Failure to Thrive and Cognitive Development in Toddlers With Infantile Anorexia Irene Chatoor, MD*; Jaclyn Surles, BA*; Jody Ganiban, PhD‡; Leila Beker, PhD*; Laura McWade Paez, CPNP*; and Benny Kerzner, MD* ABSTRACT. Objective. The goal of this study was to ailure to thrive (FTT) describes children who examine the relative contributions of growth deficiency exhibit growth deficiency, as indexed by falter- and psychosocial factors to cognitive development in ing or stunted growth. Several studies suggest toddlers with infantile anorexia. F that FTT is associated with poorer cognitive devel- Methods. Eighty-eight toddlers, ranging in age from opment, learning disabilities, and long-term behav- 12 to 33 months, were enrolled in this study. Toddlers ioral problems.1–3 More recently, Corbett et al4 de- were evaluated by 2 child psychiatrists and placed into 1 tected a significant association between the severity of 3 groups: infantile anorexia, picky eater, and healthy of growth deficiency and IQ, whereas Raynor and eater. All 3 groups were matched for age, race, gender, Rudolf5 found that 55% of the infants who were and socioeconomic status (SES). Toddlers underwent nu- tritional evaluations and cognitive assessments with the failing to thrive exhibited developmental delay. In 6 Bayley Scales of Infant Development. Toddlers and their addition, a study by Reif et al reported that children mothers were also videotaped during feeding and play with a history of FTT were found to have more interactions, which later were rated independently by 2 learning difficulties and evidenced developmental observers. delay at follow-up 5 years after the initial presenta- Results. On average, toddlers with infantile anorexia tion. performed within the normal range of cognitive devel- These findings from the pediatric literature have opment. However, the Mental Developmental Index led many to believe that FTT alone is sufficient to cause developmental delays. However, a critical (110 ؍ MDI) scores of the healthy eater group (MDI) were significantly higher than those of the infantile an- problem with many previous studies is that FTT is groups. frequently confounded with psychosocial risk factors (96 ؍ and picky eater (MDI (99 ؍ orexia (MDI Within the infantile anorexia group, correlations be- (including low socioeconomic status [SES], maternal tween MDI scores and the toddlers’ percentage of ideal education levels, and maternal deprivation) that are ؍ body weight approached statistical significance (r .32). independently related to lower Mental Developmen- Across all groups, the toddlers’ MDI scores were associ- tal Index (MDI) scores.1,4 As a result, psychosocial ated with the quality of mother–child interactions, SES level, and maternal education level. Collectively, these factors may contribute to the apparent association variables explained 22% of the variance in MDI scores. between FTT and cognitive delay. Consequently, the Conclusions. This study demonstrated that psychoso- conclusion that FTT is sufficient to cause significant cial factors, such as mother–toddler interactions, mater- cognitive delay requires additional exploration. nal education level, and SES level, are related to the The tendency to confound FTT and psychosocial cognitive development of toddlers with feeding prob- risk factors grew from early studies that used non- lems and explain more unique variance in MDI scores organic FTT and maternal deprivation as synony- than nutritional status. Pediatrics 2004;113:e440–e447. mous terms.7,8 Whereas several authors have pro- URL: http://www.pediatrics.org/cgi/content/full/113/ posed that FTT should be considered a single 5/e440; failure to thrive, feeding disorder, infantile an- symptom that describes growth deficiency,9–12 others orexia, cognitive development, growth deficiency, mother- have used nonorganic FTT as a clinical syndrome toddler interactions. that encompasses children who exhibit FTT in addi- tion to psychosocial risk factors.1,3,4 Consequently, ABBREVIATIONS. FTT, failure to thrive; SES, socioeconomic sta- several authors have argued strongly for disentan- tus; MDI, Mental Developmental Index; BSID, Bayley Scales of gling FTT (growth deficiency) from psychosocial fac- Infant Development. tors and examining FTT as a single symptom of a feeding disorder, rather than a clinical syn- drome.11,13,14 Such a distinction is critically impor- tant for identifying the developmental consequences specifically related to growth deficiency, as well as From the *Children’s National Medical Center, Washington, DC; and ‡George Washington University, Washington, DC. the multiple pathways that can lead to growth defi- Received for publication Aug 3, 2003; accepted Dec 1, 2003. ciency.11,13,14 Although many factors, genetic and en- Reprint requests to (I.C.) Department of Psychiatry, Children’s National vironmental, can contribute to cognitive develop- Medical Center, 111 Michigan Ave, NW, Washington, DC 20010. E-mail: ment in young children, the goal of this article is to [email protected] PEDIATRICS (ISSN 0031 4005). Copyright © 2004 by the American Acad- tease apart the effects of growth deficiency and psy- emy of Pediatrics. chosocial risk on cognitive development. e440 PEDIATRICS Vol.Downloaded 113 No. 5 from May www.aappublications.org/news 2004 http://www.pediatrics.org/cgi/content/full/113/5/ by guest on September 28, 2021 e440 The study described in this article focused on in- ents of toddlers who had infantile anorexia and were referred to fantile anorexia, a feeding disorder that is charac- the study by pediatricians and gastroenterologists at the hospital and in the community were asked to participate in the study. terized by extreme food refusal, growth deficiency, None of the parents refused consent. The diagnosis of infantile 15,16 and an apparent lack of appetite. Importantly, anorexia was made independently by 2 child psychiatrists, who infantile anorexia is not associated with maternal had excellent interrater agreement (␬ ϭ .89). The diagnosis was deprivation or neglect, and most children with this based on the following criteria: 1) refusal to eat adequate amounts feeding disorder come from middle- to upper-mid- of food for at least 1 month; 2) onset of the food refusal under 3 15,17 years of age, most commonly during the transition to spoon- and dle-class families. Therefore, studying this pop- self-feeding; 3) failure to communicate hunger signals, lack of ulation affords the opportunity to disentangle the interest in food, but strong interest in exploration and/or interac- contributions of growth deficiency and psychosocial tion with caregivers; 4) significant growth deficiency; and 5) no risk factors to cognitive outcomes. evidence that the food refusal followed a traumatic event or is associated with an underlying medical illness. Infantile anorexia was first described in a series of Picky eaters and healthy eaters were recruited from an urban 18 case studies by Chatoor and Egan, and at that time ambulatory care center. Parents of toddlers who ranged in age it was referred to as a separation disorder. Infantile between 12 and 36 months were asked to complete a brief ques- anorexia arises in the first 3 years of life, most com- tionnaire on their children’s feeding habits. When the parents monly between the ages of 9 and 18 months, as described their toddlers as “often” or “always” healthy eaters, they were considered for recruitment to the healthy eater group. infants become more autonomous and make the When the parents described their children as “often” or “always” transition to spoon- and self-feeding. Children with picky eaters, they were considered for recruitment to the picky infantile anorexia fail to communicate signals of hun- eater group. Assignment to the picky eater group also depended ger, but they show a strong interest in exploration, on additional screening for medical and growth problems. Specif- ically, toddlers were assigned to the picky eater group when they play, and/or interaction with their caregivers. They demonstrated 1) persistent refusal (for at least 1 month) to eat all exhibit extreme food refusal and frequently fail to types of food or certain types of food to cause concern to the take in sufficient calories to sustain growth. As a parents and 2) no evidence of growth deficiency. The require- result, these children display acute and/or chronic ments for placement in the group of healthy eaters were 1) no food malnutrition.16 refusal of concern for at least 1 month and 2) no evidence of growth deficiency. Only parents whose toddlers matched the Drawing from the rich literature on growth defi- study subjects by age, gender, race, and SES were invited to ciency and the multiple factors that can have an participate in the study. Ten toddlers from the original sample impact on the cognitive development of young chil- were excluded from this study because they were Ͼ33 months old dren, this article examines the relationship of cogni- at the time of testing. The final sample included 34 children in the healthy eater group (age: 23 months; standard deviation [SD]: 5 tive development to physical growth, mother–tod- months), 26 children in the picky eater group (age: 24 months; SD: dler interactions during feeding and play, maternal 5 months), and 32 children in the infantile anorexia group (age: 21 education, and SES. We examine these relationships months; SD: 6 months). The 3 groups did not differ in regard to in a group of children who have infantile anorexia gender (␹2 ϭ 4.54, P