A community based study of failure to thrive in Israel

Eating Disorders in Infancy: Assessment and Interventions

This article aims to integrate the physical and emotional dimensions of eating problems in infancy into the assessment process and the intervention approach. We emphasize the distinction between the child's own eating pattern and the parent-child feeding relationship. We describe the classification of eating behavior disorders in infancy and provide 2 short clinical vignettes that illustrate using the DC:0 to 5 classification framework. The assessment section includes the recommended physical/medical workup. Finally, we describe 2 clinical vignettes that illustrate the integrated multidisciplinary model of intervention for eating disorders in infancy and early childhood.

Evaluating Malnutrition Practices and Mother's Education on Children Failure to Thrive Symptoms Using Entropy-Weight and TOPSIS Method

BACKGROUND/OBJECTIVES

Failure to thrive (FTT) is mostly caused by insufficient consumption of nutrient-rich food, recurrent infections like diarrhea and intestinal worms, substandard caregiving practices, and limited availability of health and other vital services. Furthermore, there was a correlation between the educational level of mothers and the occurrence of FTT in children aged 6-12 months. Thus, the objective of the current research is twofold: (i) to investigate other factors related to FTT and (ii) to evaluate the impact of them on FTT in Sub-Saharan African countries and their urban areas.

METHODS

We used weight entropy and TOPSIS methods to approach the research question. In particular, the entropy-weight method is effective for precisely evaluating the relative significance of the selected criteria for TOPSIS computation. Thus, data were retrieved from the database of UNICEF for the year 2019 for nine Sub-Saharan countries, and based on the methods used, five criteria have been selected for consideration. Those of mothers in higher education were identified as having a higher weight, which means that this can affect positively the ability of mothers to mitigate the situation of FTT and protect their children.

RESULTS

The findings of the study highlight the factors of maternal education at a higher level and unhealthy habits as those with the greatest weight and impact on the FTT. Moreover, the results indicate that the association between maternal education, and especially higher education, and FTT is stronger in Ethiopia. Despite the limited amount of research on the specified relationship in Sub-Saharan countries, this study is among the initial ones to examine it.

CONCLUSIONS

The current study can aid policymakers in devising appropriate policies and implementing effective measures to tackle FTT in Sub-Saharan Africa, like enhancing the number of mothers in these countries to be integrated into the educational system to help both themselves and their children mitigate or avoid the symptoms of FTT.

Effects of parent- and child-related behavioral feeding problems in early childhood on malnutrition

OBJECTIVE

Children's responses to food and their caregivers during normal developmental periods are known as feeding behavior. For the healthy development of these behaviors, parent and child relationships must also be healthy. Therefore, we aimed to investigate the effect of behavioral feeding problems on primary malnutrition (PM).

METHOD

The Behavioral Pediatric Nutrition Assessment Scale (BPFAS) was administered to 300 malnourished and 300 control pediatric patients aged from 9 months to 4 years who were referred to our pediatric gastroenterology outpatient clinic. Pre- and posttreatment data were compared between the two groups.

RESULTS

There was no statistically significant difference between patients with and without malnutrition in terms of gender and age (p = 0.191, p = 0.128, respectively). Total behavioral frequency (TBF) and total behavioral problem (TBP) scores were significantly higher in the malnutrition group (p < 0.001). In the logistic regression analysis of risk factors that may affect malnutrition we found that a total TBF score of ≥85 increases the risk of developing malnutrition 3.731 times, a child TBF score of ≥62 increases it 2.644 times, and a parental TBF score of ≥21 increases it 4.82 times (p < 0.001). When anthropometric measurements and BPFAS scores of 127 PM patients who received behavioral therapy with enteral products and who attended follow-up were compared with their pretreatment data, there was a significant improvement (p < 0.05).

CONCLUSION

Our study showed that behavioral feeding problems may increase the risk of PM and that behavioral therapy together with enteral products has a positive effect on treatment. Therefore, in addition to nutritional support in patients with PM, offering behavioral feeding therapy to parents will positively affect both the child's physical development and the relationship between the parents and their child.

Infancy weight faltering and childhood neurodevelopmental disorders: a general population birth-cohort study

While it is known that intrauterine growth restriction is associated with later mental disorders, it is still unclear whether similar associations exists for postnatal weight faltering, also known as 'failure to thrive' in infancy. This study examined the potential connection between infancy weight faltering and mental disorders diagnosed in childhood focusing specifically on neurodevelopmental disorders. The Copenhagen Child Cohort (CCC2000) was used to explore weight gain in infancy assessed by community health nurses. Data from the Danish national registries were used to quantify ICD-10 mental disorders diagnosed between birth and 12 years of age, as well as potential child and family confounders. Of 4.476 children with sufficient weight data, 339 (7.3%) children were diagnosed with a mental disorder in childhood. Both any (weight gain < -1SD) and severe infancy weight faltering (weight gain < -2SD) were associated with psychomotor delays, while severe infancy weight faltering was also associated with intellectual impairments. Notably, no significant associations were found between weight faltering and autism spectrum disorders or attention deficit hyperactivity disorders. Weight faltering in infancy may be an early marker of neurodevelopmental delays. This possibility should be considered when assessing infants with slow weight gain, to early identification and treatment of co-occurring neurodevelopmental disorders.

Eating and feeding behaviours in children in low-income areas in Nairobi, Kenya

Child eating and caregiver feeding behaviours are critical determinants of food intake, but they are poorly characterized in undernourished children. We aimed to describe how appetite, food refusal and force‐feeding vary between undernourished and healthy children aged 6–24 months in Nairobi and identify potential variables for use in a child eating behaviour scale for international use. This cross‐sectional study was conducted in seven clinics in low‐income areas of Nairobi. Healthy and undernourished children were quota sampled to recruit equal numbers of undernourished children (weight for age [WAZ] or weight for length [WLZ] Z scores ≤2SD) and healthy children (WAZ > 2SD). Using a structured interview schedule, questions reflecting child appetite, food refusal and caregiver feeding behaviours were rated using a 5‐point scale. Food refusal and force‐feeding variables were then combined to form scores and categorized into low, medium and high. In total, 407 child–caregiver pairs, aged median [interquartile range] 9.98 months [8.7 to 14.1], were recruited of whom 55% were undernourished. Undernourished children were less likely to ‘love food’ (undernourished 78%; healthy 90% p = < 0.001) and more likely to have high food refusal (18% vs. 3.3% p = <0.001), while their caregivers were more likely to use high force‐feeding (28% vs. 16% p = 0.03). Undernourished children in low‐income areas in Nairobi are harder to feed than healthy children, and force‐feeding is used widely. A range of discriminating variables could be used to measure child eating behaviour and assess the impact of interventions.

Sensory Processing Difficulties in Toddlers With Nonorganic Failure-to-Thrive and Feeding Problems

OBJECTIVES

Failure-to-thrive is defined as an abnormally low weight and/or height for age. The term "nonorganic failure-to-thrive" (NOFT) has been used to describe "failure-to-thrive" without an obvious cause underlying the growth failure. The purpose of the present study was to compare sensory processing abilities between toddlers with NOFT and feeding problems and age-matched controls.

METHODS

Toddlers with NOFT and feeding problems (N = 16) were recruited from the pediatric feeding clinic in a tertiary university hospital, and age-matched controls (N = 16) were recruited from community volunteers. They were evaluated for sensory processing ability using an Infant/Toddler Sensory Profile (ITSP), and for development of cognition, motor skills, and language using the Bayley Scales of Infant Development II and Sequenced Language Scale for Infants. Behavior at mealtime was evaluated using the Behavioral Pediatrics Feeding Assessment Scale.

RESULTS

In the NOFT with feeding problems group, atypical performances were more frequently observed in 3 of 5 ITSP section items (tactile, vestibular, and oral) compared with those in the control group. Significant delayed development of cognition, motor skills, and language was observed in the NOFT with feeding problems group compared with that in the control group. In addition, children who showed 1 or more atypical performances in ITSP had delayed development in cognition, motor skills, and language.

CONCLUSIONS

Sensory processing problems were more commonly observed in toddlers with feeding problems and growth deficiency. The present study could provide a preliminary evidence for a possible impact of the sensory processing problems on the feeding difficulties in toddlers with NOFT. Future large studies should be conducted to clarify the relation between sensory processing difficulties and feeding problems in toddlers.

An evaluation of factors influencing feeding in babies with a cleft palate with and without a cleft lip

The objective of this article was to determine the impact of different bottles and teats for feeding babies with a cleft palate (with and without a cleft lip) on weight velocity, feeding behaviour, and maternal self-esteem. A mixed methods study incorporating the use of diaries to record feeding patterns of babies and levels of professional support received was used. Growth was assessed by converting weights into standard deviation scores and using the differences to express weight velocity over a six-week period. Visual analogue scales were used to assess mothers' perceptions of their children and themselves. The Edinburgh Postnatal Depression Score (EPDS) was used to identify maternal depression. The study demonstrated that the most significant effect on weight was determined by cleft type. Babies with isolated clefts of the hard and soft palate experienced greater feeding problems and suffered the biggest weight losses. This remained significant independently of the type of bottle/teat used. Poor weight gain was also associated with a mother's low perception of herself and her child, and her tendency towards depression. The study highlights the importance of the early assessment of babies' feeding skills and regular follow-up and support from trained and experienced nurse specialists.

Are diet and feeding behaviours associated with the onset of and recovery from slow weight gain in early infancy?

Infants with slow weight gain cause concern in parents and professionals, but it is difficult to be certain whether such infants are genetically small or whether their energy intake is insufficient. The aim of the present study was to assess the impact of diet and feeding behaviours on slow weight gain early in infancy. The sample was 11 499 term infants from the Avon Longitudinal Study of Parents and Children (ALSPAC). A total of 507 cases of slow weight gain from birth to 8 weeks were identified and the remaining 10 992 infants were used as controls. It was found that infants who gained weight slowly between birth and 8 weeks were more likely to exhibit feeding problems such as weak sucking and slow feeding during this period. Feeding problems were substantially reduced during the recovery phase (8 weeks to 2 years) when these infants exhibited enhanced catch-up in weight. The proportion of mothers breast-feeding in the 4th week after birth was higher for slow weight gainers, but they were more likely to switch to formula at the start of recovery. During recovery, slow-weight gain infants had a slightly higher energy intake from formula and solids than controls. In conclusion, feeding problems seem to be the most important factors associated with the onset of early slow weight gain. Subsequently, a reduction of feeding problems and an increase in overall energy intake may contribute to their weight recovery. Health professionals should look for feeding problems in the first few weeks after birth and help mothers establish adequate feeding practices.

Psychosocial and educational outcomes of weight faltering in infancy in ALSPAC

OBJECTIVES

To investigate whether infants with weight faltering have impaired psychosocial and educational outcomes in later childhood.

DESIGN

Follow-up of infants with weight faltering in a large UK cohort study.

SETTING

The Avon Longitudinal Study of Parents and Children (ALSPAC).

PARTICIPANTS

11 534 term infants from ALSPAC with complete weight records. Weight gain (conditional on initial weight) was calculated for three periods: from birth to 8 weeks, 8 weeks to 9 months, and birth to 9 months. Cases of weight faltering were defined as those infants with a conditional weight gain below the 5th centile, and these were compared with the rest of the cohort as the control group.

OUTCOMES

Between 6 and 11 years, social, emotional and behavioural development was measured by direct assessment of the children and parental and teacher report. Educational outcomes included Standardised Assessment Test results at 7 and 11 years and Special Educational Needs status at age 11.

RESULTS

Differences seen on univariate analysis in attention, non-verbal accuracy, educational attainment and special educational needs became non-significant after adjustment for confounding. Children with weight faltering in infancy did not differ from controls on any measures of self-esteem, peer relationships, experience of bullying, social cognition, antisocial activities, anxiety, depression or behavioural problems.

CONCLUSIONS

Weight faltering in early infancy was associated with poorer educational outcomes in later childhood, but these associations were explained by confounding. The subsequent psychosocial development of infants with slow weight gain was not different from that of their peers.

Postdischarge feeding patterns in early- and late-preterm infants

OBJECTIVE

To compare the incidence of postdischarge feeding dysfunction and hospital/subspecialty visits for feeding problems during the first year of life in late (34 to 36 6/7 weeks) and early-preterm (25 to 33 6/7 weeks) infants.

METHODS

In this prospective study, the authors sent questionnaires to parents of early (n = 319) and late (n = 571) preterm infants at 3, 6, and 12 months corrected age. Parents' perceptions of infants' feeding skills, comfort with feeding, and hospital/subspecialty visits for feeding difficulties were obtained. Results were analyzed with χ(2) tests and Spearman's correlations.

RESULTS

Early preterms had more oromotor dysfunction at 3 (29% vs 17%) and 12 months (7% vs 4%) and more avoidant feeding behavior at 3 months (33% vs 29%). In both groups, oromotor dysfunction and avoidant feeding behavior improved over time. Frequency of poor appetite and hospitalization/subspecialty visits were similar.

CONCLUSION

Pediatricians should screen all preterm infants for feeding dysfunction during the first year.

Early rapid growth: no association with later cognitive functions in children born not small for gestational age

BACKGROUND

There is an association between rapid growth in early life and overweight in childhood. This adverse association needs to be balanced against potential beneficial effects on cognitive functioning observed in children who are born small for gestational age (SGA).

OBJECTIVE

We examined potential beneficial effects of rapid growth on cognitive functions in non-SGA children.

DESIGN

We performed a systematic literature search of 3 databases. In addition, we analyzed data from the Avon Longitudinal Study on Parents and Children (ALSPAC). The association of rapid weight or length gain (defined as an increase of gt 0.67 in the SD score of weight or length between birth and the age of 25 mo) on intelligence quotient (IQ) measurements at 49 mo and 8 y (n = 836 and n = 701, respectively) was assessed in linear models adjusted for potential confounders.

RESULTS

We identified 14 studies that assessed associations between any kind of early weight gain and cognitive outcome and that included non-SGA children. No study explicitly examined the effect of rapid weight gain. In the ALSPAC data, there was no positive association between rapid weight gain and IQ scores at either 49 mo [effect estimate (95% CI): minus 1.4 ( minus 3.6, 0.7)] or 8 y [ minus 0.8 ( minus 3.4, 1.9)] in non-SGA children. Subgroup analyses with stratification by sex of the children yielded similar results, as did analyses with rapid length gain. Supplementary analyses showed no linear association between weight gain and IQ.

CONCLUSION

We showed no evidence that proposed adverse effects of rapid growth regarding later overweight will be counterbalanced by beneficial effects on cognitive functions in non-SGA children.

Antenatal and postpartum depressive symptoms are differentially associated with early childhood weight and adiposity

Antenatal depression is associated with small-for-gestational age, but few studies have examined associations with weight during childhood. Similarly, few studies address whether antenatal and postpartum depression differentially affect child weight. Among 838 mother-child dyads in Project Viva, a prospective cohort study, we examined relationships of antenatal and postpartum depression with child weight and adiposity. We assessed maternal depression at mid-pregnancy and 6 months postpartum with the Edinburgh Postnatal Depression Scale (score > or =13 indicating probable depression). We assessed child outcomes at age 3 years: body mass index (BMI) z-score, weight-for-height z-score, sum of subscapular (SS) and triceps (TR) skinfold thickness (SS + TR) for overall adiposity, and SS : TR ratio for central adiposity. Sixty-nine (8.2%) women experienced antenatal depression and 59 (7.0%) postpartum depression. Mean (SD) outcomes at age 3 were: BMI z-score, 0.45 (1.01); SS + TR, 16.72 (4.03) mm; SS : TR, 0.64 (0.15). In multivariable models, antenatal depression was associated with lower child BMI z-score (-0.24 [95% confidence interval: -0.49, 0.00]), but higher SS : TR (0.05 [0.01, 0.09]). There was no evidence of a dose-response relationship between antenatal depression and these outcomes. Postpartum depression was associated with higher SS + TR (1.14 [0.11, 2.18]). In conclusion, whereas antenatal depression was associated with smaller size and central adiposity at age 3 years, postpartum depression was associated with higher overall adiposity.

Do maternal ratings of appetite in infants predict later Child Eating Behaviour Questionnaire scores and body mass index?

In a longitudinal birth cohort maternal ratings of children's appetite made at 6 weeks, 12 months and 5-6 years were correlated with one another and with subscales from the Child Eating Behaviour Questionnaire (CEBQ) at 5-6 years, and body mass index (BMI) at 6-8 years. Statistically significant correlations were found between the children's appetite ratings. Appetite ratings in infancy were also correlated with the CEBQ subscale scores at 5-6 years to a limited extent, but not with the BMI at 6-8 years. The appetite rating at 5-6 years and three of the CEBQ subscales were independently associated with BMI. Children with higher levels of Emotional Over-Eating and Desire to Drink had higher BMIs, and children with higher levels of Satiety Responsiveness had lower BMIs. These results provide further evidence that there are concurrent associations between appetite ratings in childhood and BMI but suggest that appetite ratings in infancy are related only weakly to later appetite measures and do not predict later BMI.

In-depth mental health evaluation of a community sample of nonreferred infants with feeding difficulties

OBJECTIVE

Evaluate the clinical characteristics of feeding difficulties in 30 community (i.e., nonreferred) infants in the first 2 years of life, and their correlation with mother/child interactions.

METHOD

An "in depth" mental health evaluation of feeding difficulties, and the psychosocial functioning of the child in other areas. The mother-infant relationship and the feeding interactions were also assessed.

RESULTS

Four "groups" were identified. (1) Young infant with difficulties in regulating states and sucking. (2) Older infant with difficulties in self-regulation, focusing, hyper-alert, and with aversion to feeding. (3) Older infants hypersensitive to stimuli (taste, odor) and with difficulties in chewing. (4) Group of with varied and unique feeding problems (pica, rumination).

CONCLUSION

Feeding problems tend to have patterns according to the age of the baby in a nonreferred sample. They are not associated with an altered parent-infant relationship nor poor feeding technique. Parents often adapt successfully to the uniqueness of the baby to maintain weight gain.

How do toddler eating problems relate to their eating behavior, food preferences, and growth?

OBJECTIVES

Eating problems are a common cause of concern for the parents of toddlers, but few studies have examined the correlates of eating problems or the growth patterns associated with them in a large population-based sample. Our goal was to examine the distribution of eating behaviors in a large representative sample of toddlers and their mothers' approach to feeding. In addition, we describe the prevalence of parentally perceived eating problems and how they relate to specific behaviors, food preferences, and growth in the child.

METHODS

We conducted a cross-sectional analysis of data from a United Kingdom population-based birth cohort, the Gateshead Millennium Baby Study, which included 455 questionnaires completed by parents when their children were aged 30 months.

RESULTS

Eating was perceived to be a problem by 89 (20%) parents. Eating a limited variety (79 [17%]) and preferring drinks to food (57 [13%]) were the most prevalent problem behaviors. Thirty-seven children (8%) were described by parents as definitely "faddy" (picky), and these children liked fewer foods and had higher eating restriction scores than those described as not faddy. Children who were described as having an eating problem gained less weight over the first 2 years; 11.1% had weight faltering compared with 3.5% in children not described as having an eating problem. Being faddy was only weakly associated with poor growth, and simply eating a limited variety was unrelated to growth. High milk consumption was associated with lower appetite but not with poor growth.

CONCLUSIONS

Eating problems are common in toddlers and in the majority are associated with normal growth, although weight faltering is more common in such children. Excessive milk-drinking may be a cause of low appetite at meal times.

Weight faltering in infancy and IQ levels at 8 years in the Avon Longitudinal Study of Parents and Children

OBJECTIVE

Our goal was to investigate the association between failure to thrive (defined as weight faltering in the first 9 months of life) and IQ levels 8 years later.

METHODS

Weight gain (conditional on initial weight) from birth to 8 weeks, 8 weeks to 9 months, and birth to 9 months was measured on term infants from the Avon Longitudinal Study of Parents and Children. Cases of weight faltering were defined as those infants with a conditional weight gain below the 5th centile who were compared with the rest of the cohort as the control group. At the age of 8 years, 5771 infants born at term with no major congenital abnormalities had IQ measured by using the Wechsler Intelligence Scale for Children, Third Revision.

RESULTS

Mean (SD) IQ scores were 104.7 (16.3) (total), 107.6 (16.5) (verbal), and 100.2 (16.9) (performance). Children whose weight faltered from birth to 9 months had a total IQ that was significantly lower by an average of -2.71 points at 8 years, equivalent to 0.17 SD. Weight gain from birth to 8 weeks had a positive linear association with child IQ at 8 years. This remained significant in a multivariate regression despite controlling for correlates of both infant growth and child IQ; 1 SD of weight gain was associated with a difference of 0.84 points in the total IQ score. In contrast to early weight faltering, weight gain from 8 weeks to 9 months was not related to IQ at 8 years.

CONCLUSIONS

Failure to thrive in infancy was associated with persisting deficits in IQ at 8 years; the critical period for growth faltering was birth to 8 weeks. The relationship between infant growth from birth to 8 weeks and later intellectual development was approximately linear over the whole range of weight velocities.

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

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

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

OBJECTIVES

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

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.

The influence of temperament on weight gain in early infancy

Difficult temperament has been associated with fast weight gain and slow weight gain, although the latter mostly in referred subjects studies in late infancy. The current study set out to investigate early weight gain in relation to all domains of temperament in a community-screened sample. Weight gain from birth to 8 weeks was assessed in 75 infants recruited from local health care clinics who had demonstrated slow, average, or fast weight gain. Mothers completed a temperament questionnaire and a 2-day diary recording infant behaviors (sleeping, feeding, fussing, and crying). Weight gain from birth to 8 weeks was significantly related to infant temperament. The temperament dimension fear (acceptance or rejection of new objects or persons) was related to slow weight gain and the temperament dimension distress to limitations (negative emotionality and the infant's reaction to frustrating situations) was related to fast weight gain. The regression model explained 59% of the variance, with the temperament dimensions explaining 11%. Diary data showed that infants who scored high on fear tended to cry a lot, while infants with high scores on distress to limitations tended to sleep less and cry and fuss more. The results emphasize that different temperament domains influence slow and fast weight gain. In addition, the data suggest that infant temperament plays a part in physical development in early infancy.

Physical and emotional development, appetite and body image in adolescents who failed to thrive as infants

BACKGROUND

Previous studies suggest that failure to thrive in infancy may be associated with adverse sequelae in childhood. Although cognitive abilities have been extensively investigated, little systematic research is available on other aspects of development.

METHODS

Eighty-nine children who failed to thrive as infants and 91 controls were followed up when twelve years old and examined using anthropometric measurement, self-ratings of appetite and body image, the Dutch Eating Behaviour Questionnaire, the Self-perception Profile for Children, The Revised Children's Manifest Anxiety Scale, the parent and child form of the Mood and Feelings Questionnaire and the parent and teacher's form of the Child Behavior Checklist.

RESULTS

The children who failed to thrive were significantly shorter and lighter at twelve and had significantly lower BMIs, but they did not go into puberty any later. They were more likely to rate their appetite as lower than their best friend's, were generally more satisfied with their body shape, and had significantly lower restraint score on the Dutch Eating Behaviour Questionnaire. They were not significantly different from controls on any of the measures reflecting anxiety, depression or low self-esteem.

CONCLUSIONS

Failure to thrive in infancy is not associated with adverse emotional development in childhood.

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.

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.

Mother-Child touch patterns in infant feeding disorders: relation to maternal, child, and environmental factors

OBJECTIVE

To examine mother and child's touch patterns in infant feeding disorders within a transactional framework.

METHOD

Infants (aged 9-34 months) referred to a community-based clinic were diagnosed with feeding disorders (n = 20) or other primary disorder (n = 27) and were case matched with nonreferred controls (n = 47). Mother-child play and feeding were observed and the home environment was assessed. Microcoding detected touch patterns, response to partner's touch, and proximity at play. Relational behaviors were coded during feeding.

RESULTS

Compared with infants with other primary disorder and case-matched controls, less maternal affectionate, proprioceptive, and unintentional touch was observed in those with feeding disorders. Children with feeding disorders displayed less affectionate touch, more negative touch, and more rejection of the mother's touch. More practical and rejecting maternal responses to the child's touch were observed, and children were positioned more often out of reach of the mothers' arms. Children with feeding disorders exhibited more withdrawal during feeding and the home environment was less optimal. Feeding efficacy was predicted by mother-child touch, reduced maternal depression and intrusiveness, easy infant temperament, and less child withdrawal, controlling for group membership.

CONCLUSIONS

Proximity and touch are especially disturbed in feeding disorders, suggesting fundamental relationship difficulties. Mothers provide less touch that supports growth, and children demonstrate signs of touch aversion. Touch patterns may serve as risk indicators of potential growth failure.

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.

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.

Effect of maternal mental health on infant growth in low income countries: new evidence from South Asia

Impaired infant growth, a major problem in South Asia, may require interventions to improve maternal mental health in addition to current interventions targeting infant nutrition

Salutogenesis as a framework for child protection: literature review

AIM

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

METHODS

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

FINDINGS

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

CONCLUSIONS

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

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.

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.

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.

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.

Biological vulnerability in infants with failure to thrive: the association with birthweight

The development of failure to thrive (FTT) is hypothesized to be caused by the interaction between biological and environmental factors. Birthweight is one biological variable thought to play a role in the infant's growth failure. In studies that enrolled infants with FTT who were full-term at birth, the reported birthweights of these infants were significantly less than healthy control infants (M = 2959 g vs. M = 3364 g), t(14) = -4.597, P < 0.000. There is growing evidence that there is a subgroup of full-term newborn infants who actually may have experienced some degree of intrauterine growth retardation but their birthweights remain above the traditional cut-off of 2500 g so that they go unrecognized. The question to consider is whether these infants are as behaviourally vulnerable as full-term infants with classic intrauterine growth retardation. It may be that this unrecognized group is at a higher risk of developing FTT. The purpose of this manuscript is to discuss birthweight as a possible precursor to the development of FTT.

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.

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 and cognitive status in school-aged children with a history of failure to thrive during early childhood

Twenty-seven school children (aged 8-12 years) earlier diagnosed with nonorganic failure to thrive (FTT) were compared with a normal socioeconomically matched control group (N=17) on current height and weight parameters as well as cognitive, achievement, and behavioral measures from the Child Behavior Checklist (CBCL). The former FTT children were, on average, smaller, less cognitively able, and more behaviorally disturbed than the control children and national normative samples. Sixty percent of former FTT children were below the 20th percentile in height and 48% were below the 20th percentile in weight; 52% had IQs below 80 and 30% had reading standard scores below 80; 48% had clinically adverse attention ratings and 30% had clinically adverse aggression ratings on the CBCL. Within the FTT sample, however, there were no significant associations between current growth measures and cognitive/achievement outcome measures. Mothers' IQs provided the strongest prediction of the FTT children's reading scores. The mothers of the FTT children had not achieved as high levels of education as the mothers of the control children, and more of them were single parents. Early growth problems put children at high risk for multiple adverse sequelae in middle childhood, especially if mothers are poorly educated. Careful ongoing follow-up of such children by pediatricians is encouraged.

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.

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

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

Health promotion at Swedish Child Health Centres

Effective health promotion intervention is understood to modify appropriate risk and protective factors. The relevance of such interventions for the Child Health Service (CHS) was examined in three steps. In the first step, the six most important public health problems in the target group that might be affected by CHS interventions were identified. The health problems include sudden infant death syndrome (SIDS), mental health problems, injuries, infections, asthma and allergic and nutritional disorders. In the second step, three groups of modifiable determinants were identified: risk and protective factors for (i) SIDS, asthma and allergic disorders and airway tract infections (determinants: breastfeeding, environmental tobacco smoke, sleeping non-prone and lacking indoor ventilation). (ii) injuries and (iii) mental health problems. In the third step, evidence for the preventive measure's ability to alleviate the effects of these risk factors was scrutinized. Evidence was found for effectiveness of CHS interventions aiming at decrease of environmental tobacco smoke. Evidence was also found for injury prevention provided that the intervention is a part of a wider community effort, and possibly also if it is very focused. Requirements for mental health promotion are also at hand. Thus, effective health promotion via CHS interventions is feasible.

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.

Cerebral intracellular lactic alkalosis persisting months after neonatal encephalopathy measured by magnetic resonance spectroscopy

We have found that cerebral lactate can be detected later than 1 month of age after neonatal encephalopathy (NE) in infants with severe neurodevelopmental impairment at 1 y. Our hypothesis was that persisting lactate after NE is associated with alkalosis and a decreased cell phosphorylation potential. Forty-three infants with NE underwent proton and phosphorus-31 magnetic resonance spectroscopy at 0.2-56 wk postnatal age. Seventy-seven examinations were obtained: 25 aged <2 wk, 16 aged > or = 2 to < or = 4 wk, 25 aged > 4 to < or = 30 wk, and 11 aged > 30 wk. Neurodevelopmental outcome was assessed at 1 y of age: 17 infants had a normal outcome and 26 infants had an abnormal outcome. Using univariate linear regression, we determined that increased lactate/creatine plus phosphocreatine (Cr) was associated with an alkaline intracellular pH (pHi) (p < 0.001) and increased inorganic phosphate/phosphocreatine (Pi/PCr) (p < 0.001). This relationship was significant, irrespective of outcome group or age at time of study. Between outcome groups, there were significant differences for lactate/Cr measured at < 2 wk (p = 0.005) and > 4 to < or = 30 wk (p = 0.01); Pi/PCr measured at < 2 wk (p < 0.001); pHi measured at < 2 wk (p < 0.001), > or = 2 to < or = 4 wk (p = 0.02) and > 4 to < or = 30 wk (p = 0.03); and for N-acetylaspartate/Cr measured at > or = 2 to < or = 4 wk (p = 0.03) and > 4 to < or = 30 wk (p = 0.01). Possible mechanisms leading to this persisting cerebral lactic alkalosis are a prolonged change in redox state within neuronal cells, the presence of phagocytic cells, the proliferation of glial cells, or altered buffering mechanisms. These findings may have implications for therapeutic intervention.