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

Evaluation and Management of Pediatric Feeding Disorder

Feeding disorders are increasingly common in children, especially as medical advancements improve the life expectancy of children born with prematurity and complex medical conditions. The most common symptoms include malnutrition, refusal to eat and drink, food pocketing, disruptive feeding behavior, slow feeding, food selectivity or rigid food preferences, limited appetite, and delayed feeding milestones. A unifying diagnostic definition of pediatric feeding disorder has been proposed by a panel of experts to improve the quality of health care and advance research. Referral to specialized care should be considered when feeding problems are complex or difficult to resolve. In this review, we provide an overview of the evaluation and management of pediatric feeding disorders and information that may be useful when considering whether referral to specialized care may be beneficial.

How much do preverbal children signal a wish to be fed? Nested case control study comparing weight faltering and healthy infants

We aimed to 1/develop an observational tool to rate non-verbal cues infants give when being fed 2/test whether these differ between healthy children and those with weight faltering (WF) 3/describe how well these predict whether offered food is eaten.

SUBJECTS

and methods: The study used videos of infants eating a standardised meal studied in a case control study nested within the Gateshead Millennium Study (GMS). Infants with weight faltering (WF) were each matched to 2 healthy controls. Half the control videos (N = 28) were used to develop the scale. Food offers were identified and the child's head, eyes, hands, and mouth position/activity rated as signalling a readiness to be fed (engaged), or not (disengaged) as well as whether food was accepted; 5 of these videos were used to assess inter-rater and test-re- test reliability. The scale was then applied to the videos of 28 WF infants (mean age 15.3 months) and 29 remaining controls (mean age 15.8 months) to identify and code all feeding events.

RESULTS

test-re-test rates varied from 0.89 for events to 0.74 for head; inter-rater reliability varied from 0.78 for hands to 0.67 for mouth. From 2219 observed interactions, 48% showed at least one engaged element, and 73% at least one disengaged; 67% of interactions resulted in food eaten, with no difference between WF and control. Food was eaten after 73% interactions with any engagement, but also in 62% with disengagement.

CONCLUSIONS

Infants were commonly disengaged during meals, but a majority accepted food despite this. Those with weight faltering did not differ compared to healthy controls.

Tongue protrusions modify the syntax of skilled reaching for food by the mouse: Evidence for flexibility in action selection and shared hand/mouth central modulation of action

Skilled reaching for food by the laboratory mouse has the appearance of an action pattern with a distinctive syntax in which ten submovements occur in an orderly sequence. A mouse locates the food by Sniffing, Lifts, Aims, Advances, and Shapes the hand to Pronate it over a food target that it Grasps, Retracts, and Withdraws to Release to its mouth for eating. The structure of the individual actions in the chain are useful for the study of the mouse motor system and contribute to the use of the mouse as a model of human neurological conditions. The present study describes tongue protrusions that modify the syntax of reaching by occurring at the point of the reaching action at which the hand is at the Aim position. Tongue protrusions were not related to reaching success and were not influenced by training. Tongue protrusions were more likely to occur in the presence of a food target than with reaches made when food was absent. There were vast individual differences; some mice always make tongue protrusions while other mice never make tongue protrusions. That the syntax of reaching can be altered by the insertion of a surrogate (co-occurring) movement adds to a growing body of evidence that skilled reaching is assembled from a number of relatively independent actions, each with its own sensorimotor control that are subject to central modulation. That tongue and hand reaching movements can co-occur suggests a privileged relation between neural mechanisms that control movements of the tongue and hand.

The Eating and Drinking Ability Classification System in a population-based sample of preschool children with cerebral palsy

AIM

To determine (1) the reproducibility of the Eating and Drinking Ability Classification System (EDACS); (2) EDACS classification distribution in a population-based cohort with cerebral palsy (CP); and (3) the relationships between the EDACS and clinical mealtime assessment, other classifications, and health outcomes.

METHOD

This was a cross-sectional population-based cohort study of 170 children with CP at 3 years to 5 years (mean 57.6mo, standard deviation [SD] 8.3mo; 105 males, n=65 females). Functional abilities were representative of a population sample (Gross Motor Function Classification System level I=74, II=34, III=21, IV=18, V=23). The EDACS was the primary classification of mealtime function. The Dysphagia Disorders Survey was the clinical mealtime assessment. Gross motor function was classified using the Gross Motor Function Classification System.

RESULTS

EDACS classification had 88.3% intrarater agreement (κ=0.84, intraclass correlation coefficient=0.95; p<0.001) and 51.7% interrater agreement (κ=0.36, intraclass correlation coefficient=0.79; p<0.001). In total, 56.5% of children were classified as EDACS level I. There was a strong stepwise relationship between the Dysphagia Disorders Survey and EDACS (r=0.96, p<0.001). Parental stress (odds ratio=1.3, p=0.05) and feeding tubes (odds ratio=6.4, p<0.001) were significantly related to more limited function on the EDACS.

INTERPRETATION

The EDACS presents a viable adjunct to clinical assessment of feeding skills in children with CP for use in surveillance trials and clinical practice. A rating addendum would be a useful contribution to the tool to enhance reproducibility.

Endocannabinoids and Food Intake: Newborn Suckling and Appetite Regulation in Adulthood

The appetite-stimulating effects of the cannabis plant (Cannabis sativa) have been known since ancient times, and appear to be effected through the incentive and rewarding properties of foods. Investigations into the biological basis of the multiple effects of cannabis have yielded important breakthroughs in recent years: the discovery of two cannabinoid receptors in brain and peripheral organ systems, and endogenous ligands (endocannabinoids) for these receptors. These advances have greatly increased our understanding of how appetite is regulated through these endocannabinoid receptor systems. The presence of endocannabinoids in the developing brain and in maternal milk have led to evidence for a critical role for CB, receptors in oral motor control of suckling during neonatal development. The endocannabinoids appear to regulate energy balance and food intake at four functional levels within the brain and periphery: (i) limbic system (for hedonic evaluation of foods), (ii) hypothalamus and hindbrain (integrative functions), (iii) intestinal system, and (iv) adipose tissue. At each of these levels, the endocannabinoid system interacts with a number of better known molecules involved in appetite and weight regulation, including leptin, ghrelin, and the melanocortins. Therapeutically, appetite stimulation by cannabinoids has been studied for several decades, particularly in relation to cachexia and malnutrition associated with cancer, acquired immunodeficiency syndrome, or anorexia nervosa. The recent advances in cannabinoid pharmacology may lead to improved treatments for these conditions or, conversely, for combating excessive appetite and body weight, such as CB, receptor antagonists as antiobesity medications. In conclusion, the exciting progress in the understanding of how the endocannabinoid CB receptor systems influence appetite and body weight is stimulating the development of therapeutic orexigenic and anorectic agents. Furthermore, the role of cannabinoid CB, receptor activation for milk suckling in newborns may open new doors toward understanding nonorganic failure-to-thrive in infants, who display growth failure without known organic cause.

Clinical Characteristics of 2 Groups of Children With Feeding Difficulties

OBJECTIVES

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

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.

Feeding difficulties in children with food protein-induced gastrointestinal allergies

BACKGROUND AND AIM

There is paucity of data on the prevalence of feeding difficulties in Food Protein-Induced Gastrointestinal Allergies (FPIGA) and their clinical characteristics. However, it is a commonly reported problem by clinicians. We set out to establish the occurrence of feeding difficulties in children with FPIGA, the association with gastrointestinal and extra-intestinal symptoms and number of foods eliminated from the diet.

METHODS

This retrospective observational analysis was performed in patients seen between 2002 and 2009 at Great Ormond Street Children's Hospital, Gastroenterology Department, London. Medical records where FPIGA was documented using the terms from the National Institute of Allergy and Infectious Disease and National Institute of Clinical Excellence and confirmed using an elimination diet, followed by a challenge were included. Feeding difficulties were assessed using a criteria previously used in healthy toddlers in the UK.

RESULTS

Data from 437 children (203 female) were collected. Significantly more children with feeding difficulties presented with abdominal distention and bloating (P = 0.002), vomiting (P < 0.0001), weight loss (P < 0.0001), rectal bleeding (P = 0.025), and constipation (P < 0.0001). We also found that having extra-intestinal manifestations were significantly (P < 0.0001) associated with the presence of feeding difficulties. Additionally, a significantly higher number of foods eliminated from the diet in the children with/without feeding difficulties (P = 0.028).

CONCLUSIONS

Clinical manifestations like vomiting, constipation, rectal bleeding, weight loss, and the presence of extra-intestinal manifestations in addition to the number of foods avoided are in our FPIGA population linked to feeding difficulties.

A systematic review of ordinal scales used to classify the eating and drinking abilities of individuals with cerebral palsy

AIM

The aim of this review was to examine systematically the scope, validity, and reliability of ordinal scales used to classify the eating and drinking ability of people with cerebral palsy (CP).

METHOD

Six electronic databases were searched to identify measures used to classify eating and drinking ability; in addition, two databases were used to track citations of key texts. The constructs assessed by each measure were examined in relation to the World Health Organization International Classification of Functioning, Disability and Health. Evidence of validity and reliability of the identified scales was appraised from peer-reviewed studies using standard criteria.

RESULTS

Fifteen scales were identified in 23 papers. Clinician or researcher assessment was required for 13 scales; nine scales made use of information from parents and carers through interviews or questionnaires. Eight scales used the terms mild, moderate, and severe (with varying definitions) to describe different aspects of eating and drinking impairment. There was an assessment of either content validity and/or reliability for five scales; however, none met the recommended psychometric quality standards.

INTERPRETATION

Currently, there is a lack of evidence of the validity and reliability of ordinal scales of functional eating and drinking abilities of people with CP.

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.

Feeding and gastrointestinal problems in children with cerebral palsy

The aim of our study was to identify feeding and gastrointestinal system (GIS) problems in children with cerebral palsy (CP), and to evaluate the relationship between these problems and the severity of CP. A total of 120 children with CP were enrolled consecutively into the study (67 males, 53 females; mean age: 6.0±2.4 years; range: 2-12 years). The children were classified according to the Swedish classification as diplegic, hemiplegic, or quadriplegic. Severity of CP was classified based on the Gross Motor Function Classification System. The amount of time that the caregiver allocated to mealtimes, modifications of the food, as well as feeding and GIS problems was evaluated. Feeding dysfunction was classified as mild, moderate, or severe. Comparisons of GIS and feeding disorders and the severity of CP were carried out using χ test. The results indicated lack of appetite in 46 of the 120 children (38.3%), sialorrhea in 37 (30.8%), constipation in 30 (25%), difficulty in swallowing in 23 (19.2%), and feeding dysfunction in 26 (21.7%). On the basis of the Gross Motor Function Classification System (GMFCS), the incidence of GIS problems and feeding dysfunction was found to be significantly higher in the children classified in the severe group. The time taken to consume meals was significantly longer among children with feeding dysfunction. Feeding and GIS problems are frequent in children with CP, and more marked in those with severe CP. Approximately one fourth of children with CP suffer from feeding dysfunction, and more time has to be allocated to consume meals.

Feeding and sleeping problems in infancy--a follow-up at early school age

BACKGROUND

Feeding and sleeping problems are common during infancy. Many regulatory problems of this kind are connected to various child and family factors. This study is a follow-up of children with early feeding and/or sleeping problems, 6 years after clinical contacts.

METHODS

A total of 230 families (72%) participated in the questionnaire follow-up. Children and parents were compared with 227 (71%) reference families regarding sleeping and feeding problems, health factors in parent and child, psychosocial problems, stressful life events, social support, life satisfaction, and externalizing and internalizing behaviour in the child.

RESULTS

Six years after clinical contacts the children with early feeding and/or sleeping problems still had more problems of this kind compared with the reference children. Early child health problems were more frequent within the clinical group, but recent health problems did not separate the two groups. Mothers in the clinical sample reported more health problems than mothers in the reference group and clinical parents were less content with their social support and had more psychosocial problems, including stressful life events. Children in the clinical sample had more internalizing problems than comparison children. Recent feeding and sleeping problems were connected to more externalizing and internalizing problems.

CONCLUSIONS

  Early regulatory problems, concerning sleeping or feeding, are less frequent when the child grows up, but nevertheless tend to remain. A clinical recommendation for child health care is to take both child and family factors into account, to individualize contacts, work with an all-inclusive perspective and have close follow-ups.

Identifying clinically relevant feeding problems and disorders

This paper outlines what is currently understood, and what can be hypothesized about paediatric feeding dysfunctions. The paper highlights the current lack of awareness of psychological factors implicated in infant and child feeding, and promotes a behavioural approach to the identification, referral and treatment of non-organic derived feeding problems and disorders. Potential risk factors to poor feeding development are outlined, and characteristic child and caregiver behaviours which may signify problems with feeding are suggested. The aim of this paper is to promote early identification of these symptoms in frontline healthcare in the hope of increasing early intervention before physical complaints, medical complications and/or disorders arise.

Risk factors for weight faltering in infancy according to age at onset

The aim of this study was to identify risk factors for failure to thrive (FTT) or weight faltering according to age of onset. The study is part of a Danish longitudinal population study of early risk mechanisms in child psychiatric disorders, The Copenhagen Child Cohort, which consists of a birth cohort of 6090 children born during the year 2000 and followed prospectively from birth. Weight faltering/FTT was defined as slow conditional weight gain, and divided into subtypes according to age of onset in the first year of life: birth to 2 weeks, 2 weeks to 4 months, and 4-8 months. Regardless of the age of onset, slow weight gain was found to be strongly associated with feeding problems, but the risk factors involved differed according to age of onset. Thus, onset within the first weeks of life clearly differed from faltering later on, the former being strongly associated with low birthweight and gestational age, with single parenthood and with mother having smoked during pregnancy. Onset between 2 weeks and 4 months was associated with congenital disorders and serious somatic illness, and with deviant mother-child relationship, whereas, onset between 4 and 8 months seemed to represent a group of children with feeding problems arising de novo in otherwise healthy children. In conclusion, weight faltering in infancy is clearly associated with contemporary measured feeding problems, but the risk mechanisms involved differ in early vs. late onset.

Childhood autism, feeding problems and failure to thrive in early infancy. Seven case studies

Despite longstanding clinical experience of unusual feeding difficulties in children with autism, there is no published literature describing their association with early onset FTT. This paper examines literature that may link feeding problems and abnormal growth with developmental and psychiatric conditions and describes seven cases of children with autism, who showed growth failure caused by severe feeding problems starting in the first year of life. Inadequacies in existing classifications systems are highlighted. The presence of severe or atypical feeding problems and FTT in infancy should alert professionals to possible underlying ASD. The aetiology of feeding disorders in autism appears to involve an unusually complex interactional model with biological vulnerabilities due to dysfunction in sensory, cognitive and emotional response interacting with dysfunctional attachment and learnt behaviours to produce a severe and intractable problem. Effective treatment therefore requires a novel multifaceted approach that can address each of these areas.

Inhibition of milk ingestion and growth after administration of a neutral cannabinoid CB1 receptor antagonist on the first postnatal day in the mouse

We have shown previously that neonatal exposure to the cannabinoid CB1 receptor antagonist/inverse agonist rimonabant (SR141716) interfered with suckling and development. However, it was not clear whether the developmental deficiencies were induced by neutral CB1 receptor blockade, thereby inhibiting endogenous cannabinoid "tone," or by inverse agonist reduction of constitutive CB1 receptors. CB1 receptor blockade supports our hypothesis that low CB1 receptor concentrations and/or reduced endocannabinoid levels underlie infant nonorganic failure to thrive (NOFTT). Inverse agonism implies that lower constitutive CB1 receptor activity may be responsible for impaired food intake in newborns. In the present study, we injected the neutral CB1 receptor antagonist 5-(4-chlorophenyl)-3-[(E)-2-cyclohexylethenyl]-1-(2,4-dichlorophenyl)-4-methyl-1H-pyrazole (VCHSR1) to 1-d-old mouse pups and recorded weight gain, gastric milk contents (milkbands), axillary temperature, and survival between age 1 and 10 d. The results showed a dose-related interference with all measures. These data show that (1) growth failure induced by rimonabant is generalized to another CB1 antagonist and (2) cannabinoid CB1 receptor activation by endocannabinoids is essential for normal milk ingestion and development in mice. This supports our hypothesis that endocannabinoid deficiency and perhaps CB1 receptor dysfunction represents the uncharacterized biologic vulnerability, which underlies NOFTT.

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.

Feeding outcomes of extremely premature infants after neonatal care

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

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

OBJECTIVE

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Withdrawal behavior and depression in infancy

This paper describes the history of the concept of infant depression, which has been at the beginning of the discipline of infant mental health, and reviews classification and diagnosis issues, along with some animal models. Several diagnostic criteria have yielded different prevalence rates, and some being unrealistic, but we still do not know when infant depression begins, what its outcome is, and what are its different aspects. It is suggested that infant depression needs a certain amount of emotional and cognitive development to unfold, and that it might not exist before 18-24 months of age, a crossover during which major autoreflexive, cognitive, and emotional abilities emerge. Depression could be an outcome of attachment disorganization in infancy, as depression and disorganization seem to share the same learned helpnessness psychopathological process. Developmental psychopathology considers trouble more from a dimensional point of view rather than from a categorical one, and more as the result of several factors with a sequential action rather than the effect of a genetic disorder with direct expression. Before the limit of 18-24 months, the concept of relational withdrawal seems more applicable and useful.

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.

The endocannabinoid-CB1 receptor system in pre- and postnatal life

Recent research suggests that the endogenous cannabinoids ("endocannabinoids") and their cannabinoid receptors have a major influence during pre- and postnatal development. First, high levels of the endocannaboid anandamide and cannabinoid receptors are present in the preimplantation embryo and in the uterus, while a temporary reduction of anandamide levels is essential for embryonal implantation. In women accordingly, an inverse association has been reported between fatty acid amide hydrolase (the anandamide degrading enzyme) in human lymphocytes and miscarriage. Second, CB(1) receptors display a transient presence in white matter areas of the pre- and postnatal nervous system, suggesting a role for CB(1) receptors in brain development. Third, endocannabinoids have been detected in maternal milk and activation of CB(1) receptors appears to be critical for milk sucking by newborn mice, apparently activating oral-motor musculature. Fourth, anandamide has neuroprotectant properties in the developing postnatal brain. Finally, prenatal exposure to the active constituent of marihuana (Delta(9)-tetrahydrocannabinol) or to anandamide affects prefrontal cortical functions, memory and motor and addictive behaviors, suggesting a role for the endocannabinoid CB(1) receptor system in the brain structures which control these functions. Further observations suggest that children may be less prone to psychoactive side effects of Delta(9)-tetrahydrocannabinol or endocannabinoids than adults. The medical implications of these novel developments are far reaching and suggest a promising future for cannabinoids in pediatric medicine for conditions including "non-organic failure-to-thrive" and cystic fibrosis.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

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.

Behavior patterns associated with institutional deprivation: a study of children adopted from Romania

This study examined the prevalence and persistence of behaviors associated with institutional rearing in a sample of 144 children from Romania adopted by UK families. Patterns of rocking, self-injury, unusual sensory interests, and eating problems were assessed in children aged between a few weeks and 43 months who were adopted from institutional care. Forty-seven percent of the institutionally reared children rocked at the time of UK entry and 24% engaged in self-injurious behavior. By age 6 years, the percentages were 18% and 13%, respectively. Eleven percent of the children were displaying unusual sensory interests at the time of arrival, and at 6 years 13% of the children did so. Fifteen percent of the children were still experiencing difficulties with chewing and swallowing solid food at age 6 years. The primary factor affecting the prevalence and persistence of the behaviors was the length of time the children had spent in institutional deprivation.

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.

Feeding dysfunction is associated with poor growth and health status in children with cerebral palsy

OBJECTIVE

To describe parent-reported feeding dysfunction and its association with health and nutritional status in children with cerebral palsy.

DESIGN

Anthropometry was measured and z scores calculated. The Child Health Questionnaire was used to assess health status, and a categorical scale (none to severe) was used to classify subjects according to severity of feeding dysfunction.

SUBJECTS

230 children (9.7+/-4.6 years; 59% boys) with moderate to severe cerebral palsy were recruited from 6 centers in the United States and Canada.

STATISTICAL ANALYSES

Descriptive statistics, the Kruskal-Wallis and Pearson chi2 tests.

RESULTS

Severity of feeding dysfunction was strongly associated with indicators of poor health and nutritional status. The mean weight z scores were -1.7, -2.5, -3.3, and -1.8 among children with none, mild, moderate, or severe (largely tube-fed) feeding dysfunction, respectively (P= .003). Similar results were observed for height z score (P=.008), triceps z score (P=.03), and poor Global Health score (part of the Child Health Questionnaire) (P<.001). Subjects who were tube fed were taller (P=.014) and had greater body fat stores (triceps z score, P=.001) than orally fed subjects with similar motor impairment. For subjects exclusively fed by mouth, a dose-response relationship was observed between feeding dysfunction severity and poor nutritional status. Subjects with only mild feeding dysfunction had reduced triceps z score (-0.9) compared with those with no feeding problems (-0.3).

CONCLUSION

For children with moderate to severe cerebral palsy, feeding dysfunction is a common problem associated with poor health and nutritional status. Even children with only mild feeding dysfunction, requiring chopped or mashed foods, may be at risk for poor nutritional status. Parental report of feeding dysfunction with a structured questionnaire may be useful in screening children for nutritional risk.

Feeding disorders in infants and children

Feeding disorders are common in infants and children. Multiple interacting behavioral, anatomic, and functional factors all can impact on the feeding process, making the evaluation and treatment of pediatric disorders complex and challenging. Knowledge of the normal process of feeding and swallowing, a careful history, observation of the patient during a feeding session, and selected tests usually provide an understanding of the underlying cause of feeding difficulties. Treatment of underlying pathology and careful balancing of the risks and benefits of oral feeding underlie the selection of an optimal management strategy.

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.

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.

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

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

Feeding problems in infants with gastro-oesophageal reflux disease: a controlled study

OBJECTIVE

Gastro-oesophageal reflux disease (GORD) in infants is commonly associated with feeding problems but has not been subject to systematic controlled study. We evaluated feeding, dietary, behavioural data obtained from systematic objective studies of six-month old infants with and without GORD.

METHODS

Infants with GORD (defined by 24-h pH monitoring, n = 20), and age, gender, gestation, and socio-economic matched healthy infants (n = 20) had standardised assessments of dietary intake, oromotor function by videoanalysis (Feeding Assessment Schedule, FAS), and infant feeding behaviour by Testers and Maternal Ratings (TRIB and MRIB). Videofluoroscopic analyses of swallowing was undertaken in 11/20 GORD infants and analysed by standardised paediatric check list.

RESULTS

Compared with control data: GORD infants had significantly lower energy intakes; the FAS showed GORD infants to have significantly fewer adaptive skills and readiness behaviour for solids, significantly more food refusal and food loss; the TRIB showed GORD infants to be significantly more demanding and difficult with feeds; and the MRIB revealed that mothers of GORD infants had significantly more negative feelings, significantly less enjoyment of feeds, and reported significantly more crying behaviour. On videofluoroscopy, oral-preparatory and oral phase problems predominated, particularly with solids, silent aspiration occurred during the pharyngeal phase in 2/11, and delayed oesophageal transit occurred in 4/11.

CONCLUSIONS

Feeding problems affecting behaviour, swallowing, food intake, and mother-child interaction occur in infants with GORD, who displayed a lack of development of age-appropriate feeding skills. The contribution of feeding problems to morbidity in GORD in infants has been underestimated in the past.

Ergebnisse der Bayerischen Entwicklungsstudie

Zusammenfassung. Die Bayerische Entwicklungsstudie untersuchte die Entwicklung von Kindern, die innerhalb der ersten zehn Lebenstage in eine Kinderklinik in Südbayern aufgenomen wurden zu fünf Zeitpunkten während der ersten neun Lebensjahre. Dazu gehörten sehr Frühgeborene < 32 Tragzeitwochen, neonatale Risikokinder > 31 Tragzeitwochen und reifgeborene Kontrollkinder. Sehr Frühgeborene hatten mehr als zehnmal häufiger kognitive Defizite als reifgeborene Kontrollen und besondere Probleme bei der ganzheitlichen Informationsverarbeitung. Oft waren mehrere Funktionsbereiche gleichzeitig betroffen (IQ, Lesen, Schreiben, Rechnen, Sprache). Es traten häufiger Aufmerksamkeitsprobleme auf und 22% der sehr Frühgeborenen besuchten eine Sonderschule. Auch die größeren Hoch-Risikokinder hatten häufiger kognitive Probleme. Dieses Defizit wurde jedoch ab dem dritten Lebensjahr besser durch soziale als durch biologische Faktoren erklärt. Im Gegensatz dazu waren protektive Faktoren für die Entwicklung der sehr Frühgeborenen geringe neonatale Komplikationen, geringere Intensität der Versorgung und frühes Kopfaufholwachstum. Die Probleme sehr früher Geburt sind langfristig und bei anhaltenden Defiziten wahrscheinlich hirnorganischer Natur. Interventionen zur Vermeidung sekundärer Schäden sollten vor der Entlassung aus der Klinik einsetzen. Größere Frühgeborene (> 31 Tragzeitwochen) profitieren am meisten von psycho-pädagogischen Maßnahmen in der frühen Kindheit.

A stepwise approach to evaluation of undernutrition and failure to thrive

The primary care physician is key to evaluating children who are undernourished or failing to thrive. The comprehensive stepwise approach to evaluation is simple and effective. Positive outcomes can be expected.

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.

Oral-motor dysfunction and feeding problems in infants with myelodysplasia

Oral motor function and feeding problems have received little attention in infants with myelomeningocele (MMC). We compared objective video assessments of oral motor skills, diet and feeding function of 20 infants (aged 6 months) with MMC, with data from 20, age, gender, and socioeconomically matched healthy infants using the Feeding Assessment Schedule (FAS), Feeding Environment Check (FEC), Tester's Ratings of Infant Behaviour (TRIB), an Infant Feeding Questionnaire (IFQ), and a 24 hour dietary analysis (DQA). MMC infants had significant feeding difficulty, related to sensory motor integration problems such as hypotonicity, positioning, and hand function. Despite these problems, there was minimal behavioural disruption in infants with MMC and their mothers experienced no marked food aversion or negative feeding experiences. MMC infants consumed feedings which were significantly lower in energy than controls, with possible imbalance of other nutrients. These studies indicate that compared with healthy infants MMC infants have significantly altered oral motor function which we speculate could be early features of the Chiari II malformation. The dietary changes may reflect altered energy requirement. Early identification and management of feeding problems associated with this condition is emphasized.

An exploration of feeding difficulties in children with Down syndrome

Detailed examination of several aspects of feeding was carried out on a representative sample of a defined geographical population of children with Down syndrome. The examination included standardised assessments both of oral-motor function and of parent-child interaction. The findings suggest that the development of oral-motor function in children with Down syndrome not only lags behind intellectual development, but also follows an aberrant pathway. In particular, specific aspects of tongue and jaw function were impaired together with problems initiating and maintaining a smooth sequence of feeding actions. Also, parent-child interactions, as in studies on play, tended to be more controlling. Parents of children with Down syndrome do not spontaneously report the extent of their child's feeding problems unless specific enquiry is made, preferably accompanied by observation of feeding.

Neonatal sucking and maternal feeding practices

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