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An open or shut case
By JUDY SIEGEL-ITZKOVICH
15/12/2013
Eating problems plague not only underweight and overweight teens; they can affect toddlers and even infants. A Hadassah University Medical Center seminar recently studied the problems.
 
Anorexia and bulimia in teens, especially girls, have received much publicity in recent years, however, few people know feeding problems can affect young children and even infants. While the media can induce overeating and the consumption of junk food in youngsters, the main eating problems in this age group are due to genetics, congenital disorders and psychological and other problems.

A recent all-day seminar on feeding challenges and eating behaviors of babies and children, organized by the eating disorders center of Hadassah University Medical Center on Jerusalem’s Mount Scopus, discussed the issues.

Although it was very professional, the selection of refreshments for the mid-morning break and the stand-up lunch in the Schacht Auditorium lobby was unfortunate.

Packets of Materna baby formula were handed out, and the Osem food company, which sponsored the meeting, supplied sweet cakes, yogurts and soft drinks, gum drops, white pita bread, and powdered instant soup mixes (albeit with fresh baby carrots and bottles of water). They were hardly examples of healthy foods.

The 150-or-so participants were greeted by the medical center’s director-general Dr. Osnat Levtzion- Korach and Prof. Eitan Kerem, director of the pediatrics division both on Mount Scopus and at the Hadassah’s Ein Kerem campuses.

Dr. Pnina Hertz, a developmental psychologist who heads the eating disorders center it is part of center for pediatric chronic diseases, said it was established because it was so hard for parents to run from one place to another to consult with different specialists.

“Coping with young children who have eating problems is difficult enough. It’s better to have one holistic, coordinated, multidisciplinary place where all the experts are. We thought of it when the parent of one premature baby suggested it because he had to go from one place to another to get help.”

But even so, said Hertz, the center still has a two- or three-month waiting list.

Between 25 percent and 29% of children will at least once in their lives suffer from feeding problems.

The Mount Scopus Center has patients who are brought in from all over the country. There is a constant growth in such difficulties because very premature babies who until recent years would not have lived do survive and suffer from feeding difficulties that have to be treated for them to thrive.

Prof. Wexler Isaiah, who specializes at Hadassah in pediatric metabolism and feeding disorders and heads the day hospital, noted that there are numerous hospital centers dealing with feeding problems.

“But each has a different philosophy and approach. It’s important to listen to all views. All of us agreed that the families need our help in the best possible way.”

SOROKA UNIVERSITY Medical Center in Beersheva performs 16,000 deliveries a year, the second most in Israel after Shaare Zedek Medical Center (around 21,000 annually, including those at its Bikur Cholim Hospital branch) in Jerusalem. Dr. Gal Meiri, head of pediatric psychiatry there, told the participants that Soroka receives many requests for help that involve babies’ and young children’s eating disorders – perhaps one-third of all referrals. “We too have a holistic approach combining medical, psychiatric and developmental matters,” he said.

The “bible” of psychiatric problems, known as the Diagnostic and Statistical Manual of Mental Disorders (now in its Fifth Edition), classifies problems of feeding and eating disorders. There is a large variety of problems, from pica (characterized by an appetite for non-nutritive substances such as dirt, ice, clay, chalk or sand) to rumination disorder (an under-diagnosed chronic condition of effortless regurgitation of most meals). The parent only and not the child may be involved, as in the psychiatric Munchausen-by-proxy syndrome, in which a parent (usually the mother) or caregiver deliberately exaggerates or fabricates a child’s “refusal” to eat and wants the child to appear to be sick.

Feeding babies and young children often becomes a struggle for parents. They complain they eat too little, refuse solids or to eat other things beyond breast milk, have bad or strange eating habits or are selective eaters. Even in a premature baby unit, some newborns seem to refuse to eat. Sometimes eating is accompanied by vomiting.

Babies may have slow weight increases and failure to thrive. All of these issues affect about 1% of children before their first birthdays; among all babies and toddlers, about a quarter have eating problems.

Meiri noted that there is a diagnostic classification from zero to three according to severity. The problems may involve neurological, behavioral, cardiorespiratory, metabolic and other problems. Eating behavioral disorder, for example, is the difficulty of following a regular eating pattern. There are children who will eat at home but refuse to eat elsewhere.

“There is even infantile anorexia, in which a child under the age of three refuses to eat enough for at least a month,” he said. “This is...

even though the baby has been found to have no medical disease or trauma. It usually begins at six months of age and can continue for up to three years. Such a child shows no signs of hunger and seems to have little interest in food, but he may be curious and show good interaction with parents. The problem can cause a significant delay in development.”

Rarely, Meiri said, “a baby may not make eye connection with a parent, smile or make gurgling noises. The mother might not be aware that there’s a problem; she may have her own problems of postpartum depression. A child may have difficulty remaining alert enough to be left quietly for eating or he may be too sleepy. This can result in a failure to gain enough or even weight loss. A feeding tube may be the last resort.”

It is usually normal for babies frequently to spit up milk, so a parent feels unsure how much more he needs. In the majority of cases, the problem does not result in the stomach being emptied. Try feeding the infant again; if he fights it, the parent feels more pressured and may feed him by force. The baby then feels stress and doesn’t want to be fed. Never force-feed a baby, Meiri urged. Instead, go for medical help.

Babies and toddlers may in rare cases develop sensory food aversions – turning down specific tastes, textures, odors or forms of food. He will eat better if he gets the food he really likes. Other reasons for refusal to eat may involve post-traumatic feeding disorder – the refusal to eat after experiencing a traumatic event. The baby may refuse to drink from a bottle or eat from a spoon. Desensitization can be used to treat it. Sometimes this is the first symptom of autism, which affects nearly one in 90 children.

HADASSAH MOUNT Scopus clinical dietitian Hila Elyashar-Iron discussed overweight and obesity in young children. While in previous generations, families spent most of their time together, enjoyed meals around the dinner table together and children played outside, today most mothers work outside the home and fathers spend even more time at work. Children are left alone in the home and eat alone, usually fast food they heat up in the microwave. Instead of getting exercise outdoors, they tend to spend a majority of their free time at the computer, with their smartphone and in front of the TV – all of which promote overweight.

Exposed to advertising in the media, children are encouraged to eat junk food.

Somehow, most people admire fat babies and regard them as the height of good health, but they are wrong. “Israel ranks among the top 10 countries with overweight children, according to the Health Ministry’s Mabat study of 2003- 2004, and it probably is worse today,” Elyashar-Iron said.

The body-mass index (BMI), a formula based on height and weight, is accurate in determining underweight, normal weight, overweight and obesity in adults, but it is not reliable in children. Instead, special growth charts according to age of boys and girls (separately) should be used.

Between 10% and 20% of fat babies will be fat children, 40% will be fat teens, and 75% to 89% will be fat adults. All of this excess weight can lead to diabetes; learning problems; depression; hypertension; cardiac, orthopedic and respiratory disease; liver disorders; and even cancer in adulthood, said the dietitian. “The ministry says there is no greater public health challenge than to prevent overweight and obesity throughout life – at home, in school, at work and during leisure time.”

Digestive problems in children were discussed by Dr. Perri Millman, a Hadassah pediatric gastroenterologist.

“There are parents who feed babies while they’re asleep because they claim they can’t do it when the infant is awake, as well as those who claim their children ‘don’t eat anything’ although they look fine. Many parents with healthy babies whose ribs “show” refuse to recognize that this can be completely normal.

“If the baby is fat, that is not normal.

Force-feeding is absolutely wrong and can cause psychological trauma; often it is done by parents who have high hopes about their children’s growth, and they think they are not getting enough.”

As women who breastfeed cannot know how much their infants are getting, they should go to Tipat Halav [well-baby clinics] and have the child’s weight and development compared to the norm in growth charts.

Spitting up (reflux) is also normal, as the sphincter muscle at the top of the esophagus may not be developed enough at that age. But there are medical problems – heartburn, colic, pneumonia, asthma, failure to thrive and refusal to eat, that have to be treated. “We can perform tests, but usually we can take the young patient’s medical history and figure it out.” Surgery is sometimes necessary, said Millman, who recalled the case of a seven-year-old girl who “hated to eat” and didn’t grow properly and developed asthma, with pneumonia every year, reflux esophagitis and heartburn. She underwent an operation and was free of asthma and pneumonia.

Dr. Shlomit Semish, a retired expert in biochemistry, food science and nutrition at the Hebrew University’s faculty of agriculture, food and environment showed a shocking segment from a foreign film showing a mother with difficulties feeding her toddler; she held the child’s nose closed with her fingers to force her to open her mouth. This can cause psychological problems in the child. “Early experiences such as these are preserved and can affect development.

Force feeding is always wrong. There are other ways of feeding a child with such problems,” she insisted.
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