Altering Parents' Behavior Often the Key to Correcting Infant Feeding Disorders

Paula Moyer, MA

November 01, 2006

November 1, 2006 (San Diego) — The best way to address infantile anorexia and restore normal growth is by helping the parents reduce stress and control issues around mealtimes, according to investigators who presented their findings here at the 53rd annual meeting of the American Academy of Child and Adolescent Psychiatry.

"A treatment that focuses on helping toddlers with internal regulation of eating can decrease mother-toddler conflict and struggle for control during feeding and improve weight gain in such children," according to principal investigator Irene Chapoor, MD. Dr. Chapoor is director of the infant psychiatry and eating disorders program at Children's National Medical Center in Washington, DC.

In earlier research, she and coinvestigators identified infantile anorexia as the outcome of a toddler with poor hunger regulation and caregiver parents who have difficulties setting limits and issues regarding their own regulation of eating. Infantile anorexia, unlike so-called "picky eating," is a subtype of infantile feeding disorder and is characterized by failure to gain weight or weight loss over at least 1 month, rare interest in food or expression of hunger, age of onset before the child is 3 years old, and the exclusion of trauma to the oropharyngeal area or other medical conditions.

In that previous research, the investigators identified a method for psychotherapeutic intervention that consists of 3 components: (1) education regarding the toddler temperament, (2) addressing the parents' issues regarding eating and the setting of limits for the child, and (3) several specific guidelines for feeding.

The feeding guidelines consisted of feeding the child at regular times with 3 to 4 hours between meals and snacks, with only water between; putting smaller portions on the child's plate and allowing the child to ask for repeat helpings until filled; refraining from praising or criticizing the child based on food intake; insisting that the child sit at the table until the parents are finished; using time-out for behaviors that interfere with eating.

In the current study, which was funded by the National Institute for Mental Health, the investigators wanted to know whether the previously established intervention was more effective than the control, which focused on educating the parents regarding early child development in general, rather than addressing the specific child's poor appetite and difficult temperament and the specific parents' background.

The investigators recruited 70 toddlers aged 12 to 42 months who had been diagnosed with infantile anorexia and randomly assigned them to the experimental intervention or to the control group. The study used 4 social workers of similar clinical experience, 2 for each study group, to administer the intervention and control treatments. Each treatment involved three 2-hour sessions spaced 1 week apart and three 1-hour sessions spaced 2 to 3 weeks apart. The social workers administered the interventions with both parents and not in the presence of the child.

The investigators followed the subjects at 2 weeks, 4 months, and 8 months after treatment. Of the original 70 children, 60 were available for the final data analysis. Of the 10 children excluded from the final analysis, 8 were excluded because they had been used for the social workers' training, 2 because they had comorbid food allergies, and 2 because they had moved out of the geographic area (2 children were excluded for more than 2 reasons).

Before treatment, the children in the control group were an average of 85% of their ideal body weight; those in the experimental group were 86% of the ideal. At the first follow-up, the children in both groups were an average of 88% of their ideal body weight. However, the time spent in conflict at mealtimes decreased significantly in the experimental group compared to the controls ( P < .01) as had eating-related struggles for control ( P < .05).

Dr. Chatoor explained in a phone interview the reasons that the 2 groups differed so little in their results. "Actually, both groups had some level of intervention because it would have been unethical to offer no intervention to children who were inadequately nourished," she told Medscape. "Both groups got information about how to structure mealtimes. The intervention group also got specific information about the temperament of children with infantile anorexia and an opportunity to discuss the parents' own food issues, if they had them."

Dr. Chatoor went on to explain that children with infantile anorexia are very curious and playful and dislike being interrupted to eat.

The main difference in the groups was the continuation rate: 8 families in the control group dropped out, compared with 2 in the experimental group. "Parents who received the full treatment were more likely to stay," she said. "I also realized that, in the control group, the parents who stayed were healthier and could manage quite well with only being given specific mealtime guidelines."

"When the infant's behavior is not affecting his or her health and growth, the priority is to work with the parents and child to make the eating situation less conflictual," said Nancy Winters, MD, in an interview for additional perspective on the issue of infant feeding disorders. Dr. Winters is an associate professor in the division of child and adolescent psychiatry at Oregon Health Sciences University in Portland, where she is the director of residency training. "Sometimes it's a matter of changing parents' expectations about what children are supposed to eat. Often if parents are reassured that their child is healthy, that can help."

When, as in the case of the patients in the current research, a pediatrician has determined that the child's health is being compromised by the eating behavior, a medical differential diagnosis is necessary. "You need to rule out a medical condition that is causing the child to be averse to eating," she said. For example, neurological issues such as sensitivities or difficulties with chewing and swallowing can make eating distressful to a child.

"If medical conditions are ruled out, often the psychiatrist needs to work with the parents to make meals less stressful," Dr. Winters said. "Letting the child do more self-feeding can help.

She added, "Sometimes parents are so conscientious regarding dietary fat and 'heart-healthy' foods that they make choices that are inappropriate for infants and toddlers. Higher-calorie foods are more appropriate in these cases."

The treatment, then, has 2 goals: for eating to feel good and pleasurable and for parents to feel supported as they work to make the eating environment less stressful, she said.

AACAP 53rd Annual Meeting: Abstract 24B. Presented October 27, 2006.


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