ORIGINAL ARTICLE: NUTRITION
Sensory Processing Difficulties in Toddlers With Nonorganic Failure-to-Thrive and Feeding Problems
Sook-Hee Yi, yYoo-Sook Joung, zYon Ho Choe, §Eun-Hye Kim, and jjJeong-Yi Kwon
ABSTRACT Objectives: Failure-to-thrive is defined as an abnormally low weight and/or height for age. The term ‘‘nonorganic failure-to-thrive’’ (NOFT) has been used to describe ‘‘failure-to-thrive’’ without an obvious cause underlying the growth failure. The purpose of the present study was to compare sensory processing abilities between toddlers with NOFT and feeding problems and age-matched controls. Methods: Toddlers with NOFT and feeding problems (N ¼ 16) were recruited from the pediatric feeding clinic in a tertiary university hospital, and agematched controls (N ¼ 16) were recruited from community volunteers. They were evaluated for sensory processing ability using an Infant/Toddler Sensory Profile (ITSP), and for development of cognition, motor skills, and language using the Bayley Scales of Infant Development II and Sequenced Language Scale for Infants. Behavior at mealtime was evaluated using the Behavioral Pediatrics Feeding Assessment Scale. Results: In the NOFT with feeding problems group, atypical performances were more frequently observed in 3 of 5 ITSP section items (tactile, vestibular, and oral) compared with those in the control group. Significant delayed development of cognition, motor skills, and language was observed in the NOFT with feeding problems group compared with that in the control group. In addition, children who showed 1 or more atypical performances in ITSP had delayed development in cognition, motor skills, and language. Conclusions: Sensory processing problems were more commonly observed in toddlers with feeding problems and growth deficiency. The present study could provide a preliminary evidence for a possible impact of the sensory processing problems on the feeding difficulties in toddlers with NOFT. Future large studies should be conducted to clarify the relation between sensory processing difficulties and feeding problems in toddlers. Key Words: development, failure-to-thrive, feeding disorder, sensory processing
(JPGN 2015;60: 819–824) Received October 15, 2014; accepted December 24, 2014. From the Department of Rehabilitation Medicine, Seoul Rehabilitation Hospital, the yDepartment of Psychiatry, the zDepartment of Pediatrics, Samsung Medical Center, Sungkyunkwan University School of Medicine, the §Department of Rehabilitation Medicine, Seoul Rehabilitation Hospital, and the jjDepartment of Physical and Rehabilitation Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, South Korea. Address correspondence and reprint requests to Jeong-Yi Kwon, MD, Department of Physical and Rehabilitation Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, 50 Irwon-dong, Gangnam-gu, Seoul 135-710, South Korea (e-mail: jeongyi.kwon@ samsung.com). The study was supported by a Samsung Medical Center grant (number CRS110-32-2). The authors report no conflicts of interest. Copyright # 2015 by European Society for Pediatric Gastroenterology, Hepatology, and Nutrition and North American Society for Pediatric Gastroenterology, Hepatology, and Nutrition DOI: 10.1097/MPG.0000000000000707
JPGN
Volume 60, Number 6, June 2015
What Is Known
Failure-to-thrive (FTT) may be caused by infantile feeding disorder. Disruption of the process of learning to eat and accepting new tastes during the critical period can result in oral hypersensitivity. Sensory processing problem was reported in children older than 3 years with feeding difficulties.
What Is New
Sensory processing problems were also commonly observed in toddlers with feeding problems and FTT. Delayed development was observed in the toddlers with feeding problems and FTT compared with the control group. The present study could provide a preliminary evidence for a possible impact of the sensory processing problems on the feeding difficulties.
S
ensory defensiveness may result from a difficulty in integrating oral sensory information from different channels (1). This could result in limited tactile oral exploration, which is believed to increase tolerance for a variety of oral sensations and facilitate successful introduction and progression of oral feeding (2). Disrupted or prevented development of oral feeding could exacerbate oral hypersensitivity and oral defensiveness (3). Parents of children with significant feeding difficulties may give up attempts to feed their child or may delay introduction of soft or solid foods. Although controversial, there is believed to be a critical period for introducing solid foods when the child is developmentally ready to chew (4). Disruption of the process of learning to eat and accepting new tastes during the critical period can result in oral hypersensitivity and oral-motor dysfunction (5). A variety of symptoms or outcomes have been associated with infantile feeding disorders, such as food refusal, vomiting, gagging or retching, irritability, or failure-to-thrive (FTT) (6). Using all of the FTT definitions, FTT prevalence can range between 1.3% and 20.9% of children (7). Although some children with FTT have an identifiable organic etiology, others have no obvious cause underlying their growth failure. The term ‘‘nonorganic failure-tothrive’’ (NOFT) is widely used for the latter group (8). For the diagnosis of NOFT, all of the possible medical conditions must be excluded by clinicians. Although authors’ clinical experience points to the frequent presence of sensory problems in children with feeding disorders and growth deficiencies, there are a few studies to describe sensory processing issues in this group. Davis et al retrospectively reported
819
Copyright 2015 by ESPGHAN and NASPGHAN. Unauthorized reproduction of this article is prohibited.
Kwon et al
JPGN
sensory processing problems in children older than 3 years with feeding difficulties (9). Despite the commonality of sensory issues and feeding problems in early childhood, there have been no specific reports on this phenomenon in medical literature. Therefore, the purpose of the present study was to compare sensory processing abilities between toddlers with NOFT and feeding problems and age-matched controls. In particular, we wanted to clarify the relation between development and sensory processing abilities.
METHODS
Volume 60, Number 6, June 2015
institute. Toddlers in the NOFT group experienced slow weight gain relative to the reference population, such that their weight-for-age and/or weight-for-height was below the fifth percentile on growth charts at the time of recruitment. Toddlers in the control group were above the tenth percentile for both weight-for-age and weight-forheight. A total of 16 toddlers in the NOFT with feeding problems group and 16 in the control group were included in the present study. There were no differences in demographic characteristics between both groups except for weight and height (Table 1).
Outcome Measures
Patients The study was approved by the institutional review board of the Samsung Medical Center (Seoul, Republic of Korea), and informed consent was obtained from participants’ parents or guardians. In the present study, we included only toddlers with NOFT with feeding difficulties to exclude the influence of organic etiologies. Eligibility criteria included age between 12 and 36 months, full-term gestation (37 weeks), birth weight appropriate for gestational age, and no evidence of perinatal complications, congenital disorders, or chronic illnesses. The NOFT with feeding problems group was recruited from toddlers who were referred from other pediatric clinics or whose parents visited a pediatric feeding clinic in a tertiary university hospital, because of their persistent poor weight gain longer than 2 months and feeding difficulties, and they agreed to participate in the study. A pediatrician examined all of the patients and reviewed their medical history and medical charts to ensure that there were no chronic illnesses or organic conditions in the NOFT group. Laboratory tests, chromosomal analysis, tandem mass spectrometric analysis for metabolic diseases, urinalysis, chest radiographs, magnetic resonance imaging studies of the brain, echocardiogram, abdominal and pelvic ultrasound, barium studies of the upper gastrointestinal tract, 24-hour esophageal impedance–pH monitoring, and videofluoroscopic swallowing studies were conducted when the history or present condition of the patient required further evaluation. A total of 33 toddlers were recruited for the present study, and 17 toddlers (14 preterm, 4 with intrauterine growth retardations, 2 with congenital syndromes, 5 with neurologic problems, 2 with gastrointestinal problems, and 5 with cardiorespiratory problems) were excluded according to eligibility criteria. The age-matched control group participants were recruited from volunteers in the community through advertising posters in kindergartens near our
Sensory Processing Ability The Infant/Toddler Sensory Profile (ITSP) was used for evaluating the children’s sensory processing abilities. The ITSP is a 48-item caregiver questionnaire that measures sensory processing abilities as reflected in daily experiences in children ages 7 to 36 months (10). Parents rate the frequency of child behaviors on a 5-point scale from 1 (almost always) to 5 (almost never). The total frequency of behaviors is calculated for each sensory section: auditory, visual, vestibular, tactile, and oral sensory. Scores are then grouped into 4 quadrants: low registration, sensation seeking, sensory sensitivity, and sensation avoiding. The scores for each sensory section were collected in the present study. Section scores were interpreted relative to the age norms: less than others and definitely different (>2 standard deviation [SD]), less than others and probably different (1 SD to 2 SD), typical performance (1 SD), more than others and probably different (1 SD to 2 SD), and more than others and definitely different (1 SD above the mean and was considered both statistically and clinically meaningful. Test reliability and validity were established in several previous studies (10,11).
Development of Cognition, Motor, and Language Toddlers underwent comprehensive neurodevelopmental assessments using the Bayley Scales of Infant Development-II (12). Of the 3 separate scales (mental, motor, and behavior scales) of the Bayley Scales of Infant Development-II, only the mental and motor scales were administered in the present study. Raw scores on the mental and motor scales were converted to the Mental Development Index (MDI) and Psychomotor Development Index, with a mean of 100 and an SD of 15.
TABLE 1. Demographic characteristics of participants
Sex, no. Boys Girls Age, mo Weight, kg Weight-for-age (z scorey) Height, cm Height for age (z scorey) Gestational age, wk Birth weight, kg Maternal education, y
NOFT with feeding problems group (n ¼ 16)
Control group (n ¼ 16)
P
5 11 21.56 8.40 9.29 1.70 173 0.49 79.68 7.49 1.53 0.81 38.31 1.97 2.79 0.55 16.00 1.11
9 7 23.63 7.89 12.34 1.58 0.26 0.59 87.62 5.57 0.43 0.94 38.57 1.22 2.96 0.21 16.38 0.81
0.29 0.48 0.99 0.33 0.04 0.02
Sensory Processing Difficulties in Toddlers With Nonorganic Failure-to-Thrive and Feeding Problems
Sook-Hee Yi, yYoo-Sook Joung, zYon Ho Choe, §Eun-Hye Kim, and jjJeong-Yi Kwon
ABSTRACT Objectives: Failure-to-thrive is defined as an abnormally low weight and/or height for age. The term ‘‘nonorganic failure-to-thrive’’ (NOFT) has been used to describe ‘‘failure-to-thrive’’ without an obvious cause underlying the growth failure. The purpose of the present study was to compare sensory processing abilities between toddlers with NOFT and feeding problems and age-matched controls. Methods: Toddlers with NOFT and feeding problems (N ¼ 16) were recruited from the pediatric feeding clinic in a tertiary university hospital, and agematched controls (N ¼ 16) were recruited from community volunteers. They were evaluated for sensory processing ability using an Infant/Toddler Sensory Profile (ITSP), and for development of cognition, motor skills, and language using the Bayley Scales of Infant Development II and Sequenced Language Scale for Infants. Behavior at mealtime was evaluated using the Behavioral Pediatrics Feeding Assessment Scale. Results: In the NOFT with feeding problems group, atypical performances were more frequently observed in 3 of 5 ITSP section items (tactile, vestibular, and oral) compared with those in the control group. Significant delayed development of cognition, motor skills, and language was observed in the NOFT with feeding problems group compared with that in the control group. In addition, children who showed 1 or more atypical performances in ITSP had delayed development in cognition, motor skills, and language. Conclusions: Sensory processing problems were more commonly observed in toddlers with feeding problems and growth deficiency. The present study could provide a preliminary evidence for a possible impact of the sensory processing problems on the feeding difficulties in toddlers with NOFT. Future large studies should be conducted to clarify the relation between sensory processing difficulties and feeding problems in toddlers. Key Words: development, failure-to-thrive, feeding disorder, sensory processing
(JPGN 2015;60: 819–824) Received October 15, 2014; accepted December 24, 2014. From the Department of Rehabilitation Medicine, Seoul Rehabilitation Hospital, the yDepartment of Psychiatry, the zDepartment of Pediatrics, Samsung Medical Center, Sungkyunkwan University School of Medicine, the §Department of Rehabilitation Medicine, Seoul Rehabilitation Hospital, and the jjDepartment of Physical and Rehabilitation Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, South Korea. Address correspondence and reprint requests to Jeong-Yi Kwon, MD, Department of Physical and Rehabilitation Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, 50 Irwon-dong, Gangnam-gu, Seoul 135-710, South Korea (e-mail: jeongyi.kwon@ samsung.com). The study was supported by a Samsung Medical Center grant (number CRS110-32-2). The authors report no conflicts of interest. Copyright # 2015 by European Society for Pediatric Gastroenterology, Hepatology, and Nutrition and North American Society for Pediatric Gastroenterology, Hepatology, and Nutrition DOI: 10.1097/MPG.0000000000000707
JPGN
Volume 60, Number 6, June 2015
What Is Known
Failure-to-thrive (FTT) may be caused by infantile feeding disorder. Disruption of the process of learning to eat and accepting new tastes during the critical period can result in oral hypersensitivity. Sensory processing problem was reported in children older than 3 years with feeding difficulties.
What Is New
Sensory processing problems were also commonly observed in toddlers with feeding problems and FTT. Delayed development was observed in the toddlers with feeding problems and FTT compared with the control group. The present study could provide a preliminary evidence for a possible impact of the sensory processing problems on the feeding difficulties.
S
ensory defensiveness may result from a difficulty in integrating oral sensory information from different channels (1). This could result in limited tactile oral exploration, which is believed to increase tolerance for a variety of oral sensations and facilitate successful introduction and progression of oral feeding (2). Disrupted or prevented development of oral feeding could exacerbate oral hypersensitivity and oral defensiveness (3). Parents of children with significant feeding difficulties may give up attempts to feed their child or may delay introduction of soft or solid foods. Although controversial, there is believed to be a critical period for introducing solid foods when the child is developmentally ready to chew (4). Disruption of the process of learning to eat and accepting new tastes during the critical period can result in oral hypersensitivity and oral-motor dysfunction (5). A variety of symptoms or outcomes have been associated with infantile feeding disorders, such as food refusal, vomiting, gagging or retching, irritability, or failure-to-thrive (FTT) (6). Using all of the FTT definitions, FTT prevalence can range between 1.3% and 20.9% of children (7). Although some children with FTT have an identifiable organic etiology, others have no obvious cause underlying their growth failure. The term ‘‘nonorganic failure-tothrive’’ (NOFT) is widely used for the latter group (8). For the diagnosis of NOFT, all of the possible medical conditions must be excluded by clinicians. Although authors’ clinical experience points to the frequent presence of sensory problems in children with feeding disorders and growth deficiencies, there are a few studies to describe sensory processing issues in this group. Davis et al retrospectively reported
819
Copyright 2015 by ESPGHAN and NASPGHAN. Unauthorized reproduction of this article is prohibited.
Kwon et al
JPGN
sensory processing problems in children older than 3 years with feeding difficulties (9). Despite the commonality of sensory issues and feeding problems in early childhood, there have been no specific reports on this phenomenon in medical literature. Therefore, the purpose of the present study was to compare sensory processing abilities between toddlers with NOFT and feeding problems and age-matched controls. In particular, we wanted to clarify the relation between development and sensory processing abilities.
METHODS
Volume 60, Number 6, June 2015
institute. Toddlers in the NOFT group experienced slow weight gain relative to the reference population, such that their weight-for-age and/or weight-for-height was below the fifth percentile on growth charts at the time of recruitment. Toddlers in the control group were above the tenth percentile for both weight-for-age and weight-forheight. A total of 16 toddlers in the NOFT with feeding problems group and 16 in the control group were included in the present study. There were no differences in demographic characteristics between both groups except for weight and height (Table 1).
Outcome Measures
Patients The study was approved by the institutional review board of the Samsung Medical Center (Seoul, Republic of Korea), and informed consent was obtained from participants’ parents or guardians. In the present study, we included only toddlers with NOFT with feeding difficulties to exclude the influence of organic etiologies. Eligibility criteria included age between 12 and 36 months, full-term gestation (37 weeks), birth weight appropriate for gestational age, and no evidence of perinatal complications, congenital disorders, or chronic illnesses. The NOFT with feeding problems group was recruited from toddlers who were referred from other pediatric clinics or whose parents visited a pediatric feeding clinic in a tertiary university hospital, because of their persistent poor weight gain longer than 2 months and feeding difficulties, and they agreed to participate in the study. A pediatrician examined all of the patients and reviewed their medical history and medical charts to ensure that there were no chronic illnesses or organic conditions in the NOFT group. Laboratory tests, chromosomal analysis, tandem mass spectrometric analysis for metabolic diseases, urinalysis, chest radiographs, magnetic resonance imaging studies of the brain, echocardiogram, abdominal and pelvic ultrasound, barium studies of the upper gastrointestinal tract, 24-hour esophageal impedance–pH monitoring, and videofluoroscopic swallowing studies were conducted when the history or present condition of the patient required further evaluation. A total of 33 toddlers were recruited for the present study, and 17 toddlers (14 preterm, 4 with intrauterine growth retardations, 2 with congenital syndromes, 5 with neurologic problems, 2 with gastrointestinal problems, and 5 with cardiorespiratory problems) were excluded according to eligibility criteria. The age-matched control group participants were recruited from volunteers in the community through advertising posters in kindergartens near our
Sensory Processing Ability The Infant/Toddler Sensory Profile (ITSP) was used for evaluating the children’s sensory processing abilities. The ITSP is a 48-item caregiver questionnaire that measures sensory processing abilities as reflected in daily experiences in children ages 7 to 36 months (10). Parents rate the frequency of child behaviors on a 5-point scale from 1 (almost always) to 5 (almost never). The total frequency of behaviors is calculated for each sensory section: auditory, visual, vestibular, tactile, and oral sensory. Scores are then grouped into 4 quadrants: low registration, sensation seeking, sensory sensitivity, and sensation avoiding. The scores for each sensory section were collected in the present study. Section scores were interpreted relative to the age norms: less than others and definitely different (>2 standard deviation [SD]), less than others and probably different (1 SD to 2 SD), typical performance (1 SD), more than others and probably different (1 SD to 2 SD), and more than others and definitely different (1 SD above the mean and was considered both statistically and clinically meaningful. Test reliability and validity were established in several previous studies (10,11).
Development of Cognition, Motor, and Language Toddlers underwent comprehensive neurodevelopmental assessments using the Bayley Scales of Infant Development-II (12). Of the 3 separate scales (mental, motor, and behavior scales) of the Bayley Scales of Infant Development-II, only the mental and motor scales were administered in the present study. Raw scores on the mental and motor scales were converted to the Mental Development Index (MDI) and Psychomotor Development Index, with a mean of 100 and an SD of 15.
TABLE 1. Demographic characteristics of participants
Sex, no. Boys Girls Age, mo Weight, kg Weight-for-age (z scorey) Height, cm Height for age (z scorey) Gestational age, wk Birth weight, kg Maternal education, y
NOFT with feeding problems group (n ¼ 16)
Control group (n ¼ 16)
P
5 11 21.56 8.40 9.29 1.70 173 0.49 79.68 7.49 1.53 0.81 38.31 1.97 2.79 0.55 16.00 1.11
9 7 23.63 7.89 12.34 1.58 0.26 0.59 87.62 5.57 0.43 0.94 38.57 1.22 2.96 0.21 16.38 0.81
0.29 0.48 0.99 0.33 0.04 0.02
