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A pilot study to assess the utility and perceived effectiveness of a tool for diagnosing feeding difficulties in children

A pilot study to assess the utility and perceived effectiveness of a tool for diagnosing feeding... Background: Food dislikes in children may result in avoiding particular food/s with major sources of essential nutri- ents leading to increased risk of impaired growth or cognitive development and compromised immune function. It is necessary to identify conditions contributing to feeding difficulty and associated complications. An instrument was designed to assist diagnosis and management of children with feeding difficulties. The study was conducted to test utility of the “Identification and Management of Feeding Difficulties (IMFeD)” tool in Indian children. Methods: A prospective, cross-sectional study was conducted in Indian children between 2 and 10 years identified to have picky eating behaviour. After completion of both pro forma sections (parent and physician) of the IMFeD tool, the child’s specific feeding difficulty was diagnosed and appropriate nutritional and/or behavioural counselling was provided. The subjects were followed at 30 and 60 days post-intervention. Results: According to 66% of paediatricians the IMFeD tool was very easy to use. Approximately 85% of paediatri- cians required ≤20 min to administer the tool, diagnose the feeding difficulty(ies) and provide specific counselling or behavioural management. More than 70% of parents were satisfied and willing to accept the use of the IMFeD tool. After 60 days, 65% of the parents were either less worried or not worried at all about the feeding behaviour of the child using recommendations made on the basis of the IMFeD tool. The toolkit helped parents to know what to do if their child had a feeding problem. A total of 90% of the parents expressed that the tool is useful for assessing feeding difficulties in children. Conclusion: The IMFeD tool can be effectively used to identify feeding difficulties in Indian children. This toolkit also helps to offer nutritional and behavioural guidance as a part of the management. Keywords: Child, Feeding and eating disorders of childhood, Tool use behavior quantities changes, and infants and toddlers grow, chil- Background dren indicate their likes and dislikes for specific foods Dietary intake of infants begins with a liquid diet, both behaviourally and verbally [2]. Their food dislikes involves a transition to complementary foods by may result in the avoidance of particular foods or groups 6  months, and, by 24  months, most children primar- of food that are major sources of essential nutrients and ily consume solid foods. The ages for typical progres - contribute to dietary variety. Children avoiding certain sions in feeding can vary and are influenced by, amongst types of food/s may be perceived as picky eaters, prob- other factors, maternal characteristics, ethnicity, and lem feeders, or neophobics [1]. It is not uncommon for cultural traditions [1]. As consumption of food types and parents to approach family physicians and paediatricians with concerns about feeding problems in their child. The *Correspondence: drgarg2014@gmail.com prevalence of picky eating behaviour in children ranges Pankaj Garg and Jennifer A Williams have contributed equally to this between 12 and 50% [3–7]. In one study surveying paren- work Sir Ganga Ram Hospital, Rajinder Nagar, New Delhi, India tal perceptions of children’s eating almost half of the Full list of author information is available at the end of the article © 2015 Garg et al. This article is distributed under the terms of the Creative Commons Attribution 4.0 International License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver (http://creativecommons.org/ publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated. Garg et al. Asia Pac Fam Med (2015) 14:7 Page 2 of 8 primary caregivers noted that children are ‘all the time’ two primary goals for the current study were to deter- or ‘sometimes’ picky eaters [8]. mine how the tool would be used in India specifically, Children with feeding difficulties are less likely to con - and what physicians and caregivers thought about the sume a nutritious diet than non-picky eaters [6, 9] and tool. they are at risk for impaired growth [9, 10] or cognitive development [11] along with compromised immune Methods function [12]. Parents often resort to different strategies This was a prospective, cross-sectional study conducted such as using pressure or force with the child, in an effort at 10 distinct study sites across India. The study was to improve feeding behaviours [5]. However, the possible conducted after receiving approval from an Independ- negative consequences that may result from attempts to ent Ethics Committee. The children aged 2–10  years change feeding behaviours, especially coercion, can com- whose parent/caregiver complained that their child had promise parent–child interactions [6, 7]. Early childhood two of mentioned picky eating habits like (1) the child feeding conflicts and struggles with food have been high - is too selective or ‘picky’; (2) the child eats too little; (3) lighted as risk factors for the later development of eating the child fails to advance to more complex foods; or (4) disorders such as bulimia or anorexia nervosa [13, 14]. the child only eats ‘junk food’ were included in the study. To help determine appropriate intervention for chil- Overweight, obese or children at risk being for over- dren with feeding difficulties—whether it is reassurance, weight, or suffering from chronic medical conditions, counselling to resolve behavioural problems (both the or having a chronic mental or developmental problem child and the feeder), nutritional intervention, or medical were excluded from the study. Baseline and demographic treatment—it is necessary to identify the specific condi - information of the subjects was collected after their tions that contribute to a given feeding difficulty and its enrolment in the study. associated complications. The task of categorizing and The IMFeD tool helps paediatricians identify com - treating children with feeding difficulties is often daunt - mon feeding difficulties in children and also offers some ing for the paediatrician or family physician due to time approaches for managing them by providing suggestions constraints and a lack of expertise in this particular field. for parent education. Although feeding difficulties are To overcome the limitations detailed above, the Iden- commonly recognized problems, the types of feeding tification and Management of Feeding Difficulties for problems found in a specific population or country have Children (IMFeD) tool was developed based on the not been studied broadly. research by Chatoor [4] for the classification of feed - The paediatrician administered the first component of ing difficulties, and further complemented by informa - the IMFeD tool with the parent/caregiver of the child. As tion derived from the experiences of Kerzner [3], who the questionnaire was in English, only parent/caregivers has helped provide a structured approach for manag- who understood English were enrolled in the study. After ing a child with a feeding difficulty (Fig.  1). The IMFeD completion of both sections of the IMFeD tool (parent tool consists of the diagnostic framework based on six and physician), the child’s specific feeding difficulty(ies) distinct types of feeding difficulty categories, presented was diagnosed by the paediatrician. Based on the type(s) in Fig. 2, a parent questionnaire (Fig. 3), and a physician of diagnosed feeding difficulty, appropriate nutritional questionnaire (Fig. 4). and/or behavioural counselling was provided to the par- A two-part questionnaire and pro-forma developed as ent/caregiver. All enrolled participants were followed up part of a ‘tool kit’ was designed to be utilized globally to at 30 and 60 days post-intervention, and changes in feed- assist a physician in diagnosing and managing children ing behaviours, if applicable, were captured during these with feeding difficulties. The tool is currently being vali - follow-up visits. Additionally, at the exit visit, a question- dated against professional feeding difficulties assessments naire was administered to both the paediatrician and par- [3]. Once a diagnosis or set of diagnoses is established ent to determine the acceptance of the IMFeD tool. by the physician using the pro-forma with the parent or caregiver to support the clinical reasoning process, a Statistics structured and specific set of guidelines can be provided This study is based on a convenience sample of children for treatment of the specific feeding difficulty(ies) for an identified by their parents as having feeding difficulties. individual child. We planned to enrol approximately 400 children. Statisti- cal analysis was performed using the SPSS software pack- Objective age version 10.0 (Softonic ). Demographic and baseline The tool is currently being validated and the purpose of data (n, mean, standard deviation, range) were calculated the present study is to test the usefulness of the draft ver- for continuous variables, while counts and percentages sion of the tool as part of the developmental process. The were calculated for categorical variables. Variables such as Garg et al. Asia Pac Fam Med (2015) 14:7 Page 3 of 8 Fig. 1 Diagnosis of common types of feeding difficulties in young children [3, 4]. the acceptance of the IMFeD tool by the physician and the Results parent/caregiver were estimated and presented with fre - The study was conducted between March 2011 and quency counts and percentages. All values were reported March 2012. Against the estimated plan of 400 children based on two-sided distribution, and all statistical tests enrolment, 383 children across ten centres in India were were interpreted at a 5% level of significance. enrolled. Three children were lost to follow-up, hence the Garg et al. Asia Pac Fam Med (2015) 14:7 Page 4 of 8 Fig. 2 IMFeD tool: diagnostic framework [4]. final evaluable set of subjects was 380 children. Demo - diagnosis of paediatric feeding difficulties. According to graphic data for subjects are presented in Table 1. 66% of the paediatricians, the IMFeD tool was very easy The results showed that the “IMFeD” tool helped to use (Fig.  5), and approximately 85% of the study pae- paediatricians identify the “type of feeding difficulty” diatricians (Fig.  6) required 20  min or less to administer among those children considered to be picky eaters. the tool and diagnose the feeding difficulty(ies), along Table  2 shows the prevalence of the individual diagno- with conducting specific counselling or behavioural sis categories of “feeding difficulty” based on the IMFeD management. tool, with the most common feeding difficulty assessed More than 70% of parents were satisfied and willing to as “poor appetite in fundamentally vigorous child” fol- accept the use of the IMFeD tool to manage their child’s lowed by “highly selective intake”. A total of 124 children feeding issues (Fig.  7). At the end of the 60  day study (33%) presented with more than one feeding difficulty period utilizing the recommendations from the IMFeD (Table 2). tool, 65% of the parents were either less worried or not The study also assessed the acceptance of the IMFeD worried at all about the feeding behaviour of their child tool by study paediatricians as a process aid for the (Fig.  8). On completion of the study, 51% parents were Garg et al. Asia Pac Fam Med (2015) 14:7 Page 5 of 8 Fig. 3 IMFeD tool: parent questionnaire. confident and believed that they knew what to do if their [16]. Implications can extend beyond growth impairment child had a feeding problem and were also able to apply to emotional and cognitive issues. the recommended strategies to improve their child’s Paediatricians are instrumental for resolving feeding appetite and feeding behaviour. Sixty-two percent of the issues, and they commonly address these conditions in study parents felt that the IMFeD tool used by the pae- the clinical setting. However, paediatricians, with busy diatrician for their child’s eating problems was effective, schedules and no standard protocol available for the and 90% of the parents expressed that the IMFeD tool treatment of feeding difficulties, may not be able to pro - is a good instrument to assess the feeding difficulties in vide specific counselling to their paediatric patients and children. their parents/caregivers. Some studies describe picky or fussy eating in terms of Discussion a limited variety of food in the diet [8]. This study showed The continuum of feeding difficulties can range from that the most common feeding difficulty for this specific mild behavioural issues to major organic disorders. study population suggested by the physicians using the Feeding problems such as organic disease, infantile ano- IMFeD tool were ‘fundamentally vigorous child’ followed rexia, food allergies, food aversion, food selectivity, food closely by ‘highly selective intake’ and ‘parent mispercep- refusal, selective eating, colic, fear of feeding, post-trau- tion’. The prevalence of specific feeding difficulties may matic feeding disorder, and even parental misperception differ from population to population, country to country, all fall somewhere on this scale of severity. Interestingly, and within different age groups studied. Because paediatri - organic disease as a cause is implicated in only 5% of cians are often the key stakeholders in the management of feeding difficulty diagnoses [15]. If not treated, feeding feeding difficulties, it was important to assess their opinion difficulties may cause adverse implications such as nutri - on the ease of use and average time spent while diagnos- tional deficiencies, failure to thrive, or chronic feeding ing feeding difficulty(ies) in a child with the IMFeD tool. aversion. A large scale, longitudinal study of young chil- More than 90% of paediatricians said that the tool was easy dren in Quebec found picky eaters were twice as likely as or very easy to use, and the time taken for diagnosis was non-picky eaters to be underweight at 4.5 years of age [7]. typically less than 20 min. Approximately 20% of the study A long-term follow-up study of Norwegian children with paediatricians were able to implement the tool in less than early refusal to eat demonstrated that picky and prob- 10 min. This implies that with continuous and regular use, lematic eating behaviours can persist up to 9 years of age the paediatricians became more acquainted with the tool, Garg et al. Asia Pac Fam Med (2015) 14:7 Page 6 of 8 Fig. 4 IMFeD tool: physician questionnaire. Table 1 Demographic and baseline characteristics Boys Girls P value Sample size 222 158 Age in yrs, mean ± SD 4.59 ± 02.03 4.61 ± 02.07 0.9254 Weight in kg, mean ± SD 15.49 ± 04.62 15.18 ± 04.62 0.5195 Height in cm, mean ± SD 101.15 ± 15.00 99.41 ± 16.35 0.2907 Table 2 Diagnosis of  feeding difficulties based on  the IMFeD tool Feeding difficulty category No. of  Percentage (%) cases (N = 380) Fig. 5 Physician opinion about application of the IMFeD tool. Organic disease 1 0.3 Highly selective intake 150 39.5 Parental misperception 97 25.5 Parent participation is also very important during imple- Fundamentally vigorous child 231 60.8 mentation of the management strategies designed for the Apathetic & withdrawn child 7 1.8 diagnosed feeding difficulty. For intervention success it is Fear of feeding 18 4.7 important for the parent to accept the utility of the IMFeD tool and follow the counselling provided. In this study, the majority of parents willingly accepted the use of the which reduced the time required for its implementation. IMFeD tool by the paediatrician. Continued familiarity and experience with the IMFeD Previous research has shown that picky eating can tool would facilitate ready adoption into routine practice cause considerable parental concern over the child’s by the paediatrician, possibly helping to alleviate anxi- physical and mental health [11]. Notably, more than ety or errors during the diagnosis of feeding difficulties. Garg et al. Asia Pac Fam Med (2015) 14:7 Page 7 of 8 This study has some limitations. Although the tool is not yet validated, it is currently being validated against standardized feeding difficulties assessments [3]. Sec - ondly, convenience sampling used in this study is asso- ciated with many limitations. As the sampling was not randomized, the findings of the study may not be gen - eralized more broadly to the entire population. A larger study with randomized sampling is required to determine whether our study results would hold true for a more representative sample of the population. In this study, only opinions of the physician are reported while health outcome measures are not evaluated. Further studies with data at minimum two follow up points are recom- Fig. 6 Time required by physician to administer the IMFeD tool. mended to evaluate the health outcomes in children. Conclusion This pilot study shows that the IMFeD tool can be applied by paediatricians in their routine clinical practice to iden- tify the feeding difficulties in Indian children. The IMFeD tool helps in diagnosing the type of feeding difficulty, and also offers nutritional and behavioural guidance as a part of the management and improvement of feeding difficulties. However, larger comparative studies need to be conducted to prove that the IMFeD tool is a use- ful instrument for diagnosing feeding difficulties and also enhancing nutritional status in Indian children. Abbreviation IMFeD: Identification and Management of Feeding Difficulties. Authors’ contributions Fig. 7 Parent attitudes regarding use of the IMFeD tool. All authors read and approved the final manuscript. Author details 1 2 Sir Ganga Ram Hospital, Rajinder Nagar, New Delhi, India. Abbott Nutrition Research and Development, Abbott Laboratories, Columbus, OH, USA. Scien- tific and Medical Affairs, Abbott Nutrition International India, Mumbai, India. Acknowledgements Abbott Nutrition provided funding for this present study and was responsible for study design and monitoring. We thank Dr. Nilesh Tayade and Dr.Irfan Shaikh for assistance during study start-up and study close-out activities respectively. The authors wish to thank Kailas Gandewar, Soham Consultancy for Data management and statistical analysis and Dr. Anant Patil & Manoj Prabhu for assistance in editing the manuscript. Authors also thank all the participating investigators in this study: Dr. Anuj Rastogi, Dr. Apurba Ghosh, Dr. Abhijit Mukherjee, Dr. Pallab Chhaterjee, Dr. Ravishankar, Dr. R.Manju, Dr. Soumitra Dutta, Dr. Suresh Kumar, Dr.Vishnu Murthy. Compliance with ethical guidelines Fig. 8 Parent attitudes about child’s feeding difficulty after use of the Competing interests IMFeD tool. JAW and VS are employees of Abbott Nutrition International. PG, JAW and VS were responsible for the conception and design of the study, participated in the data analysis and interpretation and also drafted the manuscript. Received: 23 June 2014 Accepted: 30 June 2015 half of the parents in this study experienced a signifi - cant decrease in their concern about their child’s feeding problem after use of the IMFeD tool. Garg et al. Asia Pac Fam Med (2015) 14:7 Page 8 of 8 References 9. Lindberg L, Östberg M, Isacson I-M, Dannaeus M (2006) Feeding disorders 1. Carruth BR, Ziegler PJ, Gordon A, Barr SI (2004) Prevalence of picky eaters related to nutrition. Acta Paediatr 95:425–429 among infants and toddlers and their caregivers’ decisions about offering 10. Wright C, Parkinson K, Shipton D, Drewett RF (2007) How do toddler a new food. J Am Diet Assoc 104(1 Suppl 1):S57–S64 eating problems relate to their eating behavior, food preferences, and 2. Carruth BR, Skinner J, Houck K, Moran J 3rd, Coletta F, Ott D (1998) The growth? Pediatrics 120:e1069–e1075 phenomenon of “Picky Eater”: a behavioral marker in eating patterns of 11. Chatoor I, Surles J, Ganiban J, Beker L, Paez LM, Kerzner B (2004) Failure toddlers. J Am Coll Nutr 17:180–186 to thrive and cognitive development in toddlers with infantile anorexia 3. Kerzner B (2009) Clinical investigation of feeding difficulties in young nervosa. Pediatrics 113:e440–e447 children: a practical approach. Clin Pediatr 48(9):960–965 12. Chandra R (2002) Nutrition and the immune system from birth to old 4. Chatoor I, Ammaniti M (2007) Classifying feeding disorders of infancy and age. Eur J Clin Nutr 56:S73–S76 early childhood. In: Narrow WE, First MB, Sirovatka PJ, Regier DA (eds) Age 13. Marchi M, Cohen P (1990) Early childhood eating behaviors and adoles- and gender considerations in psychiatric diagnosis: a research agenda for cent eating disorders. J Acad Child Adolesc Psychiatry 29:112–117 DSM-V. American Psychiatric Association, Arlington, pp 227–242 14. Kotler LA, Cohen P, Davies M, Pine DS, Walsh BT (2001) Longitudinal 5. Alarcon PA, Lin LH, Noche M Jr, Hernandez VC, Cimafranca L, Lam W et al relationships between childhood, adolescent, and adult eating disorders. (2003) Eec ff t of oral supplementation on catch-up growth in picky eaters. J Am Acad Child Adolesc Psychiatry 40:1434–1440 Clin Pediatr (Phila) 42:209–217 15. Douglas P, Hiscock H (2010) The unsettled baby: crying out for an 6. Galloway AT, Fiorito L, Lee Y, Birch LL (2005) Parental pressure, dietary integrated, multidisciplinary, primary care intervention. Med J Aust patterns, and weight status among girls who are picky eaters. J Am Diet 193:533–536 Assoc 105(4):541–548 16. Dahl M, Rydell A, Sundelin C (1994) Children with early refusal to eat: 7. Dubois L, Farmer A, Girard M, Peterson K, Tatone-Tokuda F (2007) Problem follow-up during primary school. Acta Paediatr 83:54–58 eating behaviors related to social factors and body weight in preschool children: a longitudinal study. Int J Behav Nutr Phys Act 4:9 8. Goh DY, Jacob A (2012) Perception of picky eating among children in Singapore and its impact on caregivers: a questionnaire survey. Asia Pac Fam Med 11:5 Submit your next manuscript to BioMed Central and take full advantage of:  Convenient online submission  Thorough peer review  No space constraints or color figure charges  Immediate publication on acceptance  Inclusion in PubMed, CAS, Scopus and Google Scholar  Research which is freely available for redistribution Submit your manuscript at www.biomedcentral.com/submit http://www.deepdyve.com/assets/images/DeepDyve-Logo-lg.png Asia Pacific Family Medicine Springer Journals

A pilot study to assess the utility and perceived effectiveness of a tool for diagnosing feeding difficulties in children

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Springer Journals
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Copyright © 2015 by Garg et al.
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Medicine & Public Health; General Practice / Family Medicine; Primary Care Medicine
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10.1186/s12930-015-0024-5
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Abstract

Background: Food dislikes in children may result in avoiding particular food/s with major sources of essential nutri- ents leading to increased risk of impaired growth or cognitive development and compromised immune function. It is necessary to identify conditions contributing to feeding difficulty and associated complications. An instrument was designed to assist diagnosis and management of children with feeding difficulties. The study was conducted to test utility of the “Identification and Management of Feeding Difficulties (IMFeD)” tool in Indian children. Methods: A prospective, cross-sectional study was conducted in Indian children between 2 and 10 years identified to have picky eating behaviour. After completion of both pro forma sections (parent and physician) of the IMFeD tool, the child’s specific feeding difficulty was diagnosed and appropriate nutritional and/or behavioural counselling was provided. The subjects were followed at 30 and 60 days post-intervention. Results: According to 66% of paediatricians the IMFeD tool was very easy to use. Approximately 85% of paediatri- cians required ≤20 min to administer the tool, diagnose the feeding difficulty(ies) and provide specific counselling or behavioural management. More than 70% of parents were satisfied and willing to accept the use of the IMFeD tool. After 60 days, 65% of the parents were either less worried or not worried at all about the feeding behaviour of the child using recommendations made on the basis of the IMFeD tool. The toolkit helped parents to know what to do if their child had a feeding problem. A total of 90% of the parents expressed that the tool is useful for assessing feeding difficulties in children. Conclusion: The IMFeD tool can be effectively used to identify feeding difficulties in Indian children. This toolkit also helps to offer nutritional and behavioural guidance as a part of the management. Keywords: Child, Feeding and eating disorders of childhood, Tool use behavior quantities changes, and infants and toddlers grow, chil- Background dren indicate their likes and dislikes for specific foods Dietary intake of infants begins with a liquid diet, both behaviourally and verbally [2]. Their food dislikes involves a transition to complementary foods by may result in the avoidance of particular foods or groups 6  months, and, by 24  months, most children primar- of food that are major sources of essential nutrients and ily consume solid foods. The ages for typical progres - contribute to dietary variety. Children avoiding certain sions in feeding can vary and are influenced by, amongst types of food/s may be perceived as picky eaters, prob- other factors, maternal characteristics, ethnicity, and lem feeders, or neophobics [1]. It is not uncommon for cultural traditions [1]. As consumption of food types and parents to approach family physicians and paediatricians with concerns about feeding problems in their child. The *Correspondence: drgarg2014@gmail.com prevalence of picky eating behaviour in children ranges Pankaj Garg and Jennifer A Williams have contributed equally to this between 12 and 50% [3–7]. In one study surveying paren- work Sir Ganga Ram Hospital, Rajinder Nagar, New Delhi, India tal perceptions of children’s eating almost half of the Full list of author information is available at the end of the article © 2015 Garg et al. This article is distributed under the terms of the Creative Commons Attribution 4.0 International License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver (http://creativecommons.org/ publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated. Garg et al. Asia Pac Fam Med (2015) 14:7 Page 2 of 8 primary caregivers noted that children are ‘all the time’ two primary goals for the current study were to deter- or ‘sometimes’ picky eaters [8]. mine how the tool would be used in India specifically, Children with feeding difficulties are less likely to con - and what physicians and caregivers thought about the sume a nutritious diet than non-picky eaters [6, 9] and tool. they are at risk for impaired growth [9, 10] or cognitive development [11] along with compromised immune Methods function [12]. Parents often resort to different strategies This was a prospective, cross-sectional study conducted such as using pressure or force with the child, in an effort at 10 distinct study sites across India. The study was to improve feeding behaviours [5]. However, the possible conducted after receiving approval from an Independ- negative consequences that may result from attempts to ent Ethics Committee. The children aged 2–10  years change feeding behaviours, especially coercion, can com- whose parent/caregiver complained that their child had promise parent–child interactions [6, 7]. Early childhood two of mentioned picky eating habits like (1) the child feeding conflicts and struggles with food have been high - is too selective or ‘picky’; (2) the child eats too little; (3) lighted as risk factors for the later development of eating the child fails to advance to more complex foods; or (4) disorders such as bulimia or anorexia nervosa [13, 14]. the child only eats ‘junk food’ were included in the study. To help determine appropriate intervention for chil- Overweight, obese or children at risk being for over- dren with feeding difficulties—whether it is reassurance, weight, or suffering from chronic medical conditions, counselling to resolve behavioural problems (both the or having a chronic mental or developmental problem child and the feeder), nutritional intervention, or medical were excluded from the study. Baseline and demographic treatment—it is necessary to identify the specific condi - information of the subjects was collected after their tions that contribute to a given feeding difficulty and its enrolment in the study. associated complications. The task of categorizing and The IMFeD tool helps paediatricians identify com - treating children with feeding difficulties is often daunt - mon feeding difficulties in children and also offers some ing for the paediatrician or family physician due to time approaches for managing them by providing suggestions constraints and a lack of expertise in this particular field. for parent education. Although feeding difficulties are To overcome the limitations detailed above, the Iden- commonly recognized problems, the types of feeding tification and Management of Feeding Difficulties for problems found in a specific population or country have Children (IMFeD) tool was developed based on the not been studied broadly. research by Chatoor [4] for the classification of feed - The paediatrician administered the first component of ing difficulties, and further complemented by informa - the IMFeD tool with the parent/caregiver of the child. As tion derived from the experiences of Kerzner [3], who the questionnaire was in English, only parent/caregivers has helped provide a structured approach for manag- who understood English were enrolled in the study. After ing a child with a feeding difficulty (Fig.  1). The IMFeD completion of both sections of the IMFeD tool (parent tool consists of the diagnostic framework based on six and physician), the child’s specific feeding difficulty(ies) distinct types of feeding difficulty categories, presented was diagnosed by the paediatrician. Based on the type(s) in Fig. 2, a parent questionnaire (Fig. 3), and a physician of diagnosed feeding difficulty, appropriate nutritional questionnaire (Fig. 4). and/or behavioural counselling was provided to the par- A two-part questionnaire and pro-forma developed as ent/caregiver. All enrolled participants were followed up part of a ‘tool kit’ was designed to be utilized globally to at 30 and 60 days post-intervention, and changes in feed- assist a physician in diagnosing and managing children ing behaviours, if applicable, were captured during these with feeding difficulties. The tool is currently being vali - follow-up visits. Additionally, at the exit visit, a question- dated against professional feeding difficulties assessments naire was administered to both the paediatrician and par- [3]. Once a diagnosis or set of diagnoses is established ent to determine the acceptance of the IMFeD tool. by the physician using the pro-forma with the parent or caregiver to support the clinical reasoning process, a Statistics structured and specific set of guidelines can be provided This study is based on a convenience sample of children for treatment of the specific feeding difficulty(ies) for an identified by their parents as having feeding difficulties. individual child. We planned to enrol approximately 400 children. Statisti- cal analysis was performed using the SPSS software pack- Objective age version 10.0 (Softonic ). Demographic and baseline The tool is currently being validated and the purpose of data (n, mean, standard deviation, range) were calculated the present study is to test the usefulness of the draft ver- for continuous variables, while counts and percentages sion of the tool as part of the developmental process. The were calculated for categorical variables. Variables such as Garg et al. Asia Pac Fam Med (2015) 14:7 Page 3 of 8 Fig. 1 Diagnosis of common types of feeding difficulties in young children [3, 4]. the acceptance of the IMFeD tool by the physician and the Results parent/caregiver were estimated and presented with fre - The study was conducted between March 2011 and quency counts and percentages. All values were reported March 2012. Against the estimated plan of 400 children based on two-sided distribution, and all statistical tests enrolment, 383 children across ten centres in India were were interpreted at a 5% level of significance. enrolled. Three children were lost to follow-up, hence the Garg et al. Asia Pac Fam Med (2015) 14:7 Page 4 of 8 Fig. 2 IMFeD tool: diagnostic framework [4]. final evaluable set of subjects was 380 children. Demo - diagnosis of paediatric feeding difficulties. According to graphic data for subjects are presented in Table 1. 66% of the paediatricians, the IMFeD tool was very easy The results showed that the “IMFeD” tool helped to use (Fig.  5), and approximately 85% of the study pae- paediatricians identify the “type of feeding difficulty” diatricians (Fig.  6) required 20  min or less to administer among those children considered to be picky eaters. the tool and diagnose the feeding difficulty(ies), along Table  2 shows the prevalence of the individual diagno- with conducting specific counselling or behavioural sis categories of “feeding difficulty” based on the IMFeD management. tool, with the most common feeding difficulty assessed More than 70% of parents were satisfied and willing to as “poor appetite in fundamentally vigorous child” fol- accept the use of the IMFeD tool to manage their child’s lowed by “highly selective intake”. A total of 124 children feeding issues (Fig.  7). At the end of the 60  day study (33%) presented with more than one feeding difficulty period utilizing the recommendations from the IMFeD (Table 2). tool, 65% of the parents were either less worried or not The study also assessed the acceptance of the IMFeD worried at all about the feeding behaviour of their child tool by study paediatricians as a process aid for the (Fig.  8). On completion of the study, 51% parents were Garg et al. Asia Pac Fam Med (2015) 14:7 Page 5 of 8 Fig. 3 IMFeD tool: parent questionnaire. confident and believed that they knew what to do if their [16]. Implications can extend beyond growth impairment child had a feeding problem and were also able to apply to emotional and cognitive issues. the recommended strategies to improve their child’s Paediatricians are instrumental for resolving feeding appetite and feeding behaviour. Sixty-two percent of the issues, and they commonly address these conditions in study parents felt that the IMFeD tool used by the pae- the clinical setting. However, paediatricians, with busy diatrician for their child’s eating problems was effective, schedules and no standard protocol available for the and 90% of the parents expressed that the IMFeD tool treatment of feeding difficulties, may not be able to pro - is a good instrument to assess the feeding difficulties in vide specific counselling to their paediatric patients and children. their parents/caregivers. Some studies describe picky or fussy eating in terms of Discussion a limited variety of food in the diet [8]. This study showed The continuum of feeding difficulties can range from that the most common feeding difficulty for this specific mild behavioural issues to major organic disorders. study population suggested by the physicians using the Feeding problems such as organic disease, infantile ano- IMFeD tool were ‘fundamentally vigorous child’ followed rexia, food allergies, food aversion, food selectivity, food closely by ‘highly selective intake’ and ‘parent mispercep- refusal, selective eating, colic, fear of feeding, post-trau- tion’. The prevalence of specific feeding difficulties may matic feeding disorder, and even parental misperception differ from population to population, country to country, all fall somewhere on this scale of severity. Interestingly, and within different age groups studied. Because paediatri - organic disease as a cause is implicated in only 5% of cians are often the key stakeholders in the management of feeding difficulty diagnoses [15]. If not treated, feeding feeding difficulties, it was important to assess their opinion difficulties may cause adverse implications such as nutri - on the ease of use and average time spent while diagnos- tional deficiencies, failure to thrive, or chronic feeding ing feeding difficulty(ies) in a child with the IMFeD tool. aversion. A large scale, longitudinal study of young chil- More than 90% of paediatricians said that the tool was easy dren in Quebec found picky eaters were twice as likely as or very easy to use, and the time taken for diagnosis was non-picky eaters to be underweight at 4.5 years of age [7]. typically less than 20 min. Approximately 20% of the study A long-term follow-up study of Norwegian children with paediatricians were able to implement the tool in less than early refusal to eat demonstrated that picky and prob- 10 min. This implies that with continuous and regular use, lematic eating behaviours can persist up to 9 years of age the paediatricians became more acquainted with the tool, Garg et al. Asia Pac Fam Med (2015) 14:7 Page 6 of 8 Fig. 4 IMFeD tool: physician questionnaire. Table 1 Demographic and baseline characteristics Boys Girls P value Sample size 222 158 Age in yrs, mean ± SD 4.59 ± 02.03 4.61 ± 02.07 0.9254 Weight in kg, mean ± SD 15.49 ± 04.62 15.18 ± 04.62 0.5195 Height in cm, mean ± SD 101.15 ± 15.00 99.41 ± 16.35 0.2907 Table 2 Diagnosis of  feeding difficulties based on  the IMFeD tool Feeding difficulty category No. of  Percentage (%) cases (N = 380) Fig. 5 Physician opinion about application of the IMFeD tool. Organic disease 1 0.3 Highly selective intake 150 39.5 Parental misperception 97 25.5 Parent participation is also very important during imple- Fundamentally vigorous child 231 60.8 mentation of the management strategies designed for the Apathetic & withdrawn child 7 1.8 diagnosed feeding difficulty. For intervention success it is Fear of feeding 18 4.7 important for the parent to accept the utility of the IMFeD tool and follow the counselling provided. In this study, the majority of parents willingly accepted the use of the which reduced the time required for its implementation. IMFeD tool by the paediatrician. Continued familiarity and experience with the IMFeD Previous research has shown that picky eating can tool would facilitate ready adoption into routine practice cause considerable parental concern over the child’s by the paediatrician, possibly helping to alleviate anxi- physical and mental health [11]. Notably, more than ety or errors during the diagnosis of feeding difficulties. Garg et al. Asia Pac Fam Med (2015) 14:7 Page 7 of 8 This study has some limitations. Although the tool is not yet validated, it is currently being validated against standardized feeding difficulties assessments [3]. Sec - ondly, convenience sampling used in this study is asso- ciated with many limitations. As the sampling was not randomized, the findings of the study may not be gen - eralized more broadly to the entire population. A larger study with randomized sampling is required to determine whether our study results would hold true for a more representative sample of the population. In this study, only opinions of the physician are reported while health outcome measures are not evaluated. Further studies with data at minimum two follow up points are recom- Fig. 6 Time required by physician to administer the IMFeD tool. mended to evaluate the health outcomes in children. Conclusion This pilot study shows that the IMFeD tool can be applied by paediatricians in their routine clinical practice to iden- tify the feeding difficulties in Indian children. The IMFeD tool helps in diagnosing the type of feeding difficulty, and also offers nutritional and behavioural guidance as a part of the management and improvement of feeding difficulties. However, larger comparative studies need to be conducted to prove that the IMFeD tool is a use- ful instrument for diagnosing feeding difficulties and also enhancing nutritional status in Indian children. Abbreviation IMFeD: Identification and Management of Feeding Difficulties. Authors’ contributions Fig. 7 Parent attitudes regarding use of the IMFeD tool. All authors read and approved the final manuscript. Author details 1 2 Sir Ganga Ram Hospital, Rajinder Nagar, New Delhi, India. Abbott Nutrition Research and Development, Abbott Laboratories, Columbus, OH, USA. Scien- tific and Medical Affairs, Abbott Nutrition International India, Mumbai, India. Acknowledgements Abbott Nutrition provided funding for this present study and was responsible for study design and monitoring. We thank Dr. Nilesh Tayade and Dr.Irfan Shaikh for assistance during study start-up and study close-out activities respectively. The authors wish to thank Kailas Gandewar, Soham Consultancy for Data management and statistical analysis and Dr. Anant Patil & Manoj Prabhu for assistance in editing the manuscript. Authors also thank all the participating investigators in this study: Dr. Anuj Rastogi, Dr. Apurba Ghosh, Dr. Abhijit Mukherjee, Dr. Pallab Chhaterjee, Dr. Ravishankar, Dr. R.Manju, Dr. Soumitra Dutta, Dr. Suresh Kumar, Dr.Vishnu Murthy. Compliance with ethical guidelines Fig. 8 Parent attitudes about child’s feeding difficulty after use of the Competing interests IMFeD tool. JAW and VS are employees of Abbott Nutrition International. PG, JAW and VS were responsible for the conception and design of the study, participated in the data analysis and interpretation and also drafted the manuscript. Received: 23 June 2014 Accepted: 30 June 2015 half of the parents in this study experienced a signifi - cant decrease in their concern about their child’s feeding problem after use of the IMFeD tool. Garg et al. Asia Pac Fam Med (2015) 14:7 Page 8 of 8 References 9. Lindberg L, Östberg M, Isacson I-M, Dannaeus M (2006) Feeding disorders 1. Carruth BR, Ziegler PJ, Gordon A, Barr SI (2004) Prevalence of picky eaters related to nutrition. Acta Paediatr 95:425–429 among infants and toddlers and their caregivers’ decisions about offering 10. Wright C, Parkinson K, Shipton D, Drewett RF (2007) How do toddler a new food. J Am Diet Assoc 104(1 Suppl 1):S57–S64 eating problems relate to their eating behavior, food preferences, and 2. Carruth BR, Skinner J, Houck K, Moran J 3rd, Coletta F, Ott D (1998) The growth? 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Journal

Asia Pacific Family MedicineSpringer Journals

Published: Jul 31, 2015

References