Feeding and Eating Conditions

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CHAPTER 23 Feeding and Eating Conditions

23A.

Introduction

JULIE C. LUMENG

Because eating is integral to survival, successful feeding of one’s child forms the bedrock of a healthy and fulfilling parent-child relationship. Perturbations in eating and feeding frequently come to the attention of a developmental-behavioral pediatrician. These conditions require a conceptualization of child development from medical, social, and psychological perspectives. The biological brain-based relationships between feeding and stress, emotion, and affect regulation are only just beginning to be explored. Feeding and eating disorders highlight social injustices, health disparities based on race and socioeconomic status, and the unique pressures on girls and women in our society. Finally, feeding and eating are fluid processes that rely on interaction with others and the environment and respond differentially to various influences over the course of the child’s development. They are, in summary, disorders particularly appropriate to the expertise of the developmental-behavioral pediatrician in the intersection of biology and behavior, parent-child relationships, the influence of societal issues on children’s well-being, and, most fundamentally, the myriad ways in which children change, physically, cognitively, and emotionally, as they grow.

We begin this chapter by using disorders of feeding in infancy as a framework in which to discuss the emergence of the dyadic nature of feeding and the development of feeding in early childhood. Next, in the context of a discussion of failure to thrive (FTT) and undernutrition, we discuss more heavily the medical and biological contributors to poor weight gain, as well as social contributors to undernutrition in children. Finally, we conclude by discussing two seemingly disparate conditions, restrictive eating disorders and obesity, and describe the paradoxical commonalities between them. Both problems emerge increasingly as children grow older. We discuss these disorders in tandem because they in particular highlight how affect, behavior, and weight intersect throughout the course of child and adolescent development. We review in this chapter how societal influences affect feeding and eating, as well as how mental health concerns, behavioral issues, and mental health diagnoses are intertwined with eating and feeding conditions. Perhaps most importantly, we highlight the limited evidence and data regarding the problems associated with feeding and eating and the urgent need for more research into mechanisms underlying these conditions, as well as their effective treatment. Developmental-behavioral pediatricians are in a key position to lead efforts in both advocacy and research that will improve children’s well-being with regard to the development of healthy eating behaviors, a positive body self-image, emotional well-being, and a healthy weight status.

23B. Infant Feeding Processes and Disorders

SHEILA. GAHAGAN

FEEDING DEVELOPMENT

The Dyadic Nature of Feeding

THE NURSING PERIOD

The full-term human infant is first nourished by a reciprocal process between the newborn and the mother. Breastfeeding is the prototype of the dyadic maternal-infant feeding relationship during the nursing period (first 4 to 6 months after birth). The neonate is born with primitive reflexes, including sucking and rooting that allow suckling during the first hours after birth. Gagging, a competing primitive reflex, may initially interfere with infant feeding. However, the infant’s suckling gradually increases in strength, frequency, and coordination over the first few days and, under normal circumstances, predominates over gagging. Colostrum, the first milk produced by the lactating breast, is produced in scant volume, which decreases the chance of choking, as well as regurgitation caused by overfilling of the stomach. The scant colostrum is gradually replaced with increasing volumes of transitional milk between the fourth and tenth postpartum day. By 14 days of age, the baby is usually an accomplished “nurser.”

Maternal lactation is regulated by a positive feedback loop. When suckling occurs, oxytocin and prolactin are released by the maternal hypothalamus, controlling milk ejection. Oxytocin release occurs as a conditioned response in most women and can be induced by seeing the baby or hearing the cry even before the tactile stimulus of suckling.1 Oxytocin and prolactin basal levels are elevated during the months of lactation and are higher 4 days post partum than during the third or fourth month of breastfeeding.2 Oxytocin levels in the perinatal period are influenced by characteristics of the infant, such as the infant’s birth weight. Levels are also influenced by exclusivity of breastfeeding over time, so that mothers who exclusively breastfeed have higher oxytocin and prolactin levels than do those who give supplementary feedings at 3 to 4 months. Prolactin and oxytocin have multiple influences on behaviors crucial to the survival of mammalian infants. Animal research demonstrates that oxytocin promotes maternal-infant bonding and prolactin inhibits sexual behaviors. Mammalian research contributes to the hypothesis that oxytocin and prolactin may contribute to maternal responsiveness during the attachment process. These neuroendocrine hormones may also contribute to decreased maternal interest in and responsiveness to outside stressors.

Both prolactin and oxytocin release are induced by suckling. Suckling-induced oxytocin release may be reduced by psychological stress, thereby reducing stimulation of milk flow (letdown).3 Infant suckling (on demand or frequently), provides the primary impetus that determines the actual volume of milk produced. It is difficult to overfeed a breastfed infant, because the baby influences the volume of milk by his or her own appetite and satiety. The infant hypothalamus processes infant hunger and satiety signals and coordinates stimulation and inhibition of infant feeding. This positive feedback loop can be perturbed by infant impairment such as muscle weakness or fatigue. For example, the infant with a weak suck may provide inadequate stimulation to the breast to induce oxytocin release and maintain an adequate milk supply. The positive feedback loop can also be disrupted by maternal mammary-hypothalamic-pituitary-adrenal dysregulation related to maternal fatigue, distress, or medication.

Formula feeding during the nursing period follows a pattern similar to that of breastfeeding. However, the caretaker cognitively chooses how much milk to provide in response to the infant’s cues. Theoretically, formula feeding is less fine-tuned to the infant’s appetite-satiety system. More research is needed to understand how bottle-fed infants express satiety.

Social interaction takes place during feeding as well as during holding, rocking, stroking, and visual engagement. Social interaction develops with a burst in eye contact at 4 weeks of age.4 The infant may become increasingly social during suckling with interruptions to engage, laugh, or look around. These behaviors may be erroneously interpreted as lack of interest in feeding or desire to discontinue feeding, but they more accurately reflect the infant’s emerging capability of directing attention to other interests.

Feeding continues to be a social activity throughout childhood and into adulthood. As the infant’s social capabilities increase, socialization during feeding diversifies, including involvement with other members of the family at mealtimes. Older infants, toddlers, and children should anticipate the social interactions associated with mealtimes with pleasure.

THE TRANSITIONAL FEEDING PERIOD

The transitional feeding period starts when the baby begins to ingest nonmilk food but continues to ingest a major portion of calories from milk. The timing and practices of the introduction of food to infants has varied historically and continues to vary widely across cultures. At about 1900, most infants in the United States were not fed solid food routinely until 12 months of age, but in the 1950s, mothers were encouraged to give 3-week old infants pureed or liquid food, such as pablum (rice cereal) and soft-cooked egg yolk. The American Academy of Pediatrics currently recommends gradual introduction of complementary foods containing iron at approximately 6 months of age.5 These recommendations are based on the infant’s neurodevelopmental ability to sit, hold the head erect, and turn the head when satiated, as well as scientific evidence that infants begin to need supplemental foods for calories and for iron in the second 6 months of life.

The dyadic nature of feeding does not diminish during the transitional feeding period. Infants lose some control over nutritional intake when supplemental foods are introduced, as they have less direct input into the timing, volume, and pace of feeding than during breastfeeding. However, if supplemental feeding begins beyond the neonatal and early infancy period (first 3 months), the infant’s capability to communicate desires and dislikes can aide in the self-regulation of feeding. Infants have variable capacity to signal hunger and satiety. Most newborns cry when they are hungry, but their early cries are not easily differentiated from cries for other needs such as for sleep and physical comfort.6 Therefore, these signals may be misinterpreted. As infants mature and develop relationships with caregivers, the human adult’s perceptual and problem-solving capability for interpreting the infant cry improves.6 It is quite likely that infants are sometimes fed when they are not hungry and that at times the amount may not match their desire.

During the first year of life, infants develop increasingly sophisticated communication skills. Expression of emotional states becomes more complex, including the ability to communicate displeasure without crying. The developing abilities to sit, to reach and grasp, and to turn the head all allow the infant to indicate desire or displeasure by motoric maneuvers. The infant has a great deal of power in his or her ability to turn away, throw food, or spit; however, these behaviors do not represent fine-tuned communication. The parent is left wondering whether the child is no longer hungry, does not like a particular food, or is having some other emotion or desire unrelated to food, such as a desire to get out of the chair.

ATTACHMENT THEORY

Feeding, beginning with the nursing period and continuing through the transitional feeding period and into the modified adult feeding period, is anchored in relationships. It is therefore important to consider attachment theory and how it relates to feeding development. Attachment is a behavioral system that conceivably operates in many infant behaviors, including normal feeding development. Furthermore, attachment theory can aid in the understanding of some feeding problems. In 1958, Bowlby hypothesized that human young must be equipped with a behavioral system that operates to promote sufficient proximity to the principal caregiver.7 He argued that attachment was important for humans because of their long period of immaturity and vulnerability. This system facilitated parental protection and therefore infant survival. His theory was based on the Darwinian notion of adaptation for survival of the species. Specific behaviors that attract the caregiver include crying, suckling, calling, smiling, and seeking proximity. Attachment theory describes attachment behaviors as a behavioral system, which differs from the use of the word attachment to mean a bond. Bowlby emphasized the importance of the infant’s confidence in the mother’s accessibility and responsiveness.8

Bowlby described four phases of attachment.9 The initial preattachment phase involves “orientation and signals without discrimination of figure.” This phase comes to an end within a few weeks after birth, when the infant can discriminate the mother figure from others. During the second phase, attachment in the making, the system involves “orientation and signals toward one or more discriminated figures.” The second phase lasts until the phase of clear attachment, which begins in the second half of the first year and involves the “maintenance of proximity to a discriminated figure by means of locomotion as well as signals.” This stage of attachment has been studied empirically.10 The final phase, goal-corrected partnership, which involves lessening of egocentricity and capability of seeing things from caretaker’s point of view, does not begin for most children until age 3 or 4 years.

Attachment is clearly entwined with feeding, inasmuch as feeding behaviors are an intricate part of the system of behaviors during preattachment and attachment in the making. Feeding both facilitates attachment and can be disturbed by disorders of attachment throughout early childhood.11 Feeding becomes a less important behavioral determinant of attachment during the phase of clear attachment as capabilities such as locomotion become operational.

The Context of Infant Feeding

CULTURE

Both within and outside of the United States, cultural norms strongly influence infant feeding practices. Breastfeeding initiation, frequency, and duration are influenced by cultural factors. Culture prescribes how the infant is held and for how long. Carrying and how the infant is carried (arms, sling, cradleboard, infant seat) is also culturally determined. Furthermore, where the infant sleeps, where the infant is placed when not held, and how the infant is clothed are all influenced by culture.12 In return, these practices influence feeding.

Cultural practices dictate when solid foods are introduced and whether bottle supplementation is started early. Health care providers may be integral in some cultures and may influence other cultures by their recommendations. Many families choose to feed their infants solid food earlier than the range of 4 to 6 months recommended by the American Academy of Pediatrics.5 Mothers are often encouraged to introduce solid food (before the time recommended by physicians) by grandmothers who believe that infants’ sleep will improve if they have food in their stomachs at bedtime. Conversely, some groups choose to delay feeding until later than 6 months because of cultural beliefs (often related to a theory that longer exclusive breastfeeding is more natural and perhaps healthier for the baby). Similarly, toddler feeding may be accomplished in a high chair or by allowing the toddler to take food while moving from family member to family member. Parents may introduce food into their infant’s mouth by hand or by various types of utensils. Many American Indian and African American mothers chew food for their infant and then introduce small amounts into the infant’s mouth. This practice is seen in other contemporary and historical cultures. (Research on this practice as a risk for infectious diseases focuses on children exposed to this practice who present with infectious disease, and it suffers from lack of a denominator as well as control groups.)12a

In the United States, infants have typically been allowed to progress quickly from being spoon-fed by a caregiver to independent eating. They may achieve independence by eating “finger foods” or by learning to use utensils. It is not unusual for U.S. infants to self-feed early in the second year of life. Some families do not realize that many babies need some help during this period. This practice of early independence in eating differs radically from traditional practices in many cultures. For example, in China, it is not unusual for toddlers to be entirely spoon-fed by their caregivers until they are almost school age.

The choice of foods for infants is also highly influenced by culture. Culture evolves, and eating practices of many cultures have changed dramatically since the 1960s, with increasing consumption of prepared and processed foods, larger portion sizes, some meals taken while people watch television, and more meals consumed away from the family.

When pediatricians consider feeding milestones, they are formulating assessments about the family’s childrearing practices and the infant’s neurobehavioral adaptation to feeding. Within the context of society and the family, feeding milestones have cultural meaning. For example, the timing of initiating eating solid foods conveys information about the parental values and whether they conform or diverge from their cultural norms. Many cultures value the development of independence and therefore value an infant’s ability to hold the bottle. Similarly, drinking from a cup signals a graduation of sorts from baby activities. In the toddler, emerging table manners conform to cultural norms. In most cultures (and in the pediatrician’s office), the success of feeding is at least equally judged by the infant’s physical growth. The size of the baby may be equated with the success of parenting within many cultures.

FAMILY

Infant feeding is fraught with meaning for parents, especially mothers: “Successful feeding is inherently satisfying and a powerful affirmation of competence.”13 Conversely, mothers often interpret poor infant feeding as a sign that their mothering is defective. Some mothers generalize this belief and begin to feel that they themselves are defective because their babies do not eat. Clinical experience suggests that fathers also feel competent if their children eat well for them. However, fathers are less inclined to self-blame if their children have eating problems. The grandparents are often the repository of knowledge regarding childrearing and cultural practices. Therefore, grandparents view themselves as experts. This can be problematic if the parents do not choose to follow the feeding practices recommended by the grandparents. Conflicts between pediatric recommendations and grandparental recommendations about feeding are common. Some of these differences reflect changes that have taken place in pediatric knowledge and recommendations over a generation. Feeding problems can often cause stress for grandparents, who may wonder if they could do a better job than the parents. Grandparents do not always understand the complexity of feeding problems, which may stem from neurodevelopmental differences and parent-child relationship difficulties, often in a vicious cycle. Although parents need support from the grandparents, they also need consistent advice from all sources, including their family and doctors. Because infant/toddler feeding problems are poorly understood, the family is often confused by conflicting information and advice.

Normal Feeding Development

Full-term human infants are born with the ability to suck and swallow, to protect their airway, to perceive taste, and to regulate their appetite and satiety. Swallowing occurs as early as the 11th week of fetal life.14 The coordination of sucking, swallowing, and breathing is related to neuromuscular coordination, which is a function of gestational maturity.15 Although there is individual variation, most infants can adequately coordinate sucking, swallowing, and breathing by 35 weeks’ gestational age. In preterm infants, nonnutritive sucking bursts are seen at 31 to 33 weeks’ gestational age.16 The duration of each sucking burst is about 4 seconds, and as the infants mature, the period of time between sucking bursts decreases. Nutritive sucking allows approximately one suck and swallow per second.

The infant’s developing ability to take food off of a spoon and handle thicker foods depends on neuromuscular maturation, including loss of the extrusion reflex. Infants gradually develop the ability to keep their lips closed, thereby avoiding the loss of food from their mouth. Infants who are spoon-fed before 4 to 6 months of age are likely to use a sucking pattern to ingest pureed foods. By 9 months of age, most infants can chew by using a vertical jaw movement and can transfer food from the center of the mouth to the side. At this age, diagonal rotary jaw movements are emerging. By 12 months, most children can use a controlled, sustained bite for textured food, such as a soft cookie. Well-coordinated diagonal rotary and circular rotary jaw movements are attained by 18 and 24 months, respectively. Babies with neurodevelopmental disorders, including cerebral palsy, cleft lip and palate, and hypotonia syndromes, may present with feeding disorders or FTT. Extremes of oromotor tone—spasticity and hypotonia—often cause delay in feeding milestones. Sensory problems are discussed in the following section.

FEEDING CONCERNS, DISTURBANCES, AND DISORDERS

Deviations from normal development are described in the DSM-PC16a as normal variations, problems, and disorders. Variations of normal feeding may be accompanied by parental concerns, which are commonly handled by primary care pediatricians. They are included in this chapter because developmental-behavioral pediatricians are instrumental in training pediatric residents, and provide consultation about feeding problems to pediatric generalists and specialists. More serious feeding problems, as long as they do not impair growth, are called disturbances or perturbations in this chapter. Feeding disorders are more persistent than these problems and involve vomiting and/or poor growth. After these broad categories are discussed, more specific feeding disorders are described developmentally by presenting complaint.

Feeding Variations and Concerns

Parental concern about infant feeding problems is very common. At least 25% of parents of infants (in normative samples) express concern about their child’s eating.17–19 A longitudinal study of a normative sample of infants and toddlers in Sweden found that more than half of the mothers reported feeding concerns when their children were 10 months old and at the end of the second year. However, very few of the children were experiencing highly problematic feeding at both ages. In these cases, both infant temperament and maternal sensitivity were believed to mediate the development and the maintenance of the problem.20

Although parental concern about feeding is common, it is distressing for the parent. We quote a letter written more than 50 years ago to Dr. Benjamin Spock by a mother of a boy in his practice:

“The one thing that I’ve found… to be the most irritating and long-lasting of the many problems having to do with child raising—that of eating. At just a little past a year of age my son, who had been eating everything and anything that would fit into his mouth, suddenly did a complete turnabout to the point where, today, his entire diet consists of little more than bacon, fruits and bread.… What is a mother to do? See that, above all, the baby’s mealtime is happy and give him only those foods that he likes, or insist (through tears and tantrums) that he at least taste something new occasionally.”

Dr. Spock comments, “I suspect this mother is quoting me—with a touch of irritation and sarcasm.… I agree that she is in no mood to create a happy mealtime when she’s worried sick about a child’s meager and lopsided diet. And it isn’t just that she’s anxious. She can’t help being angry. She’s bought and cooked and served good food and this tiny, opinionated whippersnapper turns it down day after day.… Her worry is not just over his… health… but what her husband, her mother, the doctor, and the neighbors will say about him as he grows thinner and thinner, and what they’ll think about her.… The only thing she did, in the beginning, to bring this about was to be a conscientious mother. The guilt she feels for getting so mad, openly or inside, complicates the picture… as time goes on.21

Initial evaluation of feeding disorders is expected to take place in the primary care practice. Some physicians ask for developmental-behavioral pediatric consultation during the initial evaluation. When a parent expresses concern about a child’s feeding behavior, the pediatrician’s first task is to determine whether the child is growing adequately and then determine whether the feeding behavior is developmentally normal, problematic, or frankly disordered. Many parents are concerned about developmentally normal behavior, such as decreased intake at 1 year of age or throwing food at 9 months of age. When feeding behavior is normal, pediatric counseling can help parents avoid feeding battles. The development of frank feeding disorders may also be averted with appropriate anticipatory guidance, including pediatric counseling about age-appropriate feeding behaviors and normal growth parameters. The pediatrician can also explore parental strategies for feeding and support strategies that are helpful to the child. An example would include allowing the 12-month-old to do some finger feeding and limiting the mealtimes to 15 minutes in length (unless he is eating eagerly at 15 minutes). The pediatrician should listen for maladaptive strategies, such as force-feeding or punishing for not finishing food, and advise against such practices.

Feeding Disturbance

A feeding perturbation (intermittent problem) or disturbance (problem lasting more than one month) is diagnosed when an infant exhibits abnormal feeding with normal growth.22 Although the infant maintains adequate growth, the abnormal behavior causes significant distress for the family. Furthermore, the feeding disturbance may put the child at risk for future eating problems. The following case from our practice is an example of a 10-month-old with a feeding disturbance:

Larry was an 8-pound 10-oz, infant born at 41 weeks’ gestational age to a primiparous 26-year-old mother and 30-year-old father. He was initially fed formula because his mother was taking medications for chronic back pain that precluded breastfeeding. The family history revealed a history of anxiety in the mother. Larry initially grew very rapidly, along the 95th percentile. When he was 3 months old, his mother attempted to return to her work as an occupational therapist, but Larry did not eat or sleep for the caretaker at the licensed day care home. Larry’s mother decided that she should quit her job to stay home with him. He then developed vomiting, which was diagnosed as gastroesophageal reflux. His oral intake gradually decreased until at 10 months of age he took only 8 ounces of formula per day and a small amount of pureed foods. By this time the parents were force-feeding him and feeding him during sleep. His weight gain slowed, with his weight for age dropping from the 95th percentile for age to the 50th percentile for age. He then continued to grow along the 50th percentile. His triceps skin fold thickness continued to be between 1 and 2 standard deviations above the mean. He appeared very well nourished.

Feeding refusal sometimes begins in response to overfeeding or the infant’s perception of being force-fed. In this case, maternal anxiety, and possibly depression, may have prevented the mother from interpreting her infant’s satiety cues accurately. Furthermore, the infant may have been experiencing discomfort after feeding because of gastroesophageal reflux. The reflux may have been exacerbated by overfeeding. We hypothesize that between 5 and 12 months, the infant’s appetite began to decrease in concert with a normally decreasing growth velocity combined with shifting linear growth. In other words, growth velocity in all babies slows between ages 5 and 12 months, but Larry’s may have been more exaggerated for a combination of reasons, including his large size at birth. By 10 months of age, this child had developed an intense dislike of drinking milk and was willing to drink only enough to remain hydrated.

Growth velocity is very rapid during the first year. However, at 1 year of age, physical growth slows, and exploring, learning, and asserting individuality may take on greater importance than eating in the daily activity of many toddlers. The ravenous appetite of the first year must diminish in order for growth to slow. The decrease in appetite, followed by decreased intake, may be interpreted by the parents as feeding refusal. Vigorous attempts to improve the infant’s intake may result in a feeding problem.

Initial evaluation for feeding problems may begin with the primary care physician. It is possible that simple interventions, such as education about normal feeding development and recommendations for adaptive parental feeding strategies appropriate for the developmental stage, will allow the family to ameliorate the child’s feeding behavior. Parental coping, mental health, and attachment should be assessed in the case of an infant’s feeding disorder. The primary care clinician may choose to refer the parent and the infant to developmental-behavioral pediatrics or mental health services. The pediatrician should remain involved to monitor the child’s feeding and growth and to support the work of the mental health professional.

Feeding Disorder

A feeding disorder (in comparison with a normal variation or problem) is a dysfunctional behavior that persists across time and situations and involves abnormal growth or vomiting. It may necessitate more intensive intervention. A system of classification of feeding disorders currently used for research was developed by Chatoor (Table 23B-1).23 These diagnostic categories were created on the basis of face validity (the extent to which the description of a category seems to accurately describe the characteristics of persons with a particular disorder).24 Infantile anorexia is the one diagnosis that has been studied for descriptive validity (the extent to which the features of a disorder are unique in comparison with other mental disorders), and reliability (how reliably a condition can be identified, as judged by test-retest and interrater reliability). Although this diagnostic schema has some limitations for both research and clinical practice, it is the only system of classification for infant feeding disorders that has been studied empirically. The remainder of this chapter describes the developmental and symptom manifestations of infant feeding disorders.

TABLE 23B-1 Infant Eating Disorders as Classified by Chatoor

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SPECIFIC INFANT FEEDING DISORDERS

Feeding Problem—Nursing Period

Feeding problems involving a breastfed infant can be related to the infant, to the mother, or to the maternal-infant dyad. It is reasonable to expect that breastfeeding problems that begin as isolated infant or maternal problems will quickly progress to involve the maternal-infant dyad. Examples of breastfeeding problems include inability to adequately coordinate sucking, swallowing, and breathing or inability to stimulate adequate breast milk production (Table 23B-2). Feeding disorders in formula-fed infants during the first 6 months of life can also result from the same issues except for stimulating breast milk production.

TABLE 23B-2 Feeding Problems during the Nursing Period That Are Related to Pathological Processes in the Infant

Infant Feeding Problem Example
Developmental disorder Prematurity
Neurological disorder Cerebral palsy
Anatomical disorder Cleft palate
Transient feeding difficulty Poor latching on
Disordered alertness, vigor Sedation, mild asphyxia
Oral-motor delays Mild neurological disorder

A maternal problem with breastfeeding may relate to inadequate milk supply, often a function of maternal exhaustion or distress. Milk production may be delayed in mothers who had a precipitous delivery and who delivered by cesarean section. Some mothers misperceive their milk supply as inadequate and attempt to supplement feeding in an infant who does not need supplementation, thereby creating risk for an eating problem.

Eating disorders that take root in the maternal-infant dyad are common. A feeding disorder of caregiver-infant reciprocity (previously called feeding disorder of attachment) can manifest during the nursing period.25 Both breastfed and formula-fed infants can develop feeding disorders when there is a disorder of caregiver-infant reciprocity. Criteria for this diagnosis include (1) onset between 2 and 8 months; (2) poor infant growth; (3) the presence of delays in cognitive, motor, or socioemotional development; (4) the presence of maternal psychopathological processes associated with lack of consistent care of the infant; and (5) poor parent-infant reciprocity during feeding. When feeding problems and poor growth are noted in the first 6 months of an infant’s life, poor attachment should be included in the differential diagnosis. Along with many other causes of failure of attachment, the clinician can consider the “ghosts in the nursery” described by Selma Fraiberg, in which unconscious response to previous losses and painful experiences in the mother’s life can distort interactions with the infant.26 For example, a mother who experienced a significant loss, such as the death of a parent or spouse, may have difficulty forming attachment to her infant. Subconscious fear of the pain associated with loss prevents closeness with the baby. Her lack of attachment translates into behavior. For example, she may tune out the baby’s crying or feed infrequently. Parents who have fewer unresolved losses are more available for knowing and responding to their child and interpreting the child’s behavior.

Another psychological risk for infant eating disorder is projection of features of a problematic person onto the baby. For example, the baby “looks just like his father, who is in prison.” The parent’s mental representation of the infant often includes adult attributes. Some mothers attribute negative feelings and wishes to their infant. For example, crying may be seen as the infant’s wish to disturb her. This can produce conflict in the desire to care for the infant and attachment may be impaired. The psychodynamic conflict appears as difficulty nurturing and feeding, which manifests to the pediatrician as poor growth.

Evaluation of the infant who is failing to thrive during breastfeeding includes history, physical examination, and observation. The detailed history focuses on possible associated medical conditions, as well as a mental health assessment of the family. It is important to screen for depression and psychosis in the mother and to refer for further evaluation if there are any concerns. Simultaneous evaluation of relationship factors and physiological factors is important for all cases of FTT, as discussed in detail later in this chapter. Observation of breastfeeding not only reveals mechanical problems related to latching on, positioning, and letdown but also assists with the assessment of attachment. Developmental-behavioral pediatricians may need to assess the volume of milk produced at a feeding. The evaluation of the formula-fed infant who is failing to thrive in the first 6 months of life differs little from that of the breastfed infant. A feeding observation focuses on the infant’s ability to coordinate sucking, swallowing, and breathing, as well as on the infant-caregiver interaction. Milk volume is more easily assessed for the formula-fed infant.

Intervention for FTT and an infant’s feeding disorder related to breastfeeding depends on the cause of the feeding disorder. Infant-initiated problems related to weakness or poor suck may be remedied by increasing the mother’s milk supply through the use of an electric breast pump and a galactologue, such as metoclopramide. Most infants require bottle or nasogastric supplementation at least initially. Infants with neurodevelopmental disorders benefit from intervention by a skilled feeding therapist trained in occupational or speech therapy. Intervention for the formula-fed infant with a feeding disorder may also require a feeding therapist. Therapy focuses on the ability to make a good seal with the bottle nipple, to coordinate sucking and swallowing, and to avert feeding-avoidant behaviors. Feeding therapists are trained to address developmental delay in feeding and sensory aversion to feeding. Their intervention relies on excellent knowledge of development stages of feeding. They use behavior modification techniques and desensitization. Intervention in the case of a maternal mental health disorder requires treatment for the mother; ideally, an infant mental health professional assists. Attention to the mother-infant relationship provides the opportunity for the parents to receive supportive therapy.

Feeding Refusal (Birth to Age 6 Months)

Feeding refusal may be seen during the first 6 months of life. Most infants who refuse to eat during the nursing period have had medical problems such as prematurity, intubation, surgery, or conditions that cause anorexia. Many of these infants are nutritionally supported with gastrostomy or nasogastric feeding. Currently, feeding therapy is provided inconsistently to these infants, and there is little research addressing the utility of feeding therapy in the development of normal eating in infants who have required tube feeding. In our experience, most of these infants eventually eat if they have the neurological capability to do so. However, some feeding refusal persists well into school age.27 A multidisciplinary approach to infant feeding refusal appears to be quite effective, albeit not empirically studied. An individualized combination of medical care, parental support, behavior modification, feeding practice, and desensitization for aversion is the current standard of care.

Feeding Refusal (Ages 6 to 18 Months)

Feeding problems during the transitional feeding period may be associated with an infant’s problem, a caretaker’s problem, or a disorder in the infant-caretaker dyad. Like feeding problems in the first 6 months of life, transitional feeding refusal associated with an infant’s problem is often related to a developmental, neurological, or anatomical disorder. During this developmental phase, some infants develop transient feeding refusal related to illness or distress. Most feeding refusal associated with temporary problems resolves and does not progress to the stage of a disorder. Even when an infant experiences anorexia, most infants respond to thirst and drink enough to remain hydrated. Table 23B-3 lists some causes in infant for feeding refusal in the transitional feeding period.

TABLE 23B-3 Possible Causes for Infants’ Feeding Refusal from 6 to 18 Months

Oral-motor delays
Self-feeding delays
Social feeding deficits
Eating rate extremes
Difficult temperament
Sensory deficit
Posttraumatic feeding disorder

Infants and toddlers may exhibit feeding refusal after trauma associated with the face or mouth or temporally with feeding. Posttraumatic feeding disorder has been well described in latency-age children after they experience choking, become preoccupied with a fear of eating, and refuse to eat.28 The following criteria can be used to diagnose posttraumatic feeding disorders in infants: (1) The infant demonstrates food refusal after a traumatic event or repeated traumatic events to the oropharynx or esophagus (e.g., choking, severe gagging, vomiting, reflux, acute allergic reaction, insertion of nasogastric or endotracheal tubes, suctioning, force-feeding); (2) the event (or events) triggered intense distress in the infant; (3) the infant experiences distress when anticipating feedings (e.g., when positioned for feeding, when shown the bottle or feeding utensils, and/or when approached with food); and (4) the infant resists feedings and becomes increasingly distressed when force-fed. Conditioned dysphagia has also been described in children with congenital heart disease, tracheoesophageal fistula, and gastroesophageal reflux.29–31 Research is needed to determine whether the pathophysiology of feeding problems associated with early oropharyngeal medical procedures or infantile illness is similar to that of posttraumatic feeding disorder in older children who have experienced choking.

Transition-stage feeding problems can relate to deficiencies in caretaker ability to assess the child’s hunger, satiety, and feeding needs. Some caretakers are not good at reading the infant’s hunger and satiety cues. The risk for cue insensitivity increases when the caretaker is inexperienced, exhausted, depressed, or hostile toward the infant. Some caretakers do not spontaneously interpret subtle signs, such as turning away, as infant communication. Furthermore, a developmentally inappropriate diet or feeding style can cause feeding refusal. Although some parents expect young infants to self-feed before they are capable, others continue to spoon-feed their infants long after the infant is capable of and desires self-feeding. Infants do not express hunger and satiety equally well. Refusal can result from a mismatch in the child’s developmental ability and feeding opportunities provided by the caretaker. Infants eat optimally in a pleasant, social feeding environment. A distracting or unsupportive feeding environment may be problematic. At the other extreme, force-feeding is aversive conditioning, and feeding refusal can result. Feeding problems initiated by a caretaker’s insensitivity or lack of knowledge can be best detected by a feeding observation. Standardized assessment tools are available for research.32,33 Development of simple assessment tools for practice are needed.

Intervention for feeding refusal secondary to caretaker problems begins with education about developmentally appropriate feeding techniques. Close follow-up is essential to ensure that feeding strategies are changing and that the infant’s symptoms are abating. Mental health services are usually needed to resolve caretaker ambivalence or hostility.

It is important to assess for individual infant-related and individual caretaker-related causes of feeding refusal; however, between 6 and 18 months of an infant’s age, disorders are likely to occur in the caretaker-infant relationship. Feeding refusal during transition to solid feeding is not typically related to poor attachment. Early individuation or beginning to separate from the symbiotic phase of infancy is a developmental challenge during the second half of the first year.34 Feeding problems may develop when caretakers are insensitive to the infant’s new developmental needs. Chatoor25,35 classifies feeding refusal during this developmental period as infantile anorexia with the following criteria: (1) refusal to eat adequate amounts of food for at least 1 month; (2) onset of the food refusal before 3 years of age, most commonly during the transition to spoon- and self-feeding, between 9 and 18 months of age; (3) lack of communication of hunger signals and lack of interest in food but interest in exploration and/or interaction with caregiver; (4) significant growth deficiency; (5) no preceding traumatic event; and (6) no underlying medical illness. Infantile anorexia is understood to stem from the infant’s increasing need for autonomy, often beginning with a battle of wills over the infant’s food intake. As the name infantile anorexia suggests, children with infantile anorexia characteristically lack appetite, beginning during infancy, seeming not to notice their own hunger. Although most infants with infantile anorexia have secure attachment to their mothers, they are somewhat more likely to have insecure mother-infant attachment than are picky eaters or normal controls. Furthermore, the likelihood of insecure attachment increases with worsening malnutrition.36

Selective Intake Disorder (Ages 6 to 18 Months)

Infants with a selective intake disorder are similar to “picky eaters”; however, their selectivity is severe. Typically, they eat only a small selection of foods. Some children with severe selective intake disorder restrict intake to carbohydrates such as rice and pasta. Other children restrict intake to one “safe food,” such as a peanut butter sandwich. As these children get older, they may exhibit symptoms of anxiety, obsessive-compulsive disorder, or autism. In some children, severe selective intake disorder fits into the classification of sensory food aversion. This disorder can also be a less severe form of infantile anorexia or posttraumatic feeding disorder.

Evaluation of children with selective intake disorder includes a careful medical history, including attention to possible symptoms of food intolerance or allergies. It is not necessary to perform swallowing studies or allergy testing if the history supports food elimination or restriction in the diet. If the selective intake disorder persists, a mental health evaluation for the child is recommended.

Intervention for selective intake disorder includes parental support; strategies to reduce anxiety and distress at mealtimes; and mental health intervention for children who meet diagnostic criteria for anxiety or obsessive-compulsive disorders. Oromotor therapy is often beneficial for selective intake disorder. Habituation therapy can also be helpful. The child is asked to taste small pieces of a food that is not part of his or her usual repertoire. By tasting the same food every day, it may gradually become familiar and therefore acceptable. This type of therapy should be performed without emotion or forcing; however, a small reward or reinforcer (such as playing a short game with the parent) is frequently used. Children whose eating disorder has an oppositional component may not respond well to this type of intervention.

Eating Disorder Related to Deprivation

Eating disorders in children can be related to severe deprivation, such as that involved in institutionalization or abandonment. It is well accepted that depressed adults often experience disordered eating. Infants who have experienced severe trauma of abandonment have been described as withdrawn, apathetic, and uninterested. They often have sleep disorders in addition to disordered eating. These children urgently need placement in a nurturing home.

Rumination

Rumination is regurgitation of food, which is then partially or completely reswallowed or rechewed. Infants often initiate rumination by inserting a hand into the mouth. They may also bring up food by thrusting the tongue to the back of the mouth or by contracting their abdominal muscles. Rumination is poorly understood but believed to be self-stimulatory. It is often associated with child neglect. The differential diagnosis of rumination includes other causes of vomiting, such as gastroesophageal reflux. Some infants (usually premature or neurologically fragile) are observed to vomit in response to stimulation such as noise, human interaction, or movement. These infants may require behavioral strategies to decrease overstimulation. Vomiting is also seen in babies with chronic medical conditions (who may also experience the institutionalization of the hospital as nonintentional neglect caused by the medical environment). The diagnosis of rumination is made by observation. Intervention for children with rumination requires increased nurturing with attention to the infant-caretaker relationship.

SIGNIFICANCE AND IMPLICATIONS

Feeding disorders in infancy and early childhood present unique challenges to the child health professional, including the simultaneous assessment of the child’s physical, developmental, and mental health; the parent’s mental health; and the infant-caretaker relationship. Although the exact prevalence of eating disorders in infants and young children is not known, it is known that more than 25% of parents are concerned about their child’s eating. Furthermore, poor growth is common in young children (5% to 10%). Eating disorders are commonly found in children with FTT when the evaluation includes systematic attention to eating behavior. The tools for this evaluation include a careful history of eating behavior; a feeding observation in the clinic, in the home, or by videotape; and a careful assessment of parental mental health and the parent-infant relationship. Feeding behavior in the infant and young child provides a window into the child’s neurodevelopmental competence and developing independent psychological state and into the functionality of the caretaker-infant relationship.

REFERENCES

1 McNeilly AS, Robinson ICA, Houston MJ, et al. Release of oxytocin and prolactin in response to suckling. BMJ (Clin Res Ed). 1983;286:257-259.

2 Uvnas-Moberg K, Widstrom AM, Werner S, et al. Oxytocin and prolactin levels in breastfeeding women. Correlation with milk yield and duration of breastfeeding. Acta Obstet Gynecol Scand. 1990;69:301-306.

3 Ueda T, Yokoyama Y, Irahara M, et al. Influence of psychological stress on suckling-induced pulsatile oxytocin release. Obstet Gynecol. 1994;84:259-262.

4 Wolff P. The Development of Behavioral States and the Expression of Emotions in Early Infancy: New Proposals for Investigation. Chicago: University of Chicago Press, 1987.

5 Gartner L, Morton J, Lawrence R, et al. Breastfeeding and the use of human milk. Pediatrics. 2005;115:496-506.

6 Barr RG, Hopkins B, Green JA, editors. Crying as a Sign, a Symptom, and a Signal. London: Mac Keith Press, 2000.

7 Bowlby J. The nature of a child’s tie to his mother. Int J Psychoanal. 1958;39:350-373.

8 Bowlby J. Attachment and Loss, Volume 2: Separation. New York: Basic Books, 1973.

9 Bowlby J. Attachment and Loss, Volume 1: Attachment. New York: Basic Books, 1969.

10 Bretherton I, Waters E. Growing points in attachment theory and research. Monogr Soc Res Child Dev. 50(1–2, Serial No. 209), 1985.

11 Ward MJ, Kessler DB, Altman SC. Infant-mother attachment in children with failure to thrive. Infant Ment Health J. 1993;14:208-220.

12 Lawrence RA. Breastfeeding: A Guide for the Medical Profession. St. Louis: CV Mosby, 1989.

12a. Steinkuller JS, Chan K, Rinehouse SE. Prechewing of food by adults and streptococcal pharyngitis in infants. J Pediatr. 1992;120:563-564.

13 Kedesdy JH, Budd KS, editors. Childhood Feeding Disorders: Biobehavioral Assessment and Intervention. Baltimore: Paul H. Brookes, 1998.

14 Diamant NE. Development of esophageal function. Am Rev Respir Dis. 1985;131:S29-S32.

15 Bu’Lock F, Woolridge MW, Baum JD. Development of coordination of sucking, swallowing and breathing: Ultrasound study of term and preterm infants. Dev Med Child Neurol. 1990;32:669-678.

16 Hack M, Estabrook MM, Robertson SS. Development of sucking rhythm in preterm infants. Early Hum Dev. 1985;11:133-140.

16a. American Academy of Pediatrics. Diagnostic and Statistical Manual of Mental Disorders: Primary Care Version. Washington, DC: American Academy of Pediatrics, 1995.

17 Linscheid TR. Behavioral treatments for pediatric feeding disorders. Behav Modif. 2006;30:6-23.

18 McDonough S: Personal communication, 2007.

19 Gahagan S: Parental concern about eating behavior in early childhood. Submitted manuscript, 2007.

20 Hagekull B, Bohlin G, Rydell AM. Maternal sensitivity, infant temperament, and the development of early feeding problems. Infant Ment Health J. 1997;18:92-106.

21 Spock B. Dr. Spock Talks With Mothers-Growth and Guidance. Cambridge, MA: Riverside, 1961.

22 Anders TF. Clinical syndromes, relationship disturbances, and their assessment. In: Sameroff AJ, Emde RN, editors. Relationship Disturbances i n Ea rly Child hood. New York: Basic Books; 1989:125-144.

23 Chatoor I. Feeding disorders in infants and toddlers: diagnosis and treatment. Child and Adolescent Psychiatric Clinics of North America. 2002;11:163-183.

24 Spitzer RL, Williams JBW. Classification of mental disorders and DSM-III. Kaplan H, Freedman AM, Sadock BJ, editors. Comprehensive Textbook of Psychiatry. Baltimore: Williams & Wilkins; 1980;4:1035-1072.

25 Chatoor I. Feeding disorders in infants and toddlers: Diagnosis and treatment. Child Adolesc Psychiatr Clin N Am. 2002;11:163-183.

26 Fraiberg S, editor. Clinical Studies in Infant Mental Health: The First Year of Life. New York: Basic Books, 1980.

27 Lumeng JC, Perez M, Gahagan S. Does Treatment of Undernutrition w ith Gastrostomy T ube Feeding Worsen Childhood Eating Disorders? PAS. May 1, 2001. Pediatric Research, 2001.

28 Chatoor I, Conley C, Dickson L. Food refusal after an incident of choking: A posttraumatic eating disorder. J Am Acad Child Adolesc Psychiatry. 1988;27:105-110.

29 Dellert SF, Hyams JS, Treem WR, et al. Feeding resistance and gastroesophageal reflux in infancy. J Pedatr Gastroenterol Nutr. 1993;17:66-71.

30 Di Scipio WS, Kaslon K. Conditioned dysphagia in cleft palate children after pharyngeal flap surgery. Psychosom Med. 1982;44:247-257.

31 Skuse D. Identification and management of problem eaters. Arch Dis Child. 1993;69:604-608.

32 Barnard K: Caregiver/Parent-Child Interaction Feeding Manual. Seattle: University of Washington School of Nursing, NCAST Publications, 1994.

33 Chatoor I, Getson P, Menville E, et al. A feeding scale for research and clinical practice to assess mother-infant interactions in the first three years of life. Infant Ment Health J. 1997;18:76-91.

34 Egan J, Chatoor I, Rosen G. Nonorganic failure to thrive: Pathogenesis and classification. Clin Pro Child Hosp Nati Med Cent. 1980;36:173-182.

35 Chatoor I, Ganiban J, Surles J, et al. Physiological regulation and infantile anorexia: A pilot study. J Am Acad Child Adolesc Psychiatry. 2004;43:1019-1025.

36 Chatoor I, Ganiban J, Hirsch R, et al. Maternal characteristics and toddler temperament in infantile anorexia. J Am Acad Child Adolesc Psychiatry. 2000;39:743-751.

23C. Food Insecurity and Failure to Thrive

STEPHANIE. BLENNER, MARYANN B. WILBUR, DEBORAH A. FRANK

EPIDEMIOLOGY AND CLINICAL SIGNIFICANCE

Food insecurity and nutritional growth failure, frequently termed failure to thrive, are common pediatric problems in the United States and even larger issues globally.1,2 Although famine and malnutrition in the developing world are widely recognized, food insecurity in the United States remains relatively invisible. Food-insecure American children rarely resemble haunting images of hunger in the international media. However, many are not receiving adequate sustenance to support crucial development in early childhood. Insufficient nutrition, even without anthropometric changes, affects a child’s behavior, learning, and social interactions.3

A startling number of American children are at risk for FTT. A U.S. Department of Agriculture study4 revealed that in 2004, nearly 12% of U.S. households were “food insecure” (defined as being unable to obtain reliably sufficient nutritious food for an active, healthy life because of economic constraints). Food insecurity is even more prevalent among households with young children. Nearly 19% of American households with children younger than 6 years (the peak age for FTT) lacked consistent access to enough food for a healthy life in 2004.

Although not all children with FTT come from food-insecure families, poverty remains the most significant social risk factor for developing FTT. In some samples, as many as 10% of young, low-income American children meet criteria for FTT (see later “Diagnosis” section).5 Developmental-behavioral clinicians usually do not become involved in a child’s care until multiple cumulative experiences of food insecurity and associated medical and developmental risks manifest as FTT. As advocates for children, however, developmental-behavioral pediatricians should be aware that in low-income communities, children with FTT represent only part of a large problem. Many additional children experience food insecurity, which often acts as a precursor as well as a concomitant of FTT within a family, community, or population. FTT, in this regard, serves as a broad sentinel indicator of the health and well-being of children’s communities.6 The threshold at which persistent developmental-behavioral risk emerges in young children on the continuum from household food insecurity without growth failure to FTT has not been established. Research findings from the Early Childhood Longitudinal Study7 suggest that living in a food-insecure household during kindergarten is correlated with impaired social skills in girls and depressed third grade reading and math scores in both boys and girls, even after confound control.

Undernutrition in a young child, often in concert with other factors, is the key but not sole mechanism that disrupts cognitive and socioemotional development in children with FTT.8 Studies of moderate to severe early malnutrition have shown detrimental effects on later cognitive measures,9 increased rates of behavioral and mental health disorders,10–13 and poorer school performance.14–16

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