or home stimulation and nutritional status. Undernutrition was found to be mainly explained by economic factors. The mothers' self-esteem was independently associated with the level of stimulation provided to the child.

CONCLUSIONS

When caring for undernourished children attention should be paid to the psychosocial status of the mother as well as the physical condition of the child.

SPONSORSHIP

Thrasher Research Fund; Campus Research and Publication Fund, UWI, Jamaica.

Psychological Treatment of Food Refusal in Young Children

Feeding and eating problems in young children are the result of a complex aetiology that often combines biological and psychological factors. The aim of this review is to describe psychological techniques of intervention used in the management of eating problems in young children that draw on a number of theoretical approaches and should be applied within a developmental framework.

Eating problems in young children

Over the past 10 years, there has been increasing recognition of the importance of eating problems in young children. Paediatricians are now also recognizing the importance of managing this problem in the context of a wide range of medical disorders. Multidisciplinary assessment and treatment is essential to manage the wide variety of childhood eating problems.

Biobehavioral characteristics of infants with failure to thrive

Failure to thrive (FTT) is a syndrome of growth failure that results in an infant who is behaviorally difficult. The current thinking is that FTT results from a problematic infant-mother interaction, with the infant making a significant contribution to the interactional process. It is possible that the behavioral characteristics of the infant with FTT may be related to underlying physiologic response patterns, specifically, activity of the autonomic nervous system. The purpose of this study is to examine the relationships among behavioral responsiveness, heart rate variability as a marker of autonomic nervous system activity, and nutritional status in infants with FTT. Infants with FTT were matched with healthy growing infants (n = 14 pairs). Results from the study indicated that infants with FTT exhibited considerably more negative behaviors and exhibited low heart rate variability. It appears that there may be a physiologic basis to the behaviors that are exhibited by infants with FTT. Prospective research is needed to further clarify this relationship.

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

PURPOSE

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

DESIGN

Comparative descriptive.

METHODS

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

RESULTS

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

CLINICAL IMPLICATIONS

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

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

AIM

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

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.

Infant growth in the context of maternal eating disorders and maternal depression: a comparative study

There is evidence of growth faltering in infants of mothers with eating disorders. The aim of the current study was to examine whether this is a specific relationship. Thus, the infants of mothers with eating disorders were compared with infants of mothers with post-natal depression and a large comparison group. This study also aimed to explore possible mechanisms whereby growth disturbance comes about. It was found that the infants of mothers with eating disorders were smaller, both in terms of weight for length and weight for age, than either comparison group infants or infants of mothers with post-natal depression. There was little evidence, however, that mothers with eating disorders preferred smaller children or were dissatisfied with their children's shape or that they misperceived their children's size. On the contrary these mothers seemed highly sensitive to their children's shape and, compared with the other two groups, were more likely to judge their children's size accurately. None of these maternal measures significantly predicted the child's growth. The mechanism whereby growth disturbance arises in the context of eating disorders does not appear to be by means of a direct extension of the maternal psychopathology to the infant.

Mother-child interaction and the cognitive and behavioural development of four-year-old children with poor growth

A whole population inner-city survey identified 23 stunted, otherwise healthy, children with persistently poor growth from infancy to 4 years. Their cognitive development was significantly retarded relative to a matched comparison group. Unstructured home observations were used to create transcripts of verbal and nonverbal mother-child interactions. In both groups child behavioural adjustment was linked to maternal negativity, and cognitive performance was correlated with quality of stimulation. The developmental delay associated with chronic failure to thrive appeared more likely to arise from other influences, perhaps a previous biological insult, than to contemporaneous parenting practices.