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

Weight gain in infants with congenital heart disease; breastfeeding alone versus supplemental spoon-feeding of expressed breast milk: an open-label, pilot, randomised control trial

OBJECTIVES

Infants with congenital heart disease and increased pulmonary blood flow frequently suffer from feeding difficulties and growth failure. Providing expressed breast milk by spoon has been hypothesised to decrease energy expenditure in these infants as compared to breastfeeding. This study assessed the effect of supplemental feeding of expressed breast milk on weight gain in infants with unoperated congenital heart disease.

METHOD

This was a prospective open-label randomised control trial. In total, 50 infants with post tricuspid left to right shunt were enrolled in the study. In the intervention group, apart from breastfeeding, a minimum predetermined volume of expressed breast milk was targeted to be given by spoon. 30-50 kcal/kg/day was given by expressed breast milk by spoon-feeding. In the control group, the infants were given at least 8 feeds per 24 hours by direct breastfeeding. Both groups were followed up for 1 month and assessed for weight gain.

RESULT

Despite a high rate of protocol breach in both groups (30% overall), infants in the intervention group had better weight gain at one-month follow-up compared to those in the control group, 780 ± 300 versus 530 ± 250 gm (p = 0.01).

CONCLUSION

In infants with left to right shunts, supplemental feeding of expressed breast milk by spoon along with breastfeeding resulted in significantly higher average weight gain at 30 days compared to the control group who received breastfeeding alone. Future studies with larger sample sizes and longer follow-ups need to be done to confirm the findings of this study.

Predictors of the inability to achieve full oral feeding in postoperative infants with CHD

OBJECTIVES

Poor oral feeding is a known contributor to growth challenges in neonates with complex CHD who require early surgery. Almost 60% of these infants do not achieve full oral feeding by hospital discharge. This study's objective was to identify predictors of the inability to achieve full oral feeding by discharge in neonates with complex CHD following surgical intervention with cardiopulmonary bypass.

STUDY DESIGN

A retrospective analysis of a prospective study of 192 full-term neonates with complex CHD was performed. A stepwise selection logistic regression model was developed to predict oral feeding status at hospital discharge. Univariate subgroup analysis was performed with groups determined based on a CHD classification system.

RESULTS

58% of neonates (112/192) failed to achieve full oral feeding by hospital discharge. A logistic regression model identified duration of deep hypothermic circulatory arrest and reintubation as predictors of the inability to achieve full oral feeding. Among neonates who achieved full oral feeding by discharge (42%), only 7.5% did so after postoperative day 10. Brain maturation, brain injury, and preoperative oral feeding were not predictors of full postoperative oral feeding.

CONCLUSIONS

Many infants with CHD fail to achieve full oral feeding by time of hospital discharge. Longer duration of deep hypothermic circulatory arrest and increased number of intubations were predictive of poor feeding after surgery. Prolonging hospitalisation solely to achieve full oral feeding after postoperative day ten is of limited utility; earlier discharge should be promoted to avoid negative impacts on neonatal neurodevelopment as unintended consequences of lengthy hospitalisations.

Creating the optimal preoperative nutritional status for neonates undergoing cardiac surgery by implementing a preoperative nutritional support plan

AIM

The purpose of this study was to explore the effect of a preoperative nutritional support programme on improving preoperative nutritional status and promoting postoperative recovery in neonates undergoing cardiac surgery.

METHODS

The clinical data of neonates undergoing cardiac surgery who received preoperative nutritional support therapy in our hospital from March 2021 to December 2021 were collected, and the clinical data of neonates undergoing cardiac surgery who did not receive preoperative nutritional support therapy in our hospital from February 2020 to February 2021 were selected as the control. The nutritional status and postoperative recovery of the two groups were compared.

RESULTS

A total of 30 neonates who received nutritional support before cardiac surgery were included in this study. A total of 28 neonates who did not receive nutritional support before cardiac surgery were included in the control group. There were no significant differences in general information or the nutritional status at birth between the two groups. The duration of nutritional support in the intervention group was 16.8 ± 7.1 days. Before the operation, the intervention group was significantly better than the control group in terms of body weight, albumin, prealbumin and haemoglobin, which indicated that the nutritional status of the intervention group was better than that of the control group. The intensive care time, ventilator time and hospital stay time in the intervention group were significantly lower than those in the control group.

CONCLUSION

Nutritional support plans after birth for neonates with severe congenital heart disease can effectively improve the nutritional status of patients before surgery and accelerate the speed of postoperative recovery.

Impact of adenotonsillectomy on growth trajectories in preschool children with mild-moderate obstructive sleep apnea

STUDY OBJECTIVES

Adenotonsillectomy (AT) forms part of first-line management for pediatric obstructive sleep apnea. In nonrandomized studies of preschool-aged children, postoperative weight gain has been seen following AT, raising concerns regarding later obesity. Using longitudinal data from a multicenter randomized controlled trial, we assessed the impact of AT on growth trajectories in preschool-aged children with mild-moderate obstructive sleep apnea.

METHODS

A total of 190 children (aged 3-5 years) with obstructive apnea-hypopnea index ≤ 10 events/h were randomly assigned to early (within 2 months) or routine (12-month wait) AT. Anthropometry and polysomnography were performed at baseline, 12-month, and 24-month time points for 126 children. Baseline characteristics were compared using a Mann-Whitney or t test for continuous variables and Fisher's exact test for categorical variables. Longitudinal data underwent linear mixed modeling.

RESULTS

For body mass index (BMI) z-score there was a significant increase in the early surgery group between 0 and 12 months (0.4, 95% confidence interval 0.1-0.8) but not from 12-24 months. For the routine surgery group there was an identical significant BMI z-score increase in the first 12 months following surgery, ie, between 12- and 24-month time points (0.45, 95% confidence interval 0.1-0.8) but not from 0-12 months (preoperative time). Final BMI z-score was similar between groups. Findings for weight-for-age z-score were similar to the findings for BMI z-score. Height-for-age z-score was not significantly different between different time points or intervention groups.

CONCLUSIONS

This study provides randomized controlled trial evidence of notable, but time-limited, increase in the BMI and weight of preschool children with mild-moderate obstructive sleep apnea in the months immediately following AT.

CLINICAL TRIAL REGISTRATION

Registry: Australian New Zealand Clinical Trials Registry; Name: POSTA Child Study (Preschool Obstructive Sleep Apnea Tonsillectomy Adenoidectomy Study); URL: https://anzctr.org.au/Trial/Registration/TrialReview.aspx?id=336273&isReview=true; Identifier: ACTRN12611000021976.

CITATION

Kevat A, Bernard A, Harris M-A, et al. Impact of adenotonsillectomy on growth trajectories in preschool children with mild-moderate obstructive sleep apnea. J Clin Sleep Med. 2023;19(1):55-62.

Disruptions in the development of feeding for infants with congenital heart disease

Congenital heart disease (CHD) is the most common birth defect for infants born in the United States, with approximately 36,000 affected infants born annually. While mortality rates for children with CHD have significantly declined, there is a growing population of individuals with CHD living into adulthood prompting the need to optimise long-term development and quality of life. For infants with CHD, pre- and post-surgery, there is an increased risk of developmental challenges and feeding difficulties. Feeding challenges carry profound implications for the quality of life for individuals with CHD and their families as they impact short- and long-term neurodevelopment related to growth and nutrition, sensory regulation, and social-emotional bonding with parents and other caregivers. Oral feeding challenges in children with CHD are often the result of medical complications, delayed transition to oral feeding, reduced stamina, oral feeding refusal, developmental delay, and consequences of the overwhelming intensive care unit (ICU) environment. This article aims to characterise the disruptions in feeding development for infants with CHD and describe neurodevelopmental factors that may contribute to short- and long-term oral feeding difficulties.

Enteral Nutrition in Term Infants with Congenital Heart Disease: Knowledge Gaps and Future Directions to Improve Clinical Practice

Optimal nutrition is essential to improve short- and long-term outcomes in newborns with congenital heart disease (CHD). Nevertheless, several issues on nutritional management and concerns about the potential risk of complications related to enteral feeding exist. This narrative review aims to summarize and discuss the available literature on enteral feeding in term infants with CHD. A wide variability in feeding management exists worldwide. Emerging approaches to improve nutritional status and outcomes in infants with CHD include: implementation of a standardized enteral feeding protocol, both preoperative and postoperative, clearly defining time of initiation and advancement of enteral feeds, reasons to withhold, and definitions of feeding intolerance; early minimal enteral feeding; enteral feeding in stable term infants on hemodynamic support; evaluation of enteral feeding in term infants with umbilical arterial catheters and during prostaglandin infusion; assessment and support of oro-motor skills; and promotion and support of breastfeeding and provision of mother's own milk or donor milk when mother's own milk is not available. As evidence from term infants is scarce, available observations and recommendations partially rely on studies in preterm infants. Thus, well-designed studies assessing standardized clinically relevant outcomes are needed to provide robust evidence and shared recommendations and practices.

Neurodevelopmental outcome in hypoplastic left heart syndrome after hybrid procedure

BACKGROUND

Little is known about the mid-term outcome and brain development in patients following the hybrid approach for hypoplastic left heart syndrome (HLHS). This study investigates neurodevelopmental outcome, quality of life (QoL) and brain MRI findings in HLHS preschoolers treated with the hybrid approach.

METHODS

Twenty HLHS patients (60% males) have been examined after neonatal hybrid Stage I and comprehensive stage II operation at the Pediatric Heart Center Giessen, Germany, between 2012 and 2016. Patients were evaluated with the Bayley Scales of Infant and Toddler Development III (Bayley-III), neurological examination, the Preschool Children Quality of Life Questionnaire (TAPQOL) at age 26.5±3.6 months, and again at 39.7±3.9 months with the Pediatric Cardiac Quality of Life Inventory (PCQLI). Furthermore, brain volumetric measurements and conventional brain MRI findings (27.3±4.5 months) were analyzed and compared with six healthy controls (29.2±11.1 months, P=0.53). Children with verified genetic comorbidities were excluded.

RESULTS

Mean cognitive, language, and motor composite scores on the Bayley-III were not different from healthy norms (100±15), and were 101±9.3 (P=0.48), 100±13 (P=0.93), and 98±11.7 (P=0.45), respectively. Status post stroke was the most common brain MRI abnormality, and was found in 3/19 (16%) patients, most common affecting the middle cerebral artery territory. In comparison to controls, total white matter volumes were reduced (P=0.014), and cerebrospinal fluid (CSF) volumes were increased (P=0.042) in patients. Overall health-related QoL in 2 to 3 years aged children HLHS was good, but inferior scores in the motor subscale were noted compared to healthy norms (P=0.007). However, at 3 to 4 years, parents reported comparable QoL for their children in the PCQLI to children with biventricular heart lesion.

CONCLUSIONS

HLHS patients followed by hybrid approach without major complications show a favorable neurodevelopment at 2-3 years of age. Despite extensive health-related burden, the vast majority of Fontan preschoolers with HLHS showed a good health-related QoL. Nevertheless, comprehensive care and establishing routine follow-up examinations are important to recognize long-term challenges and further improve neurodevelopmental outcome of this high-risk patient population.

Behavioral Outbursts in a Child with a Deletion Syndrome, Generalized Epilepsy, Global Developmental Delay, and Failure to Thrive

A 7-year-old girl with 20q13.33 deletion and a history of generalized convulsive epilepsy presented to the Developmental and Behavioral Pediatrics Clinic due to concerns about her behavioral outbursts in the context of overall delayed development. Evaluation by the Developmental and Behavioral and Gastroenterology teams revealed failure to thrive (FTT) as the primary cause of the behavioral outbursts and developed a high-calorie, high-fat, high-protein nutritional counseling plan. Children who have FTT and a genetic disorder are often thought to not thrive because of their underlying genetic disorder; however, feeding skills and nutritional intake need to be thoroughly investigated before determining an etiology for FTT. Motoric, communicative, and developmental skills in children with genetic disorders may impede appropriate feeding mechanisms, inducing or exaggerating FTT in these children with developmental disabilities due to genetic etiologies. [Pediatr Ann. 2018;47(3):e130-e134.].

Growth trajectory and neurodevelopmental outcome in infants with congenital diaphragmatic hernia

PURPOSE

The purpose of this study was to evaluate the impact of impaired growth on short-term neurodevelopmental (ND) outcomes in CDH survivors.

METHODS

Between 9/2005-12/2014, 84 of 215 (39%) CDH survivors underwent ND assessment at 12months of age using the BSID-III.

RESULTS

Mean cognitive, language, and motor scores were 92.6±13.5, 87.1±11.6, and 87.0±14.4, respectively (normal 100±15). 51% of patients scored 1 SD below the population mean in at least one domain, and 13% scored 2 SD below the population mean. Group-based trajectory analysis identified two trajectory groups ('high' and 'low') for weight, length, and head circumference (HC) z-scores. (Fig. 1) 74% of the subjects were assigned to the 'high' trajectory group for weight, 77% to the 'high' height group, and 87% to the 'high' HC group, respectively. In multivariate analysis, longer NICU stay (p<0.01) was associated with lower cognitive scores. Motor scores were 11 points higher in the 'high' HC group compared to the 'low' HC group (p=0.05). Motor scores were lower in patients with longer NICU length of stay (p<0.001).

CONCLUSIONS

At 1 year, half of CDH survivors had a mild delay in at least one developmental domain. Low HC trajectory was associated with worse neurodevelopmental outcomes.

TYPE OF STUDY

Prognosis Study/Retrospective Study.

LEVEL OF EVIDENCE

Level II.

Serum and Hair Mineral Levels in Children with Failure to Thrive According to the Type of Feeding Difficulties

This study evaluated serum and hair mineral and trace element levels as well as levels of other nutritional factors affecting growth and appetite in young children with non-organic failure to thrive (NOFTT) based on the presence or types of feeding difficulty (FD). Between August 2012 and July 2015, 136 children less than 6 years of age with NOFTT were included. FD was diagnosed based on Wolfson criteria and divided into subtypes according to Chatoor's classification. Clinical data were reviewed, and serum and hair mineral levels were measured. Of all assessed serum and hair minerals, only hair sulfur contents differed significantly between subjects with and without infantile anorexia (39,392 ± 2211 vs. 40,332 ± 2551 μg/g, P = 0.034). There were no differences in serum and hair mineral levels between children with and without sensory food aversion. Hair copper contents were significantly lower in children with FD of reciprocity (12.3 ± 6.0 vs. 22.4 ± 25.1 μg/g, P = 0.049). While hair zinc contents were also lower, the difference was not statistically significant (49.2 ± 26.8 vs. 70.6 ± 41.0 μg/g, P = 0.055). Only hair manganese contents were significantly lower in children with posttraumatic FD (0.12 ± 0.04 vs. 0.26 ± 0.73 μg/g, P = 0.037). In conclusion, there were no differences in most serum and hair mineral levels in children with NOFTT, except for relatively lower hair levels of sulfur, copper and possibly zinc, and manganese in infantile anorexia, reciprocity, and posttraumatic types of FD, respectively.

Nutrition and Mesenteric Issues in Pediatric Cardiac Critical Care

OBJECTIVES

The objectives of this review are to discuss the challenges of delivering adequate nutrition to children with congenital heart disease, including pre- and postoperative factors and the role of enteral and parenteral nutrition, as well as the evidence supporting current practices.

DATA SOURCE

MEDLINE and PubMed.

CONCLUSION

Providing adequate nutritional support is paramount for critically ill infants with congenital heart disease, a population at particular risk for malnutrition. Improved nutritional support has been associated with increased survival and reduction in overall morbidity. Further gains can be achieved by creating a clinical culture that emphasizes optimal perioperative nutritional support. Additional research is required to identify the specific nutrient composition, optimal mode, and timing of delivery to maximize clinical benefit.

Parental separation: a risk for the psychomotor development of children aged 28 to 32 months? A cross-sectional study

BACKGROUND

In Western countries, about a quarter of children are affected by parental separation and a number of authors have previously investigated how familial structure impacts children's health. The purpose of the work: to analyze the psychomotor development of children aged 28 to 32 months based on family structure (parents together or separated), independently of the influence of socio-economic environment that is well documented. To analyse the psychomotor development of children younger than 3 years based on family structure (parents together or separated) independently of the influence of socio-economic environment that is well documented.

METHODS

Cross-sectional study by examination of 28 871 children as part of a free preventive medicine consultation. The data came from an assessment conducted 28 to 32 months after birth during which information was collected about the psychomotor development: to perform a standing jump, dress themselves, draw a vertical line and circle, use the "I" pronoun, build a three-word sentence, and say their first name

RESULTS

Ten percent of the children had separated parents. Compared to parents who were together, when adjusting for the socioeconomic environment, as well as all potential confounders, the adjusted odds ratios (ORs) (95 % confidence interval [CI]) for children with separated parents, in terms of their ability to perform a standing jump, dress themselves, and draw a vertical line and circle were respectively 0.9 (0.7-1.1), 1.1 (0.9-1.2), 1.3 (1.1-1.4) and 1.2 (1.1-1.4). The adjusted ORs (95 % CI) for children's inability to say the "I" pronoun, build a three-word sentence, and say their first name were respectively 1.2 (1.1-1.3), 1.3 (1.2-1.5), and 1.2 (0.9-1.5).

CONCLUSIONS

After adjusting for sociocultural factors and other potential confounders, we observed that the children exhibited slower progression in psychomotor development, especially in language and graphic abilities when their parents were separated. While the implications of our study are somewhat limited, they do provide us with the necessary arguments enabling us to set up a prospective cohort study. Such a study should be able to better assess the impact of parental separation on the child's development, confirming our preliminary results.

Comparison of Feeding Strategies for Infants With Hypoplastic Left Heart Syndrome

Introduction:

Infants with hypoplastic left heart syndrome are at risk for growth failure, particularly after stage 1 procedures. The effect of continuous enteral feedings on weight gain has not been previously investigated.

Methods:

A randomized controlled trial was performed in infants with hypoplastic left heart syndrome and single ventricle variants after stage 1 procedures. Eligible infants were randomized to a continuous and intermittent feeding regimen or an exclusive intermittent feeding regimen after stage 1 procedures and continued until hospital discharge. Anthropometric measures and markers of nutritional status were assessed throughout hospitalization.

Results:

Twenty-six infants completed the study. There were no significant differences in weight gain, growth, or nutritional status. Weight gain on full enteral feedings was 24.3 versus 23.6 g/d ( P = .88) for the combination (continuous and intermittent) versus intermittent feeding groups. Weight-for-age Z scores at discharge were −1.37 versus −1.2 ( P = .59) for the combination versus intermittent groups.

Conclusions:

No significant differences in weight gain, growth, or nutritional status were observed at hospital discharge between the two feeding strategies. Despite both groups achieving target daily weight gain after attaining full feeds, growth failure continued to be a problem after stage 1 procedures. Further strategies to improve growth during initial hospitalization are needed.

Nutrition in the Cardiac Newborns: Evidence-based Nutrition Guidelines for Cardiac Newborns

Both protein and energy malnutrition are common in neonates and infants with congenital heart disease (CHD). Neonates with CHD are at increased risk of developing necrotizing enterocolitis (NEC), particularly the preterm population. Mortality in patients with CHD and NEC is higher than for either disease process alone. Standardized feeding protocols may affect both incidence of NEC and growth failure in infants with CHD. The roles of human milk and probiotics have not yet been explored in this patient population.

Noncardiac Challenges in the Cardiac ICU: Feeding, Growth and Gastrointestinal Complications, Anticoagulation, and Analgesia

Outcomes following cardiac intensive care unit (CICU) admission are influenced by many factors including initial cardiac diagnosis, surgical complexity, and burden of critical illness. Additionally, the presence of noncardiac issues may have a significant impact on outcomes and the patient experience during and following an intensive care unit stay. This review focuses on three common noncardiac areas which impact outcomes and patient experience in and beyond the CICU: feeding and growth, pain and analgesia, and anticoagulation. Growth failure and feeding dysfunction are commonly encountered in infants requiring cardiac surgery and have been associated with worse surgical and developmental outcomes. Recent studies most notably in the single ventricle population have demonstrated improved weight gain and outcomes when feeding protocols are implemented. Children undergoing cardiac surgery may experience both acute and chronic pain. Emerging research is investigating the impact of sedatives and analgesics on neurodevelopmental outcomes and quality of life. Improved pain scores and standardized management of pain and withdrawal may improve the patient experience and outcomes. Effective anticoagulation is a critical component of perioperative care but may be complicated by inflammation, multiorgan dysfunction, and patient factors. Advances in monitoring of anticoagulation and emerging therapies are reviewed.

Association between nutritional status and subjective health status in chronically ill children attending special schools

Purpose

In hospitalized children with a chronic disease, malnutrition was associated with a lower subjective health status. In outpatient children with a chronic disease attending special schools, this association has never been studied. The aim of this study was to assess the association between nutritional status and subjective health status in chronically ill children attending special schools.

Methods

Overall, 642 children, median age 9.8 years (IQR 7.7–11.5), 60 % male, 72 % Caucasian, were included in this prospective study in nine special schools for chronically ill children in the Netherlands. Overall malnutrition was assessed as: acute malnutrition (<−2 SDS for weight for height (WFH)) and chronic malnutrition (<−2 SDS for height for age). The malnutrition risk was assessed with the nutritional risk-screening tool STRONG_kids. Subjective health status was assessed with EQ-5D.

Results

Overall, 16 % of the children had overall malnutrition: 3 % acute and 13 % chronic malnutrition. Nurses reported ‘some/severe problems’ on the health status dimensions mobility (15 %), self-care (17 %), usual activities (19 %), pain/discomfort (22 %), and anxiety/depression (22 %) in chronically ill children. Their mean visual analogue scale score (VAS) was 73.0 (SD 11.1). Malnutrition, medication usage, and younger age explained 38 % of the variance of the VAS score.

Conclusions

The presence of overall malnutrition in chronically ill children attending special schools was associated with lower subjective health status, especially in younger children and in those with chronic medication usage. Therefore, it is important to develop and use profile-screening tools to identify these children.

Electronic supplementary material

The online version of this article (doi:10.1007/s11136-015-1130-4) contains supplementary material, which is available to authorized users.

Pediatric Malnutrition: Putting the New Definition and Standards Into Practice

In recent years, much effort has been directed at redefining malnutrition in the pediatric population to include the acute clinical population in addition to the more traditional ambulatory populations. In 2013, an expert panel convened to perform a critical review of available literature to craft a new approach to malnutrition. Closely thereafter, the Academy of Nutrition and Dietetics and the American Society for Parenteral and Enteral Nutrition published recommended indicators for the identification and documentation of malnutrition in pediatric populations. The purpose of this article is to review the domains within the new definition of malnutrition in pediatric practice, describe populations in which the recommended indicators for identification and management are problematic in clinical practice, give case studies that apply the new definition, and finally describe the implementation of a malnutrition identification program within a large tertiary care children's hospital.

Should we consider alternatives to universal well-child behavioral-developmental screening?

The prevalence of developmental disabilities in the young age is of the order of 15%. When behavioral and social-emotional disorders, physical impairments, and sensory disorders are included, the need for special intervention increases to one out of four children. As the sensitivity and specificity of the best screening tests are in the range of 70-80%, their predictive value is controversial. The cost of conducting definitive tests and repeat screening for those who fail the screening tests is high. Children with severe disorders can be identified clinically without a screening test. The poor predictability, difficulty in implementation, and the high costs of developmental testing suggest that children, particularly those in high-risk communities, might be better served by implementing intervention programs for all, instead of trying to identify the outliers through screening.

Clinical Characteristics of Failure to Thrive in Infant and Toddler: Organic vs. Nonorganic

PURPOSE

To investigate the clinical characteristics and outcomes among infants and toddlers with failure to thrive (FTT).

METHODS

This retrospective study was done with 123 patients who had visited Pusan National University Children's Hospital during their first two years of life and had received an FTT diagnosis. We compared the clinical characteristics of the patients based on the causes of their FTT and their ages at the time of first hospital visit. We investigated triggering factors, feeding practices, and outcomes in 25 patients with nonorganic FTT (NOFTT).

RESULTS

Eighty cases (65.0%) were NOFTT. The gestational ages, birth weights, and weights at the first visits were significantly lower in patients with organic FTT (OFTT) (p<0.05). Infants who had first visited the clinic at age <6 months had the least z-score. The percentage of patients with severe weight decline was higher in OFTT than in NOFTT (60.0% vs. 17.3%). The z-scores at the follow-up visits were improved after treatment in both of the groups. Preceding infection was the most common triggering factor of NOFTT and persecutory feeding as abnormal behavior of caregiver was observed in 22 cases (88.0%). After treatment with feeding method modification, all patients with NOFTT showed normal growth.

CONCLUSION

Weight decline is more severe in OFTT patients and in younger patients at the first visit. Infants with FTT can attain normal weight gain growth by treating organic diseases and supplying proper nutrition in OFTT, and by correcting abnormal dietary behavior of caregiver in NOFTT.

Patient and practice factors affecting growth of infants with systemic-to-pulmonary shunt

BACKGROUND

On recognising poor growth following neonatal palliation with a systemic-to-pulmonary shunt, we sought to determine how patient- and procedure-related factors impact growth, paying attention to the role of the primary cardiologist in this process.

METHODS

In a retrospective review, neonates (133 patients) receiving modified systemic-to-pulmonary artery shunts from 2002 to 2009 were studied and outpatient visits were reviewed. Patients with single- and two-ventricle circulations after shunt takedown were compared using weight-for-age z-score.

RESULTS

Single-ventricle patients had a higher weight-for-age z-score at neonatal surgery than two-ventricle patients (-0.4 ± 1.0 compared with -1.2 ± 0.9, with p < 0.001), but they had a greater drop in the weight-for-age z-score to the first outpatient visit (-1.1 ± 0.7 compared with -0.8 ± 0.7, with p = 0.02). After the first outpatient visit, the weight-for-age z-score was not significantly different between single-ventricle and two-ventricle patients. From multivariate analysis, a lower number of nutritional interventions by cardiologists was significantly associated with poor growth (p = 0.03). Poor growth was not associated with race, use of feeding tube, exclusive formula use, or proximity to surgical centre.

CONCLUSION

The significant drop in the weight-for-age z-score from neonatal surgery to first outpatient visit suggests that these patients may receive inadequate nutrition. The poorest performers received the least number of outpatient changes to their diet. This finding underscores the critical role of the primary cardiologist in optimising weight gain through adjustments in nutrition.

Failure to thrive

Failure to thrive is poor physical growth that results when the nutritional demands of young children are not fulfilled. This diagnosis is made when, on serial growth monitoring, the child's anthropometric parameters such as weight for age and/or height are found to be significantly below the expected values. A detailed evaluation by the treating physician, taking into account physical and psychosocial factors affecting the child's health is essential for understanding the factors contributing to failure to thrive. The treatment of this entity requires a multidisciplinary approach, correcting the macro and micronutrient deficiency in the child as well as education of parents regarding age-appropriate feeding recommendation for children. In addition, parents need to be apprised of the possible implications of malnutrition on growth and neurodevelopment of the child. Early childhood being a crucial period for growth and development, an early diagnosis and treatment will result in better outcomes in children with failure to thrive.

Growth outcomes of weight faltering in infancy in ALSPAC

OBJECTIVE

The goal of this study was to investigate growth outcomes in term infants with weight faltering.

METHODS

Conditional weight gain was calculated on term infants from the Avon Longitudinal Study of Parents and Children. Cases of weight faltering were infants with a conditional weight gain below the fifth centile. Outcome growth measurements included weight and length/height (from 9 months to 13 years), BMI, mid-arm circumference, and waist circumference (at 7, 10, and 13 years).

RESULTS

Weight data were available on 11 499 infants; 507 had "early" weight faltering (before 8 weeks), and 480 had "late" weight faltering (between 8 weeks and 9 months). The early group showed enhanced weight gain from 8 weeks until 2 years, then gained weight at the same rate as the controls. Gain in height was proportionally slower than gain in weight through childhood. By 13 years, they had BMI, mid-arm circumference, and waist circumference similar to the controls. The late group showed steady weight gain throughout childhood; enhanced weight gain compared with the controls only occurred between 7 and 10 years. Gain in height was proportional to gain in weight. This group remained considerably lighter and shorter than the controls up to the age of 13 years.

CONCLUSIONS

Children with weight faltering before 8 weeks showed a different pattern of "catch-up" to those with weight faltering later in infancy. By 13 years, the anthropometric profile of the 2 groups was within population norms.

Association of impaired linear growth and worse neurodevelopmental outcome in infants with single ventricle physiology: a report from the pediatric heart network infant single ventricle trial

OBJECTIVES

To describe neurodevelopmental outcomes in infants with single ventricle (SV) physiology and determine factors associated with worse outcomes.

STUDY DESIGN

Neurodevelopmental outcomes for infants with SV enrolled in a multicenter drug trial were assessed at 14 months of age using the Bayley Scales of Infant Development-II. Multivariable regression analysis was used to identify factors associated with worse outcomes.

RESULTS

Neurodevelopmental testing was performed at 14 ± 1 months in 170/185 subjects in the trial. Hypoplastic left heart syndrome was present in 59% and 75% had undergone the Norwood operation. Mean Psychomotor Developmental Index (PDI) and mental developmental index (MDI) were 80 ± 18 and 96 ± 14, respectively, (normal 100 ± 15, P < .001 for each). Group-based trajectory analysis provided a 2-group model ("high" and "low") for height z-score trajectory and brain type natriuretic peptide (BNP) trajectory. The predicted PDI scores were 15 points higher in the "high" height z-score trajectory compared with the "low" cluster (P < .001). A higher number of serious adverse events during the trial was associated with lower PDI scores (P = .02). The predicted MDI scores were 13-17 points lower in "low height trajectory-high BNP trajectory" group compared with the other 3 groups (P < .001). MDI scores were also lower in subjects who required extracorporeal membrane oxygenation during the neonatal hospitalization (P = .01) or supplemental oxygen at discharge (P = .01).

CONCLUSIONS

Neurodevelopmental outcome at 14 months of age is impaired in infants with SV physiology. Low height trajectory and high BNP trajectory were associated with worse neurodevelopmental outcomes. Efforts to improve nutritional status alone may not improve neurodevelopmental outcomes.

Resting energy expenditure at 3 months of age following neonatal surgery for congenital heart disease

OBJECTIVE

Infants with Congenital Heart Disease (CHD) often exhibit growth failure. This can affect anthropometric and neurodevelopmental outcomes well into childhood. To determine the resting energy expenditure (REE), body composition, and growth in infants with CHD at 3 months of age, with the secondary aim to identify predictors of REE as compared with healthy infants.

DESIGN AND METHODS

This descriptive study is a subanalysis of a prospective study investigating predictors of growth in postoperative infants with CHD compared with healthy infants. Growth measurements, REE, and body composition were obtained in all infants. Analysis included chi-square for association between categorical variables, t-tests, ANOVA and ANCOVA. Outcome measures included the REE as determined by indirect calorimetry, anthropometric z-scores and body composition at 3 months of age.

SETTING

Participants were recruited from the Cardiac Intensive Care Unit of a large, urban, pediatric cardiac center and pediatric primary care practices.

RESULTS

The analysis included 93 infants, 44 (47%) with CHD. Of the infants with CHD, 39% had single ventricle (SV) physiology. There was no difference in REE related to cardiac physiology between infants with CHD and healthy infants or between infants with SV and biventricular (BV) physiology. Anthropometric z-scores for weight (-1.1 ± 1.1, P < 0.001), length (-0.7 ± 1.1, P < 0.05), and head circumference (-0.6 ± 1.2, P < 0.001) were lower in infants with CHD at 3 months of age. The percentage of body fat (%FAT) in postoperative infants with SV (24% ± 6, P = 0.02) and BV (23% ± 5, P < 0.001) physiology were lower than in healthy infants (27% ± 5), with no difference in REE.

CONCLUSION

At 3 months of age, there was no difference in REE between postsurgical infants with CHD and healthy infants. Infants with CHD had lower growth z-scores and %FAT. These data demonstrate decreased %FAT contributed to growth failure in the infants with CHD.

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.

Nutrition algorithms for infants with hypoplastic left heart syndrome; birth through the first interstage period

Failure to thrive is common in infants with hypoplastic left heart syndrome and its variants and those with poor growth may be at risk for worse surgical and neurodevelopmental outcomes. The etiology of growth failure in this population is multifactorial and complex, but may be impacted by nutritional intervention. There are no consensus guidelines outlining best practices for nutritional monitoring and intervention in this group of infants. The Feeding Work Group of the National Pediatric Cardiology Quality Improvement Collaborative performed a literature review and assessment of best nutrition practices from centers participating in the collaborative in order to provide nutritional recommendations and levels of evidence for those caring for infants with single ventricle physiology.

Failure to thrive in childhood

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSION

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

Poor post-operative growth in infants with two-ventricle physiology

BACKGROUND

Adequate nutritional support is essential for normal infant growth and development. Infants with congenital cardiac disease are known to be at risk for growth failure. We sought to describe perioperative growth in infants undergoing surgical repair of two-ventricle congenital cardiac disease and assess for predictors of their pattern of growth.Materials and methodsFull-term infants who underwent surgical repair of two-ventricle congenital cardiac disease at a single institution were enrolled in a retrospective cohort study performed following a larger prospective study. Infants with facial, gastrointestinal, or neurologic anomalies, trisomy chromosomal abnormality, birth weight less than 2500 grams, or those transferred to another institution before discharge home were excluded. The primary outcome was change in weight-for-age z score from surgery to discharge. Our secondary outcome variable was post-operative hospital length of stay.

RESULTS

A total of 76 infants met the inclusion criteria. Medain age at surgery was 5 days with a range from 1 to 44. The median weight-for-age z score at surgery was -0.2 with a range from -2.9 to 2.8 and by discharge had dropped to -1.2 with a range from -3.4 to 1.8. The median change in weight-for-age z score from surgery to discharge was -1.0 with a range from -2.3 to 0.2. Delayed post-operative nutrition (p < 0.001) and reintubation following initial post-operative extubation (p = 0.001) were associated with decrease in weight-for-age z score.

CONCLUSIONS

Infants undergoing repair of two-ventricle congenital cardiac disease had poor growth in the post-operative period. This may be mitigated by early initiation of post-operative nutrition.

Weight change in infants with a functionally univentricular heart: from surgical intervention to hospital discharge

OBJECTIVE

The purpose of this study was to assess the pattern of weight change from surgical intervention to home discharge and to determine predictors of poor growth in this population of infants with congenital cardiac disease.

METHODS

Neonates with functionally univentricular physiology enrolled in a prospective cohort study examining growth between March, 2003 and May, 2007 were included. Weights were collected at birth, before surgical intervention, and at hospital discharge. In addition, retrospective echocardiographic data and data about post-operative complications were reviewed. Primary outcome variables were weight-for-age z-score at discharge and change in weight-for-age z-score between surgery and discharge.

RESULTS

A total of 61 infants met the inclusion criteria. The mean change in weight-for-age z-score between surgery and hospital discharge was minus 1.5 plus or minus 0.8. Bivariate analysis revealed a significant difference in weight-for-age z-score between infants who were discharged on oral feeds, minus 1.1 plus or minus 0.8 compared to infants with feeding device support minus 1.7 plus or minus 0.7, p-value equal to 0.01. Lower weight-for-age z-score at birth, presence of moderate or greater atrioventricular valve regurgitation, post-operative ventilation time, and placement of an additional central venous line were associated with 60% of the variance in weight-for-age z-score change.

CONCLUSION

Neonates undergoing staged surgical repair for univentricular physiology are at significant risk for growth failure between surgery and hospital discharge. Haemodynamically significant atrioventricular valve regurgitation and a complex post-operative course were risk factors for poor post-operative weight gain. Feeding device support appears to be insufficient to ensure adequate weight gain during post-operative hospitalisation.

Predictors of poor weight gain in infants with a single ventricle

OBJECTIVE

To assess growth from the time of neonatal discharge to the time of performance of the bidirectional Glenn (BDG) procedure in infants with a single ventricle and determine predictors of poor growth.

STUDY DESIGN

We performed a retrospective case series of infants who underwent the BDG procedure at our institution between January 2001 and December 2007 (n=102). Anthropometric and clinical data were recorded during neonatal hospitalization and before BDG. Outcome variables included weight-for-age z-score (WAZ) at the time of BDG and average daily weight gain between neonatal discharge and BDG.

RESULTS

Median age at the time of BDG was 5.1 months (range, 2.4-10 months), and median WAZ was -0.4 (range, -2.6 to 3.2) at neonatal admission and -1.3 (range, -3.9 to 0.6) at the time of BDG. Non-Caucasian infants (P=.03) and those with lower WAZ at neonatal discharge (P<.0001) had a lower WAZ at BDG. Being formula-fed at neonatal discharge (P=.04), and having higher mean pulmonary arterial pressure (P=.04) and systemic oxygen saturation (P=.006) were associated with lower average daily weight gain between neonatal discharge and BDG.

CONCLUSIONS

Infants with a single ventricle have poor weight gain between neonatal discharge and BDG. Non-Caucasian infants and those with evidence of increased pulmonary blood flow are at particular risk for growth failure.

Childhood living conditions, socioeconomic position in adulthood, and cognition in later life: exploring the associations

OBJECTIVES

This study examined the association between childhood living conditions, socioeconomic position in adulthood, and cognition in later life. Two questions were addressed: Is there an association between childhood living conditions and late-life cognition, and if so, is the association modified or mediated by adult socioeconomic position?

METHODS

Nationally representative data of the Swedish population aged 77 years and older were obtained from the 1992 and 2002 Swedish Panel Study of Living Conditions of the Oldest Old (SWEOLD). Cognition was assessed with an abbreviated version of the Mini-Mental State Examination scale. Childhood living conditions were assessed by self-reports of childhood living conditions.

RESULTS

The results showed independent associations between conflicts in the household during childhood, father's social class, education, own social class in adulthood, and cognition in later life. Exposure to conflicts during childhood, having a father classified as a manual worker, low education, and/or being classified as a manual worker in adulthood was associated with lower levels of cognition in old age. There seemed to be no modifying effect of adult socioeconomic position on the association between childhood conditions and cognition in later life.

DISCUSSION

This suggests the importance of childhood living conditions in maintaining cognitive function even in late life.

Childhood growth and development associated with need for full-time special education at school age

OBJECTIVE

To explore how growth measurements and attainment of developmental milestones in early childhood reflect the need for full-time special education (SE).

METHODS

After stratification in this population-based study, 900 pupils in full-time SE groups (age-range 7-16 years, mean 12 years 8 months) at three levels and 301 pupils in mainstream education (age-range 7-16, mean 12 years 9 months) provided data on height and weight from birth to age 7 years and head circumference to age 1 year. Developmental screening was evaluated from age 1 month to 48 months. Statistical methods included a general linear model (growth measurements), binary logistic regression analysis (odds ratios for growth), and multinomial logistic regression analysis (odds ratios for developmental milestones).

RESULTS

At 1 year, a 1 standard deviation score (SDS) decrease in height raised the probability of SE placement by 40%, and a 1 SDS decrease in head size by 28%. In developmental screening, during the first months of life the gross motor milestones, especially head support, differentiated the children at levels 0-3. Thereafter, the fine motor milestones and those related to speech and social skills became more important.

CONCLUSION

Children whose growth is mildly impaired, though in the normal range, and who fail to attain certain developmental milestones have an increased probability for SE and thus a need for special attention when toddlers age. Similar to the growth curves, these children seem to have consistent developmental curves (patterns).

Postdischarge growth and development in a predominantly Hispanic, very low birth weight population

OBJECTIVES

The goals were to assess postdischarge growth and developmental progress of very low birth weight (birth weight: <1500 g) premature infants in a predominantly Hispanic population and to identify predictors for neurodevelopmental impairment at 3 years of age.

METHODS

A cohort of 135 very low birth weight infants (gestational age: 23 to 35 weeks) were monitored to 3 years of age. Maternal and neonatal characteristics, anthropometric z scores, and developmental performance (using corrected age until 24 months) were analyzed collectively and according to gestational age groups. Specific criteria for failure to thrive and microcephaly were used.

RESULTS

A characteristic pattern of poor weight gain in the first 12 months was followed by accelerated weight gain starting at 18 months, whereas head growth decreased at 18 months, with recovery beginning at 30 months of age. Infants born at gestational age of <or=26 weeks remained growth-impaired at 3 years of age, whereas infants born at gestational age of >or=27 weeks achieved catch-up growth by 30 months of age. Mean developmental scores also decreased in infancy, with improvements in motor development emerging at 18 months and cognitive skills at 30 months. Growth z scores, particularly for head growth, correlated with developmental scores. Infants born at gestational age of <or=26 weeks were most likely to have neonatal morbidities, failure to thrive, and neurodevelopmental impairment. With adjustment for gestational age and neonatal morbidities, Hispanic acculturation, failure to thrive, and microcephaly were predictive of neurodevelopmental impairment.

CONCLUSIONS

Very low birth weight infants exhibited growth patterns that coincided with developmental progress in the first 3 years of life. Birth at gestational age of <or=26 weeks was associated with greatest risk for developmental impairment, whereas failure to thrive and microcephaly increased neurodevelopmental impairment risk regardless of gestational age.

The Importance of a Multifaceted Approach in the Assessment and Treatment of Childhood Feeding Disorders

The objective of this article is to describe the use of a multifaceted approach in the assessment and treatment of a child with a severe feeding disorder in an inpatient setting. Family and ward-staff interviews, video observations, and behavioral measures were used in the assessment and treatment of a 2-year-old girl admitted to a pediatric ward with failure to thrive and was being tube fed. Causal and maintaining factors were identified and the subsequent intervention (the feeding program) combined a behavioral treatment (learning principles applied at mealtimes) and family-centered work (systematic parent training procedures). By the time of the psychological intervention, the majority of developmentally and age-appropriate feeding behavior appeared to be absent and the child only fed through a naso-gastric tube. The number and variety of feeding behaviors and the amount and variety of foods taken increased during treatment. These behaviors were maintained during the follow-up and generalized into the home environment. There was also an observed increase in the child's capacity for emotional expression. Successful outcomes can be achieved with complex feeding problems by using a multifaceted approach that places emphasis on effective transdisciplinary collaboration and the inclusion of the family in all stages of the process.

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

OBJECTIVES

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

METHODS

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

ANALYSIS

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

RESULTS

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

CONCLUSIONS

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

Growth status related to brain responses, nutrition, home environment, and behavior in infants and toddlers

To investigate whether growth status in infants and toddlers affects processes involved in speech perception and discrimination, cortical event-related potentials (ERPs) to consonant-vowel syllables were recorded from 48 healthy babies: 26 low in growth status (LGS, < 25 th percentile in growth measures) and from 22 normal in growth status (NGS, 25t--75 th percentile in growth measures). Food records indicated no significant differences in the amounts of various nutrients consumed in the two groups, but LGS babies consumed slightly more of most nutrients than NGS babies. In response to speech stimuli (either /pa/ or /ba/ presented with 20 and 80% randomized occurrence), brain ERPs showed two prominent post-stimulus components: a large positive wave peaking at about 484 msec and a negative but positive going slow wave (SW) between 867 and 1199 msec. Principal components analysis followed by promax rotation revealed four additional important components. Maximum peak and latency values-for these components showed that NGS and LGS babies differed from one another on all measures in either amplitude, latency, or both. Comparing the two groups of babies, only the LGS group demonstrated a deficit in the phonetic discrimination of speech sounds. The growth deficiencies of the LGS group could not be attributed to the lack of an adequate diet. These negative findings are present in babies generally considered to be healthy (lowest 10-25% in growth measures). This underscores the need for research examining in more detail the relationship between growth status and cognitive growth.

The relationship between birthweight, weight gain in infancy, and educational attainment in childhood

Previous studies have examined the relationship between low weight gain (failure to thrive) in infancy and later cognitive ability, but no study to date appears to have examined the relationship between weight gain in infancy across the 'normal' range and later cognitive ability. We report results for a large prospective birth cohort of the relationship between weight gain in infancy and educational attainment at age 10. Routinely recorded weights from child health clinic records for an annual birth cohort of 3418 children born with gestation >36 weeks were collected, as well as gestation in weeks, birthweight and the postcode, for which the Townsend Deprivation Score was identified. At 10 years of age, those attending schools within the Newcastle Education Authority were given a picture vocabulary and a non-verbal ability test, and tests of educational attainment in maths and reading. These were successfully linked to the infant weight data for 2294 (63%) of the children, and complete growth data were available for 1724 (47%) of the children who had completed at least one educational test. There was a significant positive relationship between weight gain in infancy and picture vocabulary, adjusted for economic deprivation, gestational age and birthweight, but not with any of the other outcomes. There was a statistically significant association between birthweight and all four outcomes, which was positive up to about one SD above average birthweight, and negative above. In this population, the association between early growth and cognitive outcomes is stronger for growth before birth, postnatal weight gain having a relatively minor impact.

Impact of prenatal and/or postnatal growth problems in low birth weight preterm infants on school-age outcomes: an 8-year longitudinal evaluation

OBJECTIVE

The objective of this study was to assess the 8-year growth, cognitive, behavioral status, health status, and academic achievement in low birth weight preterm infants who had failure to thrive only, were small for gestational age only, had failure to thrive plus were small for gestational age, or had normal growth.

METHODS

A total of 985 infants received standardized evaluations to age 8; 180 infants met the criteria for failure to thrive between 4 and 36 months' gestational corrected age. The following outcome variables were collected at age 8: growth, cognitive, behavioral status, health status, and academic achievement. Multivariate analyses were performed among the 4 growth groups on all 8-year outcome variables.

RESULTS

Children who both were small for gestational age and had failure to thrive were the smallest in all growth variables at age 8, and they also demonstrated the lowest cognitive and academic achievement scores. The children with failure to thrive only were significantly smaller than the children with normal growth in all growth variables and had significantly lower IQ scores. Those who were small for gestational age only did not differ from those with normal growth in any cognitive or academic achievement measures. There were no differences among the 4 groups in behavioral status or general health status.

CONCLUSION

Low birth weight preterm infants who develop postnatal growth problems, particularly when associated with prenatal growth problems, demonstrate lower physical size, cognitive scores, and academic achievement at age 8. There does not seem to be an independent affect of small for gestational age status on 8-year cognitive status and academic achievement when postnatal growth is adequate.

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.

Failure to thrive and cognitive development in toddlers with infantile anorexia

OBJECTIVE

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

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

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