Dietary management of infants and young children with feeding difficulties and unsatisfactory weight gain using a nutritionally complete hypercaloric infant formula. practical considerations from clinical cases.

INTRODUCTION: A decrease in weight velocity and feeding difficulties in infants may be caused by an inadequate caloric intake and underlying medical conditions. CASE DESCRIPTION: By focusing on four clinical cases, this article illustrates the temporary use of a special infant formula in orally-fed and enterally-fed infants with unsatisfactory weight gain and special medical conditions such as gastrointestinal and neurological disorders. The formula was a nutritionally complete hypercaloric infant formula containing partially hydrolyzed whey protein. It was used after full consideration of all feeding options including breastfeeding. CONCLUSION: Implementing appropriate feeding behaviors, adapted to age and potential comorbidities, is an essential prerequisite for therapeutic management. The use of a nutritionally complete hypercaloric infant formula can be helpful to manage unsatisfactory weight gain and feeding difficulties in infants.

Emotional Deprivation in Children: Growth Faltering and Reversible Hypopituitarism.

Emotional deprivation can lead to growth faltering of infants and children. The mechanism(s) involved differ in that for infants, the major metabolic problem is inadequate energy intake for growth. In young children, it is likely that the emotional deprivation causes a syndrome not only of growth faltering, but with bizarre behaviors, especially with regard to food: hoarding, gorging and vomiting, hyperphagia, drinking from the toilet, and eating from garbage pails. Other disturbed behaviors include, poor sleep, night wanderings, and pain agnosia. The pathophysiology appears to be reversible hypopituitarism, at least for the growth hormone and hypothalamic-pituitary- adrenal axes. The review begins with an historical perspective concerning stress, children and growth and then moves to the issue of hospitalism, where young infants failed to thrive (and died) due to inadequate stimulation and energy intake. Refeeding programs at the end of World Wars I and II noted that some children did not thrive despite an adequate energy intake. It appeared that in addition taking care of their emotional needs permitted super-physiologic (catch-up) growth. Next came the first notions from clinical investigation that hypopituitarism might be the mechanism of growth faltering. Studies that address this mechanism from a number of observational and clinical research studies are reviewed in depth to show that the hypopituitarism was relieved upon removal from the deprivational environment and occurred much too quickly to be due to adequate energy alone. These findings are then compared to those from malnourished children and adoptees from emerging countries, especially those from orphanages where their psychosocial needs were unmet despite adequate caloric intake. Together, these various conditions define one aspect of the field of psychoneuroendocrinology.

Preliminary findings on the association between attachment patterns and levels of growth hormone in a sample of children with non-organic failure to thrive

Introduction: Deficiency of growth hormone (GH) in absence of pituitary injuries is one of the causes of short stature and of the non organic failure to thrive (NOFTT) condition. Advances in developmental psychology have highlighted the role of emotions and caregiving behaviors in the organization of child's personality and psychobiology, with the mother-son attachment bond being considered a fundamental developmental experience. The objective of the present preliminary study was to assess whether there are significant correlations between attachment patterns and GH levels in a sample of subjects with NOFTT. Methods: Overall, 27 children (mean age 9.49±2.63 years) with NOFTT were enrolled. Perceived attachment security was assessed through the Security Scale (SS) and its subscales focused on maternal and paternal security. Pearson partial correlation was used to test associations between GH levels and SS measures adjusting for confounding factors (i.e. age, gender and body mass index). Results: Across all subjects, GH was significantly positively correlated with general security (r=0.425; p=0.038) and maternal security (r=0.451; p=0.027) and not significantly correlated with paternal security (r=0.237; p=0.264). Discussion: These findings preliminarily suggest that the association between GH levels and perceived attachment security may play a role in the pathophysiology of NOFTT and add to the accumulating evidence that attachment patterns may be related with specific psychoendocrine underpinnings.

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.].

Prematuridade e outros fatores de risco adicional ao desenvolvimento perceptomotor e sua influência no desempenho escolar / Prematuritand additional risk factors to perceptomotor development and it´s influence on school performance / Prematuridad y otros factores de riesgo adicional al desarrollo perceptomotor y su influencia en el rendimiento escolar

Considerando que múltiplos fatores podem afetar o desempenho de alunos em tarefas acadêmicas, foram objetivos deste estudo: a) avaliar o desempenho de alunos do Ensino Fundamental sob parâmetros da performance em testes padronizados; b) identificar a influência da ocorrência de nascimento pré-termo e/ou com baixo peso e da presença de deficiência sobre as habilidades avaliadas nos testes. Participaram 77 alunos do 2º ano de uma escola pública. Sete deles nasceram prematuros e/ou com baixo peso e três foram apontados por seus responsáveis como apresentando deficiência. Para a coleta de dados foram utilizados o Teste do Desenvolvimento da Integração Visuo-Motora (Beery VMI) e o Teste de Desempenho Escolar (TDE) e um questionário desenvolvido para caracterização dos participantes. Em relação ao desempenho dos alunos no Beery VMI as médias de pontuações encontradas foram: 18 na avaliação da integração visuo-motora, 21 na avaliação de percepção visual e 22 no teste de coordenação motora. Em relação ao desempenho no TDE, a média de acertos foi: 13 no subteste de escrita, 8 na avaliação de aritmética e 46 no subteste de leitura. Constatou-se correlação positiva entre a habilidade de integração visuo-motora e a habilidade acadêmica avaliada nas tarefas de escrita, aritmética e leitura (p≤ 0,05). A presença de deficiência e a ocorrência de prematuridade ou baixo peso ao nascimento acentuaram as correlações. (AU)

Considering that multiple factors can affect student performance on academic tasks, the objectives of this study were: a) to evaluate the elementary student's performance in standardized tests, b) to identify the influence of preterm birth and/or low birth weight occurrence and the presence of disability on skills performance assessed in the tests. The participants were 77 students attending 2nd grade of a elementary public school. Seven were born prematurely and / or underweight and three were appointed by those responsible as having a disability. For data collection the Developmental Test of Visual-Motor Integration (Beery VMI) and Teste de Desempenho Escolar (TDE) and a questionnaire developed for participants' characterization were used. Regarding the students' performance in Beery VMI the average scores were: 18 in visual-motor integration test, 21 in visual perception test and 22 in motor coordination test. Regarding the performance in TDE, the mean score was 13 in writing subtest , 8 in arithmetic subtest and 46 in reading subtest .A positive correlation between the visual-motor integration ability and writing, math and reading academic skills .(p ≤ 0.05) was found. The presence of disability and the preterm birth and/or low birth weight occurrence accentuated the correlations. (AU)

Mientras que varios factores pueden afectar al rendimiento de estudiantes em tareas acadêmicas, fueron objetivos de este estúdio: a) evaluar el desempeño de estudiantes en escuela primaria bajo parámetros de rendimiento en pruebas estandarizadas, b) identificar la influencia de ocurrencia de parto prematuro y/o de bajo peso al nacer y la presencia de discapacidad en habilidades evaluadas en las pruebas. Participaran 77 estudiantes de 2º curso de una escuela pública. Siete prematuros y/o de bajo peso y tres presentavam discapacidad. Para la recolección de datos se utilizaron el Developmental Test of Visual-Motor Integration, el Teste de Desempenho Escolar y un cuestionario desarrollado para la caracterización de los participantes. En cuanto al rendimiento de los estudiantes en el Beery VMI fueron encontrado las siguiente puntuaciones medias: 18 en la evaluación de la integración visual-motor, 21 en la evaluación de la percepción visual y 22 en la prueba de la coordinación motora. En cuanto a la TDE rendimiento, la puntuación media fue de 13 por escrito substeste , 8 en la evaluación de la aritmética y 46 en lectura subprueba. Se encontró una correlación positiva entre la capacidad de integración visuo-motor y las tareas académicas de escritura, aritmética y lectura (p ≤ 0,05). La presencia de discapacidad y la incidencia de prematuridad y/o bajo peso al nacer hizo las correlaciones más acentuado. (AU)

Recovery in Young Children with Weight Faltering: Child and Household Risk Factors.

OBJECTIVE: To examine whether weight recovery among children with weight faltering varied by enrollment age and child and household risk factors. STUDY DESIGN: Observational, conducted in an interdisciplinary specialty practice with a skill-building mealtime behavior intervention, including coaching with video-recorded interactions. Eligibility included age 6-36 months with weight/age

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

OBJECTIVES: Failure-to-thrive is defined as an abnormally low weight and/or height for age. The term "nonorganic failure-to-thrive" (NOFT) has been used to describe "failure-to-thrive" without an obvious cause underlying the growth failure. The purpose of the present study was to compare sensory processing abilities between toddlers with NOFT and feeding problems and age-matched controls. METHODS: Toddlers with NOFT and feeding problems (N = 16) were recruited from the pediatric feeding clinic in a tertiary university hospital, and age-matched controls (N = 16) were recruited from community volunteers. They were evaluated for sensory processing ability using an Infant/Toddler Sensory Profile (ITSP), and for development of cognition, motor skills, and language using the Bayley Scales of Infant Development II and Sequenced Language Scale for Infants. Behavior at mealtime was evaluated using the Behavioral Pediatrics Feeding Assessment Scale. RESULTS: In the NOFT with feeding problems group, atypical performances were more frequently observed in 3 of 5 ITSP section items (tactile, vestibular, and oral) compared with those in the control group. Significant delayed development of cognition, motor skills, and language was observed in the NOFT with feeding problems group compared with that in the control group. In addition, children who showed 1 or more atypical performances in ITSP had delayed development in cognition, motor skills, and language. CONCLUSIONS: Sensory processing problems were more commonly observed in toddlers with feeding problems and growth deficiency. The present study could provide a preliminary evidence for a possible impact of the sensory processing problems on the feeding difficulties in toddlers with NOFT. Future large studies should be conducted to clarify the relation between sensory processing difficulties and feeding problems in toddlers.

Longitudinal studies using a "natural experiment" design: the case of adoptees from Romanian institutions.

OBJECTIVE: To summarize the advantages and limitations of general population, high-risk and "natural experiment" longitudinal studies for studying psychological change. The English and Romanian Adoptees study is used as an example of a "natural experiment," and detailed findings are provided. METHOD: What is new is a focus on the young people who spent the whole of their life in institutional care up to the time of adoption and who did not show subnutrition. The results were compared with a composite comparison group who had not experienced institutional care or who were adopted before the age of 6 months. The outcomes were assessed in terms of previously established deprivation-specific patterns (DSPs). RESULTS: "Pure" psychosocial deprivation was associated with a substantial increase in the rate of DSPs. It was not associated with significantly impaired head growth if institutional care lasted less than 6 months, whereas thereafter there was a 2.5 standard deviation reduction. Subnutrition differed in being accompanied by impaired head and body growth even with institutional care lasting less than 6 months. In the pure psychosocial deprivation group, 45.5% showed a DSP at 15 years compared with 1.3% in the comparison group. CONCLUSION: "Pure" psychosocial deprivation (in the absence of subnutrition) had a profound effect on psychological functioning in the form of DSPs. Subnutrition had a surprisingly small effect on DSPs.

"I want to be all gone". Psychoanalysis of a three-year-old failure-to-thrive child.

A three-year-old child said to me, "I want to be all gone." Because this very young child had the capacity to talk about and demonstrate her internal world, this case offered the opportunity to explore both her life-threatening symptoms and the underlying psychological conditions that informed these symptoms. This clinical paper explores aspects of her treatment.

Effects of placement type on the language developmental trajectories of maltreated children from infancy to early childhood.

This study describes the developmental trajectories of language skills in infants with substantiated maltreatment histories over a 5-year period and evaluates the effect of three different custodial placements on their language trajectories over time: in-home (remaining in the care of the biological parent/parents), nonkin foster care, and nonparental kinship care. Participants included 963 infants reported to child protective services prior to their first birthday and whose maltreatment was substantiated. Results from covariate-controlled growth modeling revealed no significant placement effects. Across all groups, children's auditory and expressive communication scores decreased significantly from Wave 1 (intake) in the infants' first year to Wave 4, when children were about 3.5 years of age, then improved to baseline levels by Wave 5, when children were about 6 years old. Despite these fluctuations, children's average language scores in each placement group remained below the population mean at each wave of the study.

[An interdisciplinary approach to parent-child therapy with complex and severe feeding difficulties]. / Interdisziplinäre Eltern-Kind Behandlung von schweren komplexen Fütterstorungen.

Our interdisciplinary team is based in a teaching hospital department for psychosomatics and therapeutic interventions for mothers and children. This tertiary service provides assessment and treatment of infants, children and their families presenting with complex and severe feeding disorders. We specialise in the care of children with a variety of multiple problems e. g. presenting after premature birth, and their associated relationship problems. The complexity of issues requires intervention at multiple levels in order to address the individual and family needs of the child. Each case represents opportunities and challenges. The team also addresses integrated services provision across the spectrum of services involved as well as attempting to integrate therapeutic approaches across professional boundaries. This is illustrated by a case report and complemented by a literature review.

Failure to thrive: an update.

Failure to thrive in childhood is a state of undernutrition due to inadequate caloric intake, inadequate caloric absorption, or excessive caloric expenditure. In the United States, it is seen in 5 to 10 percent of children in primary care settings. Although failure to thrive is often defined as a weight for age that falls below the 5th percentile on multiple occasions or weight deceleration that crosses two major percentile lines on a growth chart, use of any single indicator has a low positive predictive value. Most cases of failure to thrive involve inadequate caloric intake caused by behavioral or psychosocial issues. The most important part of the outpatient evaluation is obtaining an accurate account of a child's eating habits and caloric intake. Routine laboratory testing rarely identifies a cause and is not generally recommended. Reasons to hospitalize a child for further evaluation include failure of outpatient management, suspicion of abuse or neglect, or severe psychosocial impairment of the caregiver. A multidisciplinary approach to treatment, including home nursing visits and nutritional counseling, has been shown to improve weight gain, parent-child relationships, and cognitive development. The long-term effects of failure to thrive on cognitive development and future academic performance are unclear.

Mother-child feeding interactions in children with and without weight faltering; nested case control study.

AIMS: To explore whether the Mellow Parenting assessment system can detect any difference in parent-child meal time interaction between children with weight faltering (failure to thrive) and normally growing children. SUBJECTS AND METHODS: Thirty mother-infant dyads with weight faltering and 29 healthy controls nested within the Gateshead Millennium prospective cohort study were assessed at mean age 15.6 months (range 13-20). Video-tapes of two standardized meals per child by a researcher blind to infant health status were analysed using a simplified version of the Mellow Parenting Coding System (MPCS), an all events measure of maternal-child interactivity. These were linked to questionnaire data on eating behaviour and growth held on the children. RESULTS: The MPCS had good inter-rater reliability (0.82) and coherent inter-relationships between coding domains. During case meals there were significantly fewer positive interactions overall: cases median 81.5 (IQR 4-496); controls 169.5 (40-372) and within all the commonly observed domains (Anticipation (p=0.013), autonomy (p=0.003), responsiveness (p=0.005) and cooperation (p=0.016)). There were only low levels of distress and control or negative behaviours and no significant differences were found in these between the groups. The case infants had significantly lower reported appetite by the age of 4 months and higher reported avoidance of feeding at the age of 8 months than controls. CONCLUSIONS: Mothers of weight faltering infants generally showed fewer interactions with their infants at mealtimes. It is not clear whether this is causal or simply a maternal adaptive response to their child's eating behaviour.

Maternal worries about child underweight mediate and moderate the relationship between child feeding disorders and mother-child feeding interactions.

OBJECTIVE: To examine the role of maternal worries about child underweight and undereating in mother-child feeding interactions with children having a feeding disorder (FD). METHOD: Participants were 27 children diagnosed with nonorganic-based FD and 28 children without FD. Mothers were interviewed about their worries about child underweight and undereating. Mother-child interactions were videotaped during feeding. RESULTS: Maternal child weight-related worries acted as both a mediator and a moderator. The more negative mother-child interactions found in the FD group, compared to the control group, were explained by greater maternal worry regarding child underweight. Furthermore, mother-child interactions within the FD group were not at risk per se, but only when coupled with high maternal worries about children's underweight. CONCLUSION: Worry about child underweight partially explains the development of negative feeding interactions when having children with FD, signifying clinical implications for the treatment of FD.

Psychosocial dwarfism: psychopathological aspects and putative neuroendocrine markers.

There exists an extensive terminology for defining the situation of children who, in varying circumstances, suffer from affective deprivation (AD), within an unsatisfactory family situation or in institutions. Nevertheless, the neuroendocrine mechanisms (if they exist) determining it have yet to be identified. Our objective was to determine if specific neuroendocrine markers, all of them previously implicated in affective disorders, could be modified, and in which sense, in affective deprivation syndrome of the child. For this purpose, we studied three separate groups of children: (1) control group (CG); (2) children suffering from AD; and (3) children with non-organic failure to thrive (NOFT). In every case, we studied the serum levels of melatonin, serotonin, ß-endorphins and adrenocorticotropic hormone (ACTH); and kynurenine pathway tryptophan metabolites (both during the day and at night). Significantly, there was a conspicuous reduction in the levels of each of the neuroendocrine markers (melatonin, serotonin, ß-endorphins and ACTH) in the group suffering from affective deficiency, a diminution which was even more noticeable in the group of patients presenting delayed growth. Furthermore, as also occurs in other affective disorders, there were corresponding modifications in the metabolisation of tryptophan. We report the existence of neuroendocrine mechanisms that are associated with the above-mentioned clinical manifestations in these patients, mechanisms that may underlie the close connection existing between AD syndrome and the cause of NOFT. These data suggest that the AD syndrome and NOFT comprise a single process, but one with a different evolutionary continuum of psychosocial dwarfism.

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

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

A clinical study of the intergenerational transmission of eating disorders from mothers to daughters.

Clinicians and researchers have long recognized the existence of eating disorders in very young children, including infants whose mothers have eating disorders. This paper combines reviews of the literature relevant to the study of eating disorders from the perspectives of both research and psychoanalytic theory in order to explore the psychodynamics of the intergenerational transmission of eating-disordered pathology from mother to child. A developmental pathway as well as several mechanisms that illuminate the pathogenesis of the intergenerational transmission of eating disorders are proposed and described. Clinical-observational data from a therapeutic play nursery for mothers with eating disorders and their children are presented, and this material is examined in relation to the proposed psychodynamic pathways of transmission.

A review of empirical support for differential reinforcement of alternative behavior.

Differential reinforcement of alternative behavior (DRA) is one of the most common behavior analytic interventions used to decrease unwanted behavior. We reviewed the DRA literature from the past 30 years to identify the aspects that are thoroughly researched and those that would benefit from further emphasis. We found and coded 116 empirical studies that used DRA, later grouping them into categories that met APA Division 12 Task Force criteria. We found that DRA has been successful at reducing behaviors on a continuum from relatively minor problems like prelinguistic communication to life-threatening failure to thrive. DRA with and without extinction is well established for treating destructive behavior of those with developmental disabilities, and to combat food refusal.

Infant growth and hostility in adult life.

OBJECTIVE: Hostility may confer a risk of cardiovascular disease and all-cause mortality, but why is uncertain. A common origin in suboptimal fetal and early postnatal life may lie beneath. This study tested whether prenatal and postnatal growth predicts hostility in adult life. METHODS: Women (n = 939) and men (n = 740) born in Helsinki, Finland, from 1934 through 1944 filled out the Cook-Medley Hostility Scale at an average age of 63.4 years. Growth was estimated from birth, child welfare clinic, and school records. Adult body size was measured in a clinic. RESULTS: Men and women who had higher levels of hostility in adulthood were born lighter and thinner, showed slower weight gain from birth to 6 months of age, were lighter throughout childhood (standardized regression coefficients (beta) <-0.05; 95% confidence intervals (95% CI), -0.14 to -0.00; p values <.05), but were heavier in adulthood (beta values > 0.06; 95% CIs, 0.02-0.14; p values <.01). They were also shorter from 6 months until the age of 1 year (beta values <-0.09; 95% CIs, -0.14 to -0.03; p values <.003), and tended to be shorter in adulthood (beta = -0.05; 95% CI, -0.09 to 0.00; p = .06). The latter effects were largely attributable to slower growth in stature from birth to 6 months (beta = -0.08; 95% CI, -0.14 to -0.02; p = .005). The associations were not explained by major confounders. CONCLUSIONS: Our study suggests that slow prenatal and infant growth is linked with hostility in adult life.