Identifying clinically relevant feeding problems and disorders

Factors associated with age of presentation of pediatric feeding disorder

AIM

Understanding the association between pediatric feeding disorder (PFD) and age of presentation is limited. We aimed to investigate factors associated with PFD among different age groups.

METHODS

Retrospective analysis of medical records of infants and toddlers diagnosed with PFD, according to the World Health Organization-based definition. We compared children aged 1-12 months to those aged 13-72 months.

RESULTS

Included were 253 children with PFD (median [interquartile range] age 16.4 [9.5-33] months at diagnosis, 56% boys). Significantly more children in the younger age group were girls (52.6% vs. 34.4%, respectively, p = .03) and preterm (25% vs. 14%, p = .03). They had more hospitalizations (34% vs. 23%, p = .03) and needed more prescription medications (36% vs. 17%, p < .01). Additionally, disturbances in oral intake were primarily linked to feeding skills dysfunction in the younger group and nutritional dysfunction in the older group (39.6% vs. 23.7% and 55% vs. 38%, respectively, p = .02).

CONCLUSIONS

Infants under 1 year old with PFD represent a distinct patient group with unique characteristics and outcomes. The age of presentation plays a significant role in children with PFD, necessitating tailored treatment strategies.

New consensus definition on defining and measuring care for children with paediatric feeding disorder

AIM

This study addresses the absence of a definition of care for children with feeding disorders, limited agreement on key performance indicators (KPIs), and the lack of data linked to those KPIs.

METHODS

Clinicians, consumers and researchers involved in outpatient feeding care in New South Wales (NSW), Australia were invited to participate in a two-Phase study. In Phase 1, a modified Delphi method was used. Two rounds of voting resulted in a new consensus definition of a multidisciplinary paediatric feeding clinic. Three further rounds voting determined relevant KPIs. In Phase 2, the KPIs were piloted prospectively in 10 clinics.

RESULTS

Twenty-six clinicians, consumers and researchers participated in Phase 1. Participation across five voting rounds declined from 92% to 60% and a valid definition and KPI set were created. In Phase 2, the definition and KPIs were piloted in 10 clinics over 6 weeks. Data for 110 patients were collected. The final KPI set of 28 measures proposed covers clinical features, patient demographics and medical issues, parent-child interaction and outcome measures.

CONCLUSIONS

A new definition of a multidisciplinary paediatric feeding clinic is now available, linked to a standardised KPI set covering relevant performance measures. These proved viable in baseline data collection for 10 clinics across NSW. This sets a foundation for further data collection, systematic measurement of care provision and outcomes, and research needed to deliver care improvement for children with paediatric feeding disorder.

Parents' experiences of living with a child with Paediatric Feeding Disorder: An interview study in Sweden

INTRODUCTION

Children affected by Paediatric Feeding Disorder (PFD) cannot consume enough nourishment by mouth. PFD is highly prevalent and can affect the child's growth and development as well as family life.

AIM

To illuminate Swedish parents' experiences of living with a child with PFD.

METHOD

Semi-structured interviews via telephone or video calls were conducted with 14 purposefully recruited mothers and six fathers. The interviews were analysed using content analysis. Ethics approval was obtained, and the parents all gave informed consent.

RESULTS

Four overarching themes emerged: Living with stress; Advocating for the child; Adapting family life; and Gaining hope. Parents described fearing for their child's life and health, feeling pressure over meals and being emotionally affected. They told of experiencing a lack of understanding from healthcare professionals, friends and family. Parents expressed a struggle for help, the need for early interventions and more effective treatment, and developed strategies for coping with the demands of feeding and caring for their child, accepting their living reality. Finding support from a network helped, but the adaptation of daily life affected their family relations. They felt gratitude towards helpful professionals and relief and joy when their child was doing better.

CONCLUSIONS

A more cohesive chain of care is important for children with PFD, and guidelines and educational support for healthcare providers are needed. Parental experiences provide a base for knowledge for further development of early detection and intervention for children with PFD.

A qualitative inquiry of parents of extremely picky eaters: Experiences, strategies and future directions

BACKGROUND/AIM

Picky eating is a common childhood phenomenon in younger children, impacting family relationships and mealtimes. Limited qualitative studies have explored parents' experiences of parenting an extremely picky eater. This study aimed to address this gap.

METHODS

This exploratory qualitative research design included participants who were Australian-based parents (n = 10) of children aged 2-6 years with a minimum picky eating score of 3.33, indicating extreme picky eating, on the Food Fussiness subscale of the Child Eating Behavior Questionnaire (CEBQ). Parents were interviewed online via Zoom using semi-structured interviews focused on their experiences of having a child who is a picky eater. Reflexive thematic analysis was used to analyze the data.

RESULTS

Five themes were identified: 1: The picky eating journey for parents. 2: Picky eating impacts families and mealtimes. 3: Parents have attempted multiple strategies to manage picky eating. 4: Emotions associated with parenting an extremely picky eater. 5: Parents of extremely picky eaters have a positive outlook for the future.

CONCLUSION

This qualitative study demonstrates that parents' experiences of parenting an extremely picky eater are varied. Parents desire health professionals who listen to their concerns and provide evidence-based knowledge around parent feeding practices to positively impact picky eating.

Screening of Swallowing and Feeding-Related Problems in Typically Developing Children

The aim of this study was to define swallowing and feeding-related problems among typically developing children aged between 2 and 6 years. The presence of food selectivity, limited appetite, chewing dysfunction, and dysphagia signs was questioned and scored as "absent" or "present" according to parent report. Children were divided into 2 groups: children with swallowing and feeding disorders and children without swallowing and feeding disorders. The Turkish version of the Behavioral Pediatrics Feeding Assessment Scale (T-BPFAS) was used to evaluate feeding behaviors of children, and Turkish version of the Feeding/Swallowing Impact Survey (T-FS-IS) was used to measure the impact on caregivers. A total of 234 children were included. Food selectivity was defined in 62.4% (n = 146), limited appetite in 26.9% (n = 63), and chewing dysfunction in 7.3% (n = 17). The most common dysphagia-related sign was coughing. There were significant differences between groups in terms of both T-BPFAS and T-FS-IS (P < .001). In conclusion, children with typical development have experienced a wide range of swallowing and feeding-related problems, which have an impact on mothers' perceptions regarding feeding and their quality of life.

Feeding Problems in Young Children: A Cross-Sectional Study in Sweden

To describe the prevalence of feeding problems (FPs) in children aged 10, 18, and 36 months who visited Swedish Child Health Services.

Methods

Parents of children attending regular 10-, 18-, and 36-month visits at the child health care centers (CHCCs) in Sweden answered a questionnaire including a Swedish version of the Behavioral Pediatrics Feeding Assessment Scale (BPFAS) as well as demographic questions. CHCCs were stratified according to a sociodemographic index.

Results

Parents of 238 girls (115) and boys (123) completed the questionnaire. Using international thresholds for FP detection, 8.4% of the children had a total frequency score (TFS) indicating FP. Based on the total problem score (TPS), the result was 9.3%. The mean score for all children was 62.7 for TFS (median 60; range 41-100), and 2.2 for TPS (median 0; range 0-22). Children aged 36 months had a significantly higher average TPS score than younger children, but TFS scores did not differ by age. There were no significant difference in gender, parents' education, or sociodemographic index.

Conclusion

Prevalence numbers found in this study are similar to those found in studies with BPFAS in other countries. Children 36 months of age had a significantly higher prevalence of FP than children aged 10 and 18 months. Young children with FP should be referred to health care specializing in FP and PFD. Creating awareness of FP and PFD in primary care facilities and child health services may facilitate early detection and intervention for children with FP.

Evaluation and Management of Pediatric Feeding Disorder

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

Feeding Problems as an Indicator of Developmental Delay in Early Childhood

OBJECTIVE

To determine whether feeding problems are indicators of developmental delay.

STUDY DESIGN

In this prospective longitudinal cohort study, mothers of 3597 children (49% female, 35% multiples) reported on their children's feeding problems and developmental delays (using the Ages and Stages Questionnaire [ASQ]) when children were age 18, 24, and 30 months. Average scores of feeding problems were computed at each age, as well as a categorical score indicating a persistently high number of feeding problems ≥90th percentile across time. The Battelle Developmental Inventory, Second Edition (BDI-2) was used to assess development in 5 domains for a subset of children at 4 years.

RESULTS

In adjusted analyses, feeding problems (per point increase) were increasingly associated with 6 ASQ domains from 18 months (OR, 1.30-1.98) to 24 months (OR, 2.07-2.69) to 30 months (OR, 3.90-5.64). Compared with children who never experienced feeding problems, children who experienced a high number of feeding problems at 1 or 2 time points were more than twice as likely to have a delay on all ASQ domains (OR, 2.10-2.50), and children who experienced a high number of feeding problems at all 3 time points were ≥4-fold more likely to have a delay on all ASQ domains (OR, 3.94-5.05). Children with 1-point higher feeding problems at 30 months scored 3-4 points lower in all BDI-2 domains at 4 years.

CONCLUSIONS

Frequent feeding problems, especially those that persist into the third year, could be used to identify children at risk for developmental delay for more targeted screening.

Evaluation of mothers' opinions on appetite and body shape perception of their children

OBJECTIVES

In this study, we aimed to evaluate how mothers perceived the appetite and body shape of their children using gender- and age-specific development sketches.

STUDY DESIGN

The study design used in the study is a single-centred descriptive study.

METHODS

We included 153 children aged 2-14 years and their mothers who attended family medicine polyclinic outpatient services, for any reason, at the University of Health Sciences, Şişli Hamidiye Etfal Teaching and Research Hospital, Istanbul, Turkey, between February 2019 and April 2019. Weight and height measurements of both the children and their mothers were taken. In addition, the mothers completed the sociodemographic data form and were asked to select an image from the gender- and age-specific development sketches that best represented their child's body shape. Participants were divided into four groups by their body mass index (BMI) in accordance with criteria from the Centres for Disease Control and Prevention. Results were compared using appropriate statistical procedures.

RESULTS

A significant weak positive correlation was observed between maternal BMI and child BMI (r = 0.166, P = 0.041). When the maternally perceived BMI (determined by the age-specific development sketches) was compared with the actual BMI values of children, mothers perceived their underweight children to be in higher BMI groups, whereas the overweight and obese children were perceived to be in lower BMI groups. The results were similar when the same comparison was made for the mother's expectation (i.e. the body shape the mother desired for their child).

CONCLUSIONS

When mothers were asked to visually evaluate the body shape of their children, their responses were inaccurate compared with both the actual data and the researcher's evaluation. Obtaining verbal assessments from mothers about their children (e.g. an assessment of the child's bodily appearance) is important for physicians to make correct referrals and also for public health policies. It is valuable for mothers to correctly interpret the weight status of their children, thus enabling early diagnosis and treatment, and preventing future health consequences.

Feeding Problems in Typically Developing Young Children, a Population-Based Study

Feeding problems have been estimated to occur in approximately 25–45% of normally developing children. The aim of this study was to investigate the prevalence of feeding problems in typically developing young children in Greece. Child feeding behavior, parents’ feelings about their child’s feeding patterns, and parental feeding practices were also explored. Parents completed the Greek version of the Behavioral Pediatrics Feeding Assessment Scale (BPFAS). Data on 742 healthy, typically developing children aged two to seven years are presented. Overall, the majority of children in the sample showed high frequency of desirable mealtime behaviors and low frequency of undesirable mealtime behaviors. However, a significant proportion of the cohort presented with food neophobia and low consumption of vegetables. When applying test cut-off scores, it was found that 8.2% of the sample had abnormal Total Frequency Score (TFS) and 26.6% had abnormal Total Problem Score (TPS). The study showed that parent-reported feeding problems are quite common in children of typical development in Greece. Moreover, while the majority of the sample displayed a high frequency of favorable behaviors, specific child feeding behaviors are amenable to improvement.

The relationship between chronic paediatric feeding disorders and caregiver stress

Paediatric feeding disorders (PFDs) are common. Earlier studies have shown an association between PFD and caregiver stress, but these studies have been hampered by insufficient power. This study reports stress for caregivers of children diagnosed with PFD. These caregivers were then compared to community norms of the Parental Stress Index-Short Form. Caregivers also completed the Mealtime Behaviour Questionnaire, Child Behaviour Checklist and Child Development Inventory. Linear regression and hierarchical regression analyses assessed the relationship among the variables. Caregivers of 840 children with PFD responded. Negative child behaviours and lower child developmental function predicted higher levels of total parenting stress, parental distress, parent-child dysfunctional interaction and caregiver perceptions of their child as difficult. Higher rates of child internalizing and externalizing problems and child mealtime aggression were associated with parent perceptions of their child as difficult and contributed to total parental stress. Parents of older children reported higher levels of stress, whereas parents of younger children were more likely to be defensive responders. Overall, parents of children with PFD have more caregiver-related stress. These caregivers may benefit from consultations with mental health professionals to provide the most appropriate care to affected families.

Parental management of feeding problems in young children-a population-based study

OBJECTIVES

To investigate the practices that parents use to manage feeding problems in healthy children and in children with gastrointestinal diseases. Secondly, for each of these two groups we examined the association of select child and parent variables with parental feeding practices.

METHODS

This is a cross-sectional case-control study. The sample consisted of 901 children (765 healthy children of typical development and 136 children with gastrointestinal diseases), aged one to seven years. The feeding problem management practices were investigated through 23 closed-ended questions. The anthropometric and demographic data of children and the demographic data of parents were collected by administering structured set of questions to parents.

RESULTS

The prevalence of parent-reported feeding problems was 30.6% for healthy children and 45.7% for children with gastrointestinal diseases. The most common practices adopted by parents of healthy children were highlighting the benefits of food (80.5%), correlating food with pleasure (71.6%) and praising (59.1%), whereas almost half of the parents were found not to accept that their children may not be hungry and insisted on trying to feed them. Statistically significant differences were noted in many parental practices between the two groups. Parents of children with gastrointestinal diseases were generally more involved in the feeding process. Verbal praising (69.1%), correlation with pleasure (79.4%), promotion of benefits (77.2%) as well as assistance during feeding (63.2%) were the most common parental practices in the gastrointestinal group. Age, birth order, being the only child and weight status were child variables that differentiated parental behavior. Parental characteristics that affected feeding practises were age, education and work status.

CONCLUSIONS

A high prevalence of feeding problems was reported by parents of both healthy children and children with gastrointestinal diseases. Beside the presence of a disease, specific child and parent variables are significantly related to parental behavior when managing feeding problems.

An Economic Analysis of Intensive Multidisciplinary Interventions for Treating Medicaid-Insured Children with Pediatric Feeding Disorders

Background. Intensive multidisciplinary intervention (IMI) represents a well-established treatment for pediatric feeding disorders (PFDs), but program availability represents an access care barrier. We develop an economic analysis of IMI for weaning from gastronomy tube (G-tube) treatment for children diagnosed with PFDs from the Medicaid programs' perspective, where Medicaid programs refer to both fee-for-service and managed care programs. Methods. The 2010-2012 Medicaid Analytic eXtract claims provided health care data for children aged 13 to 72 months. An IMI program provided data on average admission costs. We employed a finite-horizon Markov model to simulate PFD treatment progression assuming 2 treatment arms: G-tube only v. IMI targeting G-tube weaning. We compared the expenditure differential between the 2 arms under varying time horizons and treatment effectiveness. Results. Overall Medicaid expenditure per member per month was $6814, $2846, and $1550 for the study population of children with PFDs and G-tube treatment, the control population with PFDs without G-tube treatment, and the no-PFD control population, respectively. The PFD-diagnosed children with G-tube treatment only had the highest overall expenditures across all health care settings except psychological services. The expenditure at the end of the 8-year time horizon was $405,525 and $208,218 per child for the G-tube treatment only and IMI arms, respectively. Median Medicaid expenditure was between 1.7 and 2.2 times higher for the G-tube treatment arm than for the IMI treatment arm. Limitations. Data quality issues could cause overestimates or underestimates of Medicaid expenditure. Conclusions. This study demonstrated the economic benefits of IMI to treat complex PFDs from the perspective of Medicaid programs, indicating this model of care not only holds benefit in terms of improving overall quality of life but also brings significant expenditure savings in the short and long term.

Feeding and developmental outcomes of infants in a South African community

BACKGROUND

Prevalent environmental risk factors place infants in lower-middle-income countries (LMICs) at an increased risk for feeding and developmental difficulties.

AIM

This study aimed to determine the relationship between feeding and developmental outcomes in infants, as early feeding difficulties may have a cascading effect on developmental outcomes and vice versa.

METHODS

Data on 144 infants' feeding and development [mean age (standard deviation) = 8.8 months (2.2)] from a primary health care clinic in Gauteng, South Africa were retrospectively analysed.

RESULTS

Early introduction of cup feeding was found to be a predictor of possible expressive language and articulation difficulties. Gagging, spitting, or vomiting, pocketing, the use of force feeding, and poor sucking and chewing abilities were significantly associated with behavioural and social-emotional difficulties. Breastfeeding was found to be a protective factor for language development. The results emphasise the importance of primary prevention and early identification of risks in late infancy in LMIC.

High adherence to a mediterranean diet at age 4 reduces overweight, obesity and abdominal obesity incidence in children at the age of 8

BACKGROUND/OBJECTIVES

A higher adherence to a Mediterranean diet has been shown to be protective against obesity in adults, but the evidence is still inconclusive in children at early ages. Our objective was to explore the association between adherence to Mediterranean Diet at the age of 4 and the prevalence of overweight, obesity, and abdominal obesity at 4 years of age, and incidence at the age of 8.

SUBJECTS/METHODS

We analyzed data from children of the INMA cohort study who attended follow-up visits at age 4 and 8 years (n = 1801 and n = 1527, respectively). Diet was assessed at the age of 4 using a validated food frequency questionnaire. The adherence to MD was evaluated by the relative Mediterranean diet (rMED) score, and categorized as low (0-6), medium (7-10), and high (11-16). Overweight and obesity were defined according to the age-sex specific BMI cutoffs proposed by the International Obesity Task Force, and abdominal obesity as waist circumference >90th percentile. We used Poisson regression models to estimate prevalence ratios at 4 years of age, and Cox regression analysis to estimate hazard ratios (HR) from 4-8 years of age.

RESULTS

In cross-sectional analyses at the age of 4 no association was observed between adherence to MD and overweight, obesity, or abdominal obesity. In longitudinal analyses, a high adherence to MD at age 4 was associated with lower incidence of overweight (HR = 0.38; 95% CI: 0.21-0.67; p = 0.001), obesity (HR = 0.16; 95% CI: 0.05-0.53; p = 0.002), and abdominal obesity (HR = 0.30; 95% CI: 0.12-0.73; p = 0.008) at the age of 8.

CONCLUSION

This study shows that a high adherence to MD at the age of 4 is associated with a lower risk of developing overweight, obesity, and abdominal obesity at age 8. If these results are confirmed by other studies, MD may be recommended to reduce the incidence of obesity at early ages.

A Functional Approach to Feeding Difficulties in Children

PURPOSE OF REVIEW

This review provides an approach for resolving a variety of feeding difficulties in children, ranging from normal eating behavior that is misperceived as a problem to substantial feeding disorders.

RECENT FINDINGS

Criteria to identify pediatric feeding disorders have been thoroughly addressed in the newly established designations of avoidant restrictive food intake disorder (ARFID) and pediatric feeding disorder (PFD). These diagnostic criteria improve the accuracy of identifying, classifying, and managing significant feeding disorders in young children. While recent definitions of feeding difficulties are particularly appropriate in multidisciplinary settings, in this paper, we advocate for a progressive approach of managing feeding problems in all clinical settings. It begins by identifying red flags indicative of serious threats to the child, screening for oral motor dysfunction, stabilizing nutrient intake, and eliminating aversive feeding practices. The next step, if eating behavior does not improve, involves strategies that target specific eating behaviors and parental feeding styles. In severe or resistant cases, referral to specialists or interdisciplinary feeding teams is advised.

Atypical Presentation of Viral Gastroenteritis in a Three-year-old Child Due to a UNC80 Mutation

We report a three-year-old child with a rare genetic phenomenon, a UNC80 mutation, who had an unusual presentation of viral gastroenteritis. The UNC80 gene encodes for an important voltage-independent channel in neurons and a mutation in this protein can lead to severe hypotonia. The hypotonia manifests as delayed gastric emptying, impaired respiratory clearance, and/or delayed muscle coordination, which can predispose to infection susceptibility. UNC80 gene mutations have also been shown to cause global developmental delays, failure to thrive, and phenotypic dysmorphisms. In our patient, we believe that his genetic defect precipitated a complicated hospital course. The patient’s delayed gastric emptying caused difficulty in recovering from viral gastroenteritis while a concurrent pneumonia diagnosis required assistance in clearing respiratory contents. The UNC80 mutation is under-studied, and more studies are necessary to understand the clinical implications of its phenotypes.

Association between eating frequency and eating behaviours related to appetite from 4 to 7 years of age: Findings from the population-based birth cohort generation XXI

The examination of specific characteristics of eating habits in childhood and its influence on eating behaviours is needed to better understand the establishment of appetite-related eating behaviours. This study aimed to assess the association between eating frequency (EF) (main meals vs. snacks) at 4 and 7y and problematic eating behaviours and appetite-related eating behaviours at 7y. The analysis included 1359 children from the birth cohort Generation XXI who provided 3-day food diaries, at both ages, and complete information on the Child Eating Behaviour Questionnaire, at 7y. Problematic eating behaviours were assessed using parental perception of child's poor eating (including not eating enough, eating too slow or overeating) at both ages. A time-of-day approach was used to distinguish main meals from snacks. A cross-lagged analysis was performed to check the direction of the association between EF and parental concerns regarding problematic eating behaviours. Associations between EF and appetite-related eating behaviours were evaluated through linear regression models. Between 4 and 7y a moderate tracking of EF was described as well as a strong tracking of parental concerns. We found a bidirectional relationship between EF and parental concerns. Prospectively, a higher frequency of snacks at 4y was independently associated with higher scores in 'Desire to Drink' at 7y (β = 0.051, 95%CI:0.009; 0.093). At 7y, a higher EF had a positive association with 'Satiety Responsiveness' but an inverse association with 'Enjoyment of Food'. A higher number of main meals had a positive association with 'Enjoyment of Food' and 'Food Responsiveness'. In conclusion, children who had more eating occasions seem to have more food-avoidance behaviours, traits that might protect these children from gaining excessive weight.

"It's a Long-Term Process": Description of Daily Family Life When a Child Has a Feeding Disorder

Pediatric feeding problems occur in 25% of the general pediatric population and up to 80% of those who have developmental delays. When feeding problems place the child at nutritional risk, families are typically encouraged to increase their child's intake. Family mealtime can become a battle, which further reinforces problematic feeding behaviors from the child and intensifies well-intentioned but unguided parental mealtime efforts. Family has an essential influence on feeding; however, studies to date neglect to address the family context of feeding difficulty. In this study we describe, in the context of everyday life, family management of feeding when a child had a significant feeding problem. Parents of children with feeding problems were interviewed with the Family Management Style Framework components as a guide. Twelve parents participated, representing nine families of children with feeding disorder. Description of family management of feeding provides a foundation for development of family feeding interventions.

The association of problematic eating behaviours with food quality and body mass index at 7 years of age

BACKGROUND/OBJECTIVES

There is scarce evidence of how certain eating behaviours compromise the compliance with dietary guidelines and weight status in school-aged children. This study aims to evaluate the association of children's problematic eating behaviours with food quality and body mass index at 7 years of age.

SUBJECTS/METHODS

Participants were children aged 7 years old from a population-based cohort study from Porto, Portugal-Generation XXI. Children's quantity and speed of ingestion, food refusal at the table and food rewards requesting were evaluated by caregiver's perception. Food consumption was evaluated by a food frequency questionnaire and compared with age-appropriate guidelines. Children's weight status was assessed by objective measurements and parent's perceptions. Associations were estimated by logistic regressions (odds ratio (OR), 95% confidence intervals (95% CI)) adjusted for maternal age, education, smoking during pregnancy, birth type, child's sex, weight-for-gestational age and sports (n = 3801).

RESULTS

Children eating small amounts of food, refusing to eat at the table with the rest of the family during meals and asking for food rewards showed a higher consumption of energy-dense foods (OR = 1.51; 95% CI:1.23-1.86; OR = 1.58; 95% CI:1.16-2.16; OR = 1.56; 95% CI:1.14-2.12) and presented higher odds of consuming fruit and vegetables below recommendations (OR = 1.41; 95% CI:1.22-1.64; OR = 1.20; 95% CI:1.00-1.45; OR = 1.28; 95% CI:1.05-1.55). Children displaying these eating behaviours were less likely to be overweight/obese, hence their parents were less likely to show concern with their weight. Including food quality as covariate in the final models with obesity status did not change the associations.

CONCLUSIONS

Problematic eating behaviours were associated with poorer food quality (more energy-dense foods and low fruit and vegetables), but food quality does not seem to explain the association with obesity status. Parents were less likely to be concerned about their child's weight if the child ate slowly or poorly, and accordingly the odds of them being overweight or obese were lower.

Interdisciplinary Feeding Team: A Medical, Motor, Behavioral Approach to Complex Pediatric Feeding Problems

Pediatric feeding difficulties are complex and multifactorial in nature. Children who need assessment and individualized treatment for complex feeding problems are best served by an interdisciplinary treatment team. The medical, motor, and behavioral approach to treating pediatric feeding problems is presented as an avenue to treatment. By necessity, this approach requires a well-functioning interdisciplinary team, including nurses, physicians, registered dietitians, and feeding therapists (speech-language pathologists, occupational and physical therapists). We describe a robust interdisciplinary feeding team that applies a medical, motor, and behavioral approach to treating pediatric feeding problems. Within this team, pediatric gastroenterology nurse practitioners, dietitians, and speech pathologists function as integral members of the team. Description of each team member's expertise is provided and how they operate to support children with feeding problems and their families.

Dysphagia and feeding difficulties post-pediatric ingestion injury: Perspectives of the primary caregiver

PURPOSE

To explore the experiences of children with dysphagia and/or feeding difficulties post-chemical or button battery ingestion injury from the perspective of the primary caregiver.

METHOD

Five primary caregivers of children with a history of dysphagia and/or feeding difficulties post-ingestion injury (4 chemical, 1 button battery) completed the Children's Picky Eating Questionnaire (CPEQ), and participated in a semi-structured interview. Interviews explored experiences of caring for a child with dysphagia and/or feeding difficulties, impressions of services and supports, and additional impacts to the child and family. Content analysis was used to identify key themes.

RESULT

Primary caregiver report and CPEQ results confirmed all children had some degree of persisting dysphagia and/or feeding difficulties at time of interview (mean 4.13 years' post-injury). Interviews identified five key themes: 1) The initial trauma of the injury, 2) The experience of associated and ongoing medical issues, 3) Managing altered oral intake, 4) Experiences of services and support, and 5) Impacts on the child, primary caregiver, and wider family unit. All caregivers reported significant challenges and concerns, and potential areas of service improvement were highlighted.

CONCLUSION

The current data highlights specific issues experienced by primary caregivers, and poses areas for improving primary caregiver and family supports. Family-centered models of care are needed to support the whole family unit in caring for a child with dysphagia and/or feeding difficulties post-ingestion injury.

Dietary patterns at 4 years old: Association with appetite-related eating behaviours in 7 year-old children

BACKGROUND & AIMS

A possible relationship between children's dietary intake and certain aspects of eating behaviours has been documented, but most studies are cross-sectional and do not consider the complexity of the diet. The aim of this study was to quantify the association between dietary patterns established at 4 years old and appetite-related eating behaviours identified at 7 years old.

METHODS

Participants are children from the Generation XXI population-based birth cohort. Trained interviewers collected data at birth, 4 and 7 years old on socio-demographics, health and lifestyles, and anthropometrics. At 4 years old, diet was assessed by a Food Frequency Questionnaire and three dietary patterns were identified by Latent Class Analysis: 'Healthier', 'Snacking' and 'Energy Dense Foods' (EDF). A Portuguese version of the original Children's Eating Behaviour Questionnaire (CEBQ) was self-completed by mothers at 7 year-old. This version has previously shown good psychometric properties and the 8 CEBQ sub-domains were combined into two wider dimensions: Appetite Restraint and Appetite Disinhibition. Generalized linear models were used to estimate the associations after adjustment for maternal characteristics (n = 4358). Interaction effects were tested.

RESULTS

Children belonging to the 'Snacking' (β = 0.329, 95%CI: 0.265; 0.393) and to the 'EDF' (β = 0.138, 95%CI: 0.098; 0.179) dietary patterns at 4 years old scored increasingly higher, respectively, on Appetite Restraint and Appetite Disinhibition dimensions at 7 years old, comparatively to children in the 'Healthier' dietary pattern. Maternal BMI before pregnancy modified the 'Snacking' pattern associations; they were stronger in children from underweight/normal weight mothers for Appetite Restraint and present only among overweight/obese mothers for Appetite Disinhibition.

CONCLUSIONS

This study suggests that children following less healthy dietary patterns early in life have more often disordered eating behaviours in later childhood. Maternal weight status may influence these associations.

Screening Avoidant/Restrictive Food Intake Disorder (ARFID) in children: Outcomes from utilitarian versus specialist psychometrics

This study assessed the specificity and sensitivity of two commonly used psychometric methods to assess ARFID in children. To achieve this, a sample of 329 mothers and one father completed the Behavioral Pediatrics Feeding Assessment Scale (BPFAS) and the Child Food Neophobia Scale (CFNS). A Receiver Operating Characteristic (ROC) analysis indicated that both measures were able to successfully differentiate a known clinical sample from those of typically developing population. Although the BPFAS was more accurate at differentiating ARFID from the general population, the CFNS was acceptable and on some metrics better than its longer counterpart. The ability of a food neophobia scale to differentiate clinical and population samples, and detect gradation of food avoidance within the population sample, suggests that the multitude of psychometric measures available may be measuring similar constructs. Therefore, confidence can be expected in cross-site comparisons despite each using different psychometric measures of food avoidance in children.

Phenotypic evolution of UNC80 loss of function

Failure to thrive arises as a complication of a heterogeneous group of disorders. We describe two female siblings with spastic paraplegia and global developmental delay but also, atypically for the HSPs, poor weight gain classified as failure to thrive. After extensive clinical and biochemical investigations failed to identify the etiology, we used exome sequencing to identify biallelic UNC80 mutations (NM_032504.1:c.[3983-3_3994delinsA];[2431C>T]. The paternally inherited NM_032504.1:c.3983-3_3994delinsA is predicted to encode p.Ser1328Argfs*19 and the maternally inherited NM_032504.1:c.2431C>T is predicted to encode p.Arg811*. No UNC80 mRNA was detectable in patient cultured skin fibroblasts, suggesting UNC80 loss of function by nonsense mediated mRNA decay. Further supporting the UNC80 mutations as causative of these siblings' disorder, biallelic mutations in UNC80 have recently been described among individuals with an overlapping phenotype. This report expands the disease spectrum associated with UNC80 mutations. © 2016 Wiley Periodicals, Inc.

Neurodevelopmental Profile, Growth, and Psychosocial Environment of Preterm Infants with Difficult Feeding Behavior at Age 2 Years

OBJECTIVE

To examine the association of difficult feeding behaviors in very preterm infants at age 2 years with growth and neurodevelopmental outcomes and family factors and functioning.

STUDY DESIGN

Eighty children born ≤30 weeks gestation were studied from birth until age 2 years. Feeding difficulties were assessed using the Eating Subscale of the Infant-Toddler Social Emotional Assessment at age 2 years, along with growth measurement and developmental testing. Maternal mental health and family factors were assessed using standardized questionnaires. ANOVA and χ(2) analyses were performed to determine associations between feeding difficulties and growth, neurodevelopmental outcomes, and family characteristics.

RESULTS

Twenty-one children (26%) were at risk for feeding difficulties, and an additional 18 (23%) had definite feeding difficulties at age 2 years. Those with feeding difficulties were more likely to be subject to a range of neurodevelopmental problems, including impaired cognition (P = .02), language (P = .04), motor (P = .01), and socioemotional (P < .007) skills. Compared with the parents of children with fewer feeding difficulties, parents of the children with feeding difficulties had higher parenting stress (P = .02) and reported more difficulty managing their child's behavior (P = .002) and more frequent parent-child interaction problems (P = .002). No associations were found between difficult feeding behaviors and growth, maternal mental health, or family factors.

CONCLUSION

Difficult feeding behaviors in children born very preterm appear to be highly comorbid with other developmental and family challenges, including neurodevelopmental impairment and parent-child interaction difficulties. Focusing on improving feeding skills, in conjunction with supporting positive parent-child interactions, may be beneficial for improving outcomes.

Parental perceptions of childhood feeding problems

Previous research suggests that parental report of children's feeding corresponds with their child's nutritional intake (Cooke et al., 2006; Ekstein et al., 2010). The current study aimed to determine whether there is a relationship between parental report of children's feeding problems and their child's nutritional intake in a non-clinical population and, in addition, to establish whether parental anxiety (Cooke et al., 2003) can predict whether parental report of feeding problems correspond with the child's intake. Sixty-one parents of children aged two to seven years completed the parent report measure; the Behavioural Paediatric Feeding Assessment Scale as well as a food diary detailing their child's intake, which was analysed using CompEAT nutritional software. They also completed the anxiety subscale of the Hospital Anxiety and Depression Scale. Previous findings of an association between parent report of feeding problems and child's intake (Cooke et al., 2006) were not replicated. However, an association was found between parents' anxiety and their reports of feeding problems. Parental anxiety was also found to independently predict whether parent report of feeding problems matched the child's intake. Findings highlight the importance of a multifactorial approach to understanding childhood feeding difficulties. This requires replication with a clinical sample.

Organic and Nonorganic Feeding Disorders

Feeding is one of the most important interactions between caregiver and child in the first few years of life and even later on in handicapped children. Feeding disorders can present as food refusal or low quantity of food intake due to behavioral issues or underlying organic conditions. This situation concerns mostly infants and children below 6 years of age; however, feeding problems can appear also later on in life. Feeding disorders are a concern for over 10-25% of parents of otherwise healthy children below 3 years of age, but only 1-5% of infants and toddlers suffer from severe feeding problems resulting in failure to thrive. In case of premature infants or neurologically disabled children, this rate is much higher. Feeding disorders may appear as an isolated problem, mainly due to negative behaviors during feeding, or as a concomitant disorder with an underlying organic disease or structural anomaly. The newest classification also includes the feeding style presented by the caregiver (responsive, controlling, indulgent or neglectful) as a separate cause of feeding disorders.

Early problematic eating behaviours are associated with lower fruit and vegetable intake and less dietary variety at 4–5 years of age. A prospective analysis of three European birth cohorts

Problematic eating behaviours during early childhood could be mediators of poor dietary habits. This study aims to prospectively relate early eating behaviours with fruit and vegetable (F&V) intake and a healthy diet variety score of children aged between 4 and 5 years. Eating behaviours were assessed in three European birth cohorts (Generation XXI from Portugal, ALSPAC from the UK and EDEN from France) at 4–6, 12–15, 24 and 48–54 months of age, based on the child’s feeding difficulties, mother’s perception of child’s poor eating (eating small quantities at each meal, not eating enough or needing to be stimulated to eat), food refusal and difficulties in the establishment of daily food routines. Daily servings of F&V (>1 v. ≤1 serving/d, except in Generation XXI: >3 v. ≤3) and the Healthy Plate Variety Score (categorised by the median score of each sample) were calculated using FFQ. Associations were tested by logistic regressions adjusted for maternal age, education, smoking during pregnancy, any breast-feeding and the child’s z-score BMI at 4–5 years of age. Children with more feeding difficulties, poor eating, food refusal/neophobia and difficulties in establishing a daily routine at 12–15, 24 and 48–54 months of age had in general lower F&V intake at 4–5 years of age. The association with vegetables was slightly stronger than with fruits. These early feeding problems were also inversely associated with the variety score at 4–5 years of age, particularly when eating behaviours were reported after 12–15 months of age. A better understanding of these early feeding difficulties may help define strategies to increase the dietary quality in children.

Obesogenic environment: a concept analysis and pediatric perspective

PURPOSE

A concept analysis was undertaken to examine the attributes, characteristics, and uses of the concept of obesogenic environment within a pediatric context.

CONCLUSIONS

Utilizing a modified version of Walker and Avant's method, the attributes and characteristics of obesogenic environment were identified as it pertains to children. Based on the review of the literature and previous definitions applied to adults, a definition of the concept of obesogenic environment within a pediatric context was developed; examples of sample cases illustrate the concept further.

PRACTICE IMPLICATIONS

Defining the concept of obesogenic environment has utility for nursing theory development, practice, research, and education.

Feeding problems in healthy young children: prevalence, related factors and feeding practices

The aim of this study was to determine the prevalence, characteristics, and factors related to feeding problems among normal children, and the differences in feeding practices between those with and without feeding problems. Caregivers of 402 healthy children aged between one and four years of age were interviewed by pediatricians involved in the research. Data included the child's medical history, food intake within a day, and feeding behaviors and practices. Parental socio-economic and demographic information, as well as information on parental education and occupation, and their concerns about feeding their children, was collected. Physical examination and anthropometric measurements were taken. The percentage of children identified as having feeding problems was 26.9%. The first child of a family had an increased risk of having feeding problems [P=0.032, odds ratio 1.68, 95% confidence interval (95%CI) 1.04-2.71]. Children with feeding problems were fed less frequently, were less likely to be fed at their own table or at the family table, and had mealtimes longer than 30 min when compared with children without feeding problems (P=0.015, 0.004 and 0.025, respectively). The results highlight that feeding problems in normally developing children are common. During consultations about feeding issues, pediatricians should focus on families with a first child. Topics such as frequency of meals per day, duration of mealtimes, and appropriate places for feeding should be discussed.

Problematic eating behaviour in Turkish children aged 12-72 months: characteristics of mothers and children

OBJECTIVE

The aim of this study was to determine prevalence of problematic eating behaviour (PEB), associated risk factors, feeding practices including place of meal, variety of diet, and habits of consuming junk food, the mothers' perception of the child growth status in comparison to his/ her peers, and the effects on anthropometric measurements.

METHODS

This study was carried out among children aged 12-72 months who attended the outpatient clinic in the Ihsan Dogramaci Children's Hospital between February-June 2007. Three hundred and thirty-one mothers of children were asked to complete an extensive questionnaire covering socio-demographic characteristics and their child's general eating behaviour and feeding practices at mealtimes. Children with PEB were identified based on their mothers' statements.

RESULTS

Three hundred and thirty-one cases were 3.32 +/- 1.39 years old. One hundred thirty-five mothers reported having a child with PEB. The mothers described the children's problematic behaviour as: need to walk around with the child during mealtime (45.6%), watching TV during meals (41.9%), picky or fussy eating (39%), vomiting and/or retching (25.7%), retaining food in the mouth for a long time (20.6%), and not eating solid foods (11.8%). In children who had ate neither meat nor vegetables and fruits, took cod-liver oil-containing supplement during the course of the study, and had taken iron supplements in the first year of life, PEB was more frequent than in others. The mean z scores of weight for age (WAZ) were significantly lower in cases with PEB than without PEB.

DISCUSSION

Counselling and supporting of the mother/caregiver could alleviate the effect of inappropriate solutions taken by families. Insistence on composing of the diet variety including especially vegetables, fruits and meat may be promoted by provision of alternative cooking/presentation samples to mothers of children who refuse some foods. Pediatricians should be alerted that lower WAZ values may be a warning indicating a problem which may cause stagnated growth in children with PEB.