Failure to Thrive and Cognitive Development in Toddlers With Infantile Anorexia
PEDIATRICS Vol. 113 No. 5 May 2004, pp. e440-e447
Irene Chatoor, MD*, Jaclyn Surles, BA*, Jody Ganiban, PhD￼, Leila Beker, PhD*, Laura McWade Paez, CPNP*, Benny Kerzner, MD*
source: Children’s National Medical Center, Washington, DC ￼ George Washington University, Washington, DC
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.
Key Words: failure to thrive • feeding disorder • infantile anorexia • cognitive development • growth deficiency • mother-toddler interactions
Failure to thrive (FTT) describes children who exhibit growth deficiency, as indexed by faltering or stunted growth. Several studies suggest that FTT is associated with poorer cognitive development, learning disabilities, and long-term behavioral problems.1–3 More recently, Corbett et al4 detected a significant association between the severity of growth deficiency and IQ, whereas Raynor and Rudolf5 found that 55% of the infants who were failing to thrive exhibited developmental delay. In addition, a study by Reif et al6 reported that children with a history of FTT were found to have more learning difficulties and evidenced developmental delay at follow-up 5 years after the initial presentation.
These findings from the pediatric literature have led many to believe that FTT alone is sufficient to cause developmental delays. However, a critical problem with many previous studies is that FTT is frequently confounded with psychosocial risk factors (including low socioeconomic status [SES], maternal education levels, and maternal deprivation) that are independently related to lower Mental Developmental Index (MDI) scores.1,4 As a result, psychosocial factors may contribute to the apparent association between FTT and cognitive delay. Consequently, the conclusion that FTT is sufficient to cause significant cognitive delay requires additional exploration.
The tendency to confound FTT and psychosocial risk factors grew from early studies that used nonorganic FTT and maternal deprivation as synonymous terms.7,8 Whereas several authors have proposed that FTT should be considered a single symptom that describes growth deficiency,9–12 others have used nonorganic FTT as a clinical syndrome that encompasses children who exhibit FTT in addition to psychosocial risk factors.1,3,4 Consequently, several authors have argued strongly for disentangling FTT (growth deficiency) from psychosocial factors and examining FTT as a single symptom of a feeding disorder, rather than a clinical syndrome.11,13,14 Such a distinction is critically important for identifying the developmental consequences specifically related to growth deficiency, as well as the multiple pathways that can lead to growth deficiency.11,13,14 Although many factors, genetic and environmental, can contribute to cognitive development in young children, the goal of this article is to tease apart the effects of growth deficiency and psychosocial risk on cognitive development.
The study described in this article focused on infantile anorexia, a feeding disorder that is characterized by extreme food refusal, growth deficiency, and an apparent lack of appetite.15,16 Importantly, infantile anorexia is not associated with maternal deprivation or neglect, and most children with this feeding disorder come from middle- to upper-middle-class families.15,17 Therefore, studying this population affords the opportunity to disentangle the contributions of growth deficiency and psychosocial risk factors to cognitive outcomes.
Infantile anorexia was first described in a series of case studies by Chatoor and Egan,18 and at that time it was referred to as a separation disorder. Infantile anorexia arises in the first 3 years of life, most commonly between the ages of 9 and 18 months, as infants become more autonomous and make the transition to spoon- and self-feeding. Children with infantile anorexia fail to communicate signals of hunger, but they show a strong interest in exploration, play, and/or interaction with their caregivers. They exhibit extreme food refusal and frequently fail to take in sufficient calories to sustain growth. As a result, these children display acute and/or chronic malnutrition.16
Drawing from the rich literature on growth deficiency and the multiple factors that can have an impact on the cognitive development of young children, this article examines the relationship of cognitive development to physical growth, mother–toddler interactions during feeding and play, maternal education, and SES. We examine these relationships in a group of children who have infantile anorexia and exhibit growth deficiency, a control group of picky eaters with normal weight, and a second control group of healthy eaters with normal weight.
The primary questions addressed by this study were as follows: 1) Is infantile anorexia associated with lower scores on the MDI? Although toddlers with infantile anorexia do exhibit growth deficiency, they typically do not experience maternal neglect and tend to be from middle- to upper-middle-class families.15,17 Consequently, we hypothesized that they would not demonstrate significant developmental delays. 2) Do psychosocial variables (SES, maternal education, quality of mother–child interactions) and growth deficiency make independent contributions to MDI scores? We hypothesized that SES, maternal education, and the quality of mother–toddler interactions would be stronger predictors of cognitive development than growth deficiency.
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