Feeding problems of infants and toddlers

Feeding problems of infants and toddlers

Feeding problems are classified under structural abnormalities, neurodevelopmental disabilities, and behavioural disorders, with overlap between categories. A medical approach also needs an evaluation of diet and an assessment of the interaction between parent and child. Treating medical or surgical conditions, increasing caloric intake, and counseling about general nutrition can alleviate mild to moderate problems. More complicated cases should be referred to multidisciplinary teams. Behavioural therapy aims to foster appropriate behaviour and discourage maladaptive behaviour.

Some 25% to 40% of infants and toddlers are reported by their caregivers to have feeding problems, mainly colic, vomiting, slow feeding, and refusal to eat. This article reviews the classification and clinical features of such problems, proposes an approach to diagnosis, and describes some practical therapeutic strategies.

Although some of these difficulties are transient, some problems, such as refusal to eat, are found in 3% to 10% of children and tend to persist. Parents soon become concerned and turn to their family physicians for advice. This article reviews the classification and clinical features of early childhood feeding problems, proposes a diagnostic approach, and describes some practical therapeutic strategies.

Feeding problems in early childhood often have multifactorial causes and a substantial behavioural component. Family physicians have a key role in detecting problems, offering advice, managing mildly to moderately severe cases, and referring more complicated cases to multidisciplinary teams.

The feeding relationship is the complex of interactions that take place between parent and child as they engage in food selection, ingestion, and regulation behaviors. Effective feeding supports a child’s developmental tasks of homeostasis, attachment, and separation. Feeding of the newborn infant is most successful when parents allow the infant to determine timing, amount, preference, pacing, and eating capability. During the attachment phase, such infant-controlled behaviors allow parents to engage affectively with the child. Successful regulation of state and attachment provides the groundwork for the separation-individuation phase. In feeding, effective parents provide opportunities to explore but also provide structure and limits. Feeding and growth problems often stem from distorted dynamics around feeding, which can be indicative of distorted parent-child interactions. Incidence estimates range from 1% to 2% for severe and prolonged problems to 25% to 35% for common difficulties such as food refusal and “overeating.” An evaluation of feeding dynamics should always be made as part of the diagnostic study of a child who is eating or growing inappropriately. To prevent problems in feeding, practitioners may teach and support positive feeding dynamics as part of primary care, refer parents for instruction in positive approaches to feeding, and detect and refer attitudinal and behavioral problems early

Classification of feeding disorders

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source: Can Fam Physician.

Impact

Poor nutritional status and growth failure are common in children with cerebral palsy (CP). The aim of this study was to assess, within a subgroup of a large and clearly defined population of children with disabilities, the impact of feeding difficulties on (1) the quality (micronutrient intake) and quantity (macronutrient intake) of their diet and (2) their growth. One hundred children with disabilities (40 females, 60 males; mean age 9 years, SD 2 years 5 months; range 4 years 6 months to 13 years 7 months) underwent a detailed dietetic analysis and a comprehensive anthropometric assessment. Diagnostic categories of disability were: CP (n=90); global developmental delay (n=3); Marfan syndrome (n=1); intractable epilepsy (n=2); agenesis of the corpus callosum (n=2); methyl malonic aciduria (n=1); and congenital rubella (n=1). Neurological impairment was classified according to difficulty with mobility which was graded as mild (little or no difficulty walking), moderate (difficulty walking but does not need aids or a helper), and severe (needs aids and/or a helper or cannot walk). Results confirmed the significant impact of neurological impairment in children on body growth and nutritional status becoming worse in those with a greater degree of motor impairment. The major nutritional deficit was in energy intake, with only one fifth reportedly regularly achieving over 100% estimated average requirement (EAR), whilst micronutrient intake was less markedly impaired and protein intake was normal in this group (96% above EAR). Many children with neurological impairment would benefit from individual nutritional assessment and management as part of their overall care.

Retrospective data on growth and cross-sectional data on growth outcome, anthropometric measurements and energy intake have been analysed according to the presence or absence of feeding problems in 42 children with cerebral palsy (CP) between 1 and 13 years of age. The mean age for boys and girls was 5.1 and 5.9 years, respectively. The study revealed a high frequency of feeding problems (50%) and growth retardation (48%) in the group. The results of weight for height, triceps skinfold thickness and energy intake indicate that 15% of the children were undernourished at the time of study. The cross-sectional analyses showed that children with feeding problems at the time of study (n = 22) had significantly lower height for age, weight for height, triceps skinfold thickness and upper-arm circumference than children without problems (P less than 0.05). Children with feeding problems also tended to have lower energy intake, but the differences were not significant. The feeding problems were most frequent among the severely disabled children. This study has shown that the presence of feeding problems is one important predictor of low growth outcome in children with CP. When parents report on feeding problems, feeding evaluation, training and nutritional intervention should be offered immediately. This is important for alleviating the heavy care-load for parents and health-workers and for some children it may be necessary to maintain an acceptable nutritional state.

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