Clinical Nutrition 34 (2015) 195e200

Contents lists available at ScienceDirect

Clinical Nutrition
journal homepage: http://www.elsevier.com/locate/clnu

Review

Current topics in the diagnosis and management of the pediatric non

organic feeding disorders (NOFEDs)
Claudio Romano a, *, Corina Hartman b, Carmen Privitera a, Sabrina Cardile a,
Raanan Shamir b
a
Pediatric Department, University of Messina, Italy
b
Institute for Gastroenterology, Nutrition and Liver Disease, Schneider Children's Medical Center, Sackler Faculty of Medicine, Tel-Aviv University, Israel

a r t i c l e i n f o s u m m a r y

Article history: Non-Organic Feeding Disorders (NOFEDs) are frequently encountered in children younger than 6 years
Received 12 March 2014 old. NOFED are characterized by feeding aversion, failure to advance to age-appropriate foods, food
Accepted 29 August 2014 selectivity and negative mealtime behaviors. Parents of children with feeding disorders often use
abnormal feeding behaviors, such as intrusive feeding. Persistent inadequate caloric intake leads to non-
Keywords: organic failure to thrive in up to 40e50% of cases. Managing children with NOFED is a challenge for even
Feeding disorders
the most experienced pediatric specialists. Management by a multidisciplinary team, as outpatient or
Failure to thrive
inpatient should address both nutritional support and feeding behavior modification. Even in the
Nutrition care plan
Aversive feeding behaviors
absence of failure to thrive, children with behavioral feeding problems are at risk of negative health,
social and emotional outcomes, including nutrient deficiencies, social and family disruption or conflict.
The aims of the current review are to present an update of the definition, classification, etiology,
epidemiology of NOFED, as well as clinical presentation, evaluation and management of this condition
and non-organic failure to thrive, often associated with NOFED.
© 2014 Elsevier Ltd and European Society for Clinical Nutrition and Metabolism. All rights reserved.

1. Introduction
Successful feeding has been acknowledged as a notable develop-
mental milestone for infants. Variation in bolus type (liquid or solid),
characteristics (hardness, homogeneity, volume, viscosity, texture,
moisture content), and other sensory particularities (taste) serve to
modulate the timing and pattern of motor components which
constitute the overall feed sequence [1]. Following breastfeeding (or
formula feeding), complementary/solid food feeding constitutes the
next major feeding stage in an infant's life. Developmental readiness
for solid foods feeding varies considerably among infants. In most
babies, the developmental skills (chewing and swallowing soft, solid
foods) needed to begin complementary foods are present between 4
and 6 months of age. Oral motor control and reduction in sensitivity to
touch within the mouth and lips are necessary to manage and accept
solid foods [2]. In fact it may be important that an infant is allowed the
opportunity to use their oral skills as soon as they develop [3]. Studies
have demonstrated that infants exposed to textures after nine months
of age were more likely to have feeding difficulties and be seen by their
parents as fussy eaters compared with children who had been
* Corresponding author. Pediatric Department, University of Messina, Via Con-
solare Valeria, 98125 Messina, Italy. Tel.: þ39 90 2212918; fax: þ39 90 2213788.
E-mail address: romanoc@unime.it (C. Romano).
introduced to lumpier textures earlier [4]. In theory, any child has the
potential to develop feeding deviations. In fact, patterns and behaviors
around mealtimes and eating have been identified in normally
developing children. Feeding difficulties, such as selective eating, food
refusal, exceedingly slow eating, and tantrums, are common among
young children. Some children, however, fail to develop the skills
necessary to manage the new feeding demands. Lengthy mealtimes,
pocketing food, and tantrums at mealtimes are typical negative be-
haviors of dysfunctional feeding.
The aims of the current review are to present an update of the
definition, classification, etiology, epidemiology of non-organic
feeding disorders (NOFED), as well as clinical presentation, evalu-
ation and management of this condition and non-organic failure to
thrive, often associated with NOFED. We carried out a systematic
search through MEDLINE via PubMed (http://www.ncbi.nlm.nih.
gov/pubmed/) to identify all the articles published in English up
to date based on the following keywords “feeding disorders” or “
failure to thrive”.
2. Non- organic feeding disorders, definition, classification,
epidemiology and risk factors
Non-organic feeding disorders (NOFEDs) is a formal diagnostic
term used to indicate a condition in children who show deviating

http://dx.doi.org/10.1016/j.clnu.2014.08.013
0261-5614/© 2014 Elsevier Ltd and European Society for Clinical Nutrition and Metabolism. All rights reserved.
196 C. Romano et al. / Clinical Nutrition 34 (2015) 195e200

feeding behaviors as food refusal, aversion to feeding, selective retardation and prematurity occurred more often in children aged
eating and low food intake without organic disease. In 1994, the less than 2 years with feeding disorders [11]. The most serious
American Psychiatric Association (APA) added “Feeding Disorder of complication of NOFED is failure to thrive (FTT). Non-organic failure
Infancy and Early Childhood” to the Diagnostic and Statistical to thrive (NOFTT) describes infants with growth faltering secondary
Manual of Mental Disorders (DSM-IV) [5]. The ICD-10 Classification to poor caloric intake in the absence of organic disease or any
of Behavioral and Mental Disorders also has a broad category called demonstrable abnormalities of swallowing mechanisms [12].
“feeding disorder of infancy and childhood”, which includes Generally, linear growth and head circumference are either not
rumination. In the last revision of the “Diagnostic Classification of affected, or are affected to a lesser degree than weight. More exact
Mental Health and Developmental Disorders of Infancy and Early definitions, based upon precise weight percentile, rate of weight
Childhood-Revised”, DC:0-3R, Zero-to-Three, a diagnostic system, gain or weight loss, or changes in other parameters exist, but are no
which classifies psychopathological pictures in the first years of life, more useful than the above definition [13]. In routine clinical
has introduced a classification of ‘’Feeding Behavior Disorder’’ practice, FTT is commonly defined as either a weight for age that
which includes three different diagnostic subtypes of FD [6]. Table 1 falls below the 5th percentile on multiple occasions or as weight
presents the classification and subtypes of NOFED. About 20e60% deceleration that crosses two major percentile lines on a growth
of parents report that their children are not eating optimally, that chart [14]. Growth variations in normal infants can confound the
they are picky, have food phobia, eat too little and have inappro- diagnosis of FTT as 25% of children change their weight or height by
priate weight gain [7]. Approximately 25% of normally developing more than 25 percentile points in the first two years of life. Within
children experience feeding problems, with 1e2% suffering from this group lie four main patterns: a) infants who have small parents
severe feeding difficulties [8]. Feeding disorders are in most cases and are growing to their genetic potential, b) infants with consti-
transient, but in 3e10% become persistent and carries the risk of tutional delay in growth, c) infants born prematurely who are
inadequate growth. The prevalence of parent-reported feeding growing below their age matched peers, and c) infants with post-
problems in children with neurological disabilities and chronic natal ‘catch down’ growth. Traditionally, FTT has been dichoto-
medical conditions is estimated at around 40e70% and even higher mized into two mutually exclusive categories based on the
in children with autistic spectrum disorders [9,10]. Other high-risk presumed etiology. Population and hospital based studies found
groups include infants of premature birth, children with craniofa- substantial organic disease in only 5e10% of children with slow
cial anomalies, and those with certain genetic syndromes. Rommel weight gain [15,16]. A number of authors have questioned the
N. et al. showed that lower length of gestation, intrauterine growth utility of a dichotomus classification for FTT. Homer and Ludwig S,
therefore, suggested that FTT is best described using three etiologic
categories: a) organic, b) nonorganic, and c) mixed (i.e., with both
Table 1 physical and psychosocial components) [16]. Such a partition
Classification. adequately accounts for the interactive influences of organic dis-
Classification Category Subtype ease and psychosocial variables on infant weight gain and
acknowledge the continuous, rather than dichotomous, nature of
DSM-IV Feeding disorder of Pica
infancy or early Rumination disorder FTT. In the United States, FTT is seen in 5e10 percent of children in
childhood primary care settings and accounts for 1e5% of pediatric hospital
DC:0-3R Eating behavior Infantile anorexia admission for children younger than 2 years [17]. However, up to
disorder Feeding disorders associated with 15e20% of hospitalized children younger than 2 years from a
insults to the gastrointestinal tract
Sensory food aversion
medically ward population met the criteria of FTT. Regardless of the
Chatoor I Feeding behavior Feeding disorder of state regulation etiology, inadequacy of nutrition and feeding difficulties are at the
disorders Feeding disorder of reciprocity heart of NOFTT [15]. Levy, et all identified five “triggers”, vulnerable
(previously “feeding disorder of conditions or children at risk of NOFTT: 1) infants with low birth
attachment”)
weight (premature, and small for-gestational age) which are often
Infantile anorexia
Sensory food aversions perceived by parents or the medical team to be too small, leading to
Feeding disorder associated with persistent attempts to feed the infant beyond the infant's hunger
concurrent medical condition cues, 2) traumatic events during feeding transition time, 3) organic
Posttraumatic feeding disorder conditions that cause decreased hunger or painful feeding and food
Crist and Complex Picky eaters
Napier-Phillips biobehavioral Toddler refusal e general
refusal, which lead to intrusive or persecutory feeding and subse-
pediatric feeding Toddler refusal e textures quent food refusal, even if the initial disease has been resolved, 4)
disorders Older children refusal e general mechanistic feeding which ignores child's hunger cues, and 5)
Stallers posttraumatic causes [18].
Burklow et al. Behavioral Structural abnormalities
Observational studies have shown that feeding difficulties such
pediatric feeding Neurologic conditions
problems Behavioral and psychosocial as low appetite, weak suck, and weaning difficulties are associated
problems with weight faltering [19e21]. The presence of oral-motor
Cardiorespiratory problems dysfunction (OMD) may prevent some children from achieving a
Metabolic dysfunction satisfactory nutritional intake due to prolonged mealtimes and
Dovey TM etal Food refusal Learning dependent food refusal
behaviors Medical complications related food
inappropriate parental responses [22]. Approximately half of the 4
refusal year olds with chronic growth retardation studied by Heptinstall
Selective food refusal et al. had some disorder of OMD and had begun to fail to thrive in
Fear based food refusal the first year of life [23]. Ramsey et al. evaluated 38 infants with
Appetite awareness and autonomy
NOFTT and 22 with organic FTT. The histories of the children with
based food refusal.
Kezner B Feeding difficulties Limited appetite so-called NOFTT were suggestive of an oral-sensor-motor impair-
Highly selective intake ment reported to be present from birth or early infancy [24]. Using
Crying interfering with feeding an assessment schedule previously shown to be both reliable and
(Colic) valid, Reilly SM et al., showed in a population-based study that a
Fear with feeding
substantial number of children previously described as having
 C. Romano et al. / Clinical Nutrition 34 (2015) 195e200
NOFTT, in fact, have significant OMD [25]. Abnormal feeding
behavior is sometimes caused or follows conditions that lead to a
painful or challenging feeding [26] NOFED associated with feeding
disorders usually manifest as refusal to feed or low food intake.
Other symptoms such as vomiting, gagging or retching, irritability,
or apparent difficulty in swallowing, are sometimes present, thus
mimicking many of the previously mentioned organic conditions.
Berlin et al. revised the medical records of 286 children (mean age
35e56 months) seen at an outpatient feeding disorders clinic. The
review generated 3 co-morbidity patterns: “Behavioral” (58% of
cases), “Developmentally Delayed” (37%), and “Autism Spectrum
Disorder” (ASD, 5%). Multiple co-occurring conditions of children
with feeding problems suggests that medical and developmental
conditions confer general, rather than specific, risk for feeding
problems in children [27]. Large cohort studies found variable as-
sociations between FTT and maternal depression: either no link or a
temporary association that disappeared by 12 months [28e34].
Furthermore, social isolation, beliefs and low self-esteem are
associated with reported FD [35e40]. In recent years studies in
unselected populations have found little evidence of a link between
slow weight gain/FTT and maternal disorder. However, two obser-
vational caseecontrol studies found associated differences in
maternal feeding behavior/responsiveness and poor weight gain
[28,33]. For example, infants with weight faltering had significantly
fewer positive interactions (where parents anticipate and support a
child's needs) during meals than controls. Chatoor and her col-
leagues proposed that the conflictual interactions between
mothers and children with FD are a result of particular child and
mother characteristics [38]. Specifically, when children refuse to
eat, vulnerable mothers may become anxious and insecure and try
to forcefully feed their children with the creation of a vicious cycle
[39]. Thus, the quality of parenteinfant interactions as measured by
mother and newborn feeding behaviors have been shown to pre-
dict infant growth velocity during the first month of life [39,40].
Observations of mother-infant/toddler relationships during meal-
times and non feeding interactions should be an integral compo-
nent of an evaluation of NOFED because they provide valuable
information about feeding problems associated with poor weight
gain and offer specific behavioral targets for intervention [41].
3. Evaluation of children with NOFED and NOFTT
The evaluation of children with NOFEDs should focused on
several key elements: 1) how is the feeding problem manifested, 2)
is the child suffering from any underlying disease, 3) have the
child's weight and development been affected, 4) are there any
great stress factors in family. The diagnosis of NOFED relies on
identifying disordered feeding behavior and a high index of sus-
picion while paying attention to signs or symptoms which may
suggest organic disease, “red flags”. In 2009, Levy Y et al. have
shown that behavioral causes that include food refusal, food fixa-
tion, abnormal parenteral feeding practices, the appearance after a
specific trigger, and the presence of anticipatory gagging were
predictive of NOFED [18]. This group developed the Wolfson criteria
and have shown that using these criteria that are based on food
refusal, abnormal feeding pattern and anticipatory gagging, higher
detection rate is achieved compared to the Chator criteria as well as
the DSM-IV criteria. Evaluation should be include alarm symptoms
and pathological physical examination that would hint to the
presence of organic disease. The medical history should rule out
symptoms such as dysphagia, odynophagia, choking or recurrent
pneumonia, feeding interrupted by crying suggestive of pain,
vomiting or diarrhea. The physical examination should look for the
presence of dysmophic features, skin rashes, cardiac findings sug-
gestive of congenital heart disease, organomegaly,
197
lymphoadenopathy, abnormal genitalia and neurological findings
[42]. Growth history should be reviewed by careful plotting of past
growth points on specific curves, and interpreted in the context of
the family's growth history and pattern. For premature born infants
adjust for prematurity up to age of 2 years. A detailed medical
assessment should include family, social, feeding, past and current
medical histories and a complete physical examination (Table 2).
Panetta et al. investigated the predictive value of predefined
symptoms and signs for the diagnosis of NOFTT in a group of 208
children (6 monthse14 years old) with FTT, defined as wasting
(ideal weight for height <85%) [43]. Multivariate logistic regression
showed that among the six variables, linked to the outcome at a
95% significance level, vomiting (OR ¼ 0.31; 95% CI ¼ 0.13e0.72)
and abdominal distension (OR ¼ 0.34; 95% CI ¼ 0.13e0.90) were
predictive of OFTT diagnosis, while vivacity (OR ¼ 5.18; 95%
CI ¼ 1.71e15.70) and food restriction and/or feeding rituals
(OR ¼ 2.78; 95% CI ¼ 1.13e6.84) characterize NOFTT. Detection of at
least one nonorganic symptom or sign with the exclusion of any
organic symptom had 90% positive predictive value in the whole
group and 96% in patients aged less than 36 months for NOFTT.
There is no formal evidence to suggest an ideal routine set of in-
vestigations, but Table 3 shows a suggested schedule of tests to rule
out possible occult pathology. An exhaustive number of in-
vestigations are often ordered in children with NOFTT of which only
a small minority contribute to the diagnosis of an organic cause in
FTT. Sills RH et al. found that, in 185 children less than 3 years old,
admitted for evaluation of FTT, only 36 out of 2.607 laboratory tests
performed (1.4%) were helpful in making a diagnosis, and all of
these 36 positive results were suspected on clinical grounds [44].
Clinical evaluation ought to include observation of the infant and
caretaker while feeding and playing. This provides clues about their
interactions, the caretaker's feeding technique and response to the
infant's physiologic or social cues. The physician should be able to
identify abnormal parental feeding practice or intrusive feeding
(nocturnal feeding, persecutory feeding, forced feeding, conditional
distraction, and prolonged meals) and possible triggers [45].
Trigger is defined as an identified external event or etiology, leading
to food refusal and NOFEDs. On the basis of clinical experience, Levy
et al. [18] have distinguished five categories of triggers for NOFEDs
as e Size, Transitional feeding, Organic cause, Mechanistic feeding,
Table 2
Medical history investigation in children with NOFEDs.
History Investigation
Gestational and Age and parity of mother, medical complication of
perinatal history pregnancy, use of medications, use of drugs, use of
alcohol, substance abuse, smoking, complications
during delivery
Feeding history Feeding history: breast feeding or formula feeding,
strength of suck, formula preparation, volume
consumed, who feeds the infants, timing and
introduction of solids, stool or vomiting patterns
associated with feeding. The history should record the
time of onset of avoidance behavior by the infant or
child, and the feeding pattern adopted by the child
caregiver
Medical history Previous child’ illness and hospitalizations, the use of
nasogastric tube feeding, surgeries and medications
Developmental Disrupted sleeping and eating patterns, behavior that is
milestones and moody, demanding, rejecting, or distractible
temperament
Family history Height, weight, timing of puberty, illness, inherited
disease and eating habits
History of maternal depression, family history of
childhood neglect or abuse
Socio-economic Family composition, employment and financial status,
status stress, child rearing beliefs
198 C. Romano et al. / Clinical Nutrition 34 (2015) 195e200
Table 3
Investigations in children with NOFTT/NOFED.
Basic investigations Advanced investigations
Complete blood examination Sweat test and fecal elastase
Full biochemistry panel Barium meal and videofluoroscopy
Thyroid function tests pH study or pH impedance
Celiac serology Gastroscopy
Urinalysis and urine culture Gastric emptying scintigraphy
Allergy testing
Post-traumatic feeding. The acronym STOMP (size, transition,
organic, mechanistic and posttraumatic) was suggested. Child
feeding behavior, including included type of refusal (global or se-
lective to mode of feeding, global or selective to a specific caregiver,
global or selective for consistency or type of food), as well as
presence of fixation/pickiness (the willingness to ingest only one
type of food or texture of food), initiation of feeding (caregiver
initiates feeding or child indicates desire for food), and autonomy of
feeding in age-appropriate patients should be noted. The “Feeding
Checklist” has been validated as an efficacious tool for systemati-
cally guiding the observations and documentations of caregiver-
child feeding dynamics in NOFTT [46]. The behavioral checklist
consists of 25 items subdivided in caregiver and child observations
but no subscales or scoring. The format is designed to highlight
behaviors that warrant professional attention and intervention. The
items reflect the caregiver's ability to respond to infant cues and the
infant's ability to provide clear signals. The “Feeding Checklist”
improved nursing documentation in a controlled study, demon-
strating that it can be helpful the objective assessment of child-
parent feeding interaction [47]. A meal time video observation
may provide additional information and has been suggested as the
basis for structured supportive feedback and advice as well as for
working with the parents to control anxiety.
4. Treatment of NOFED
Most children with NOFTT can be managed by nutrition inter-
vention and feeding behavior education within the community or
outpatient setting. A multidisciplinary team approach is often
needed, with the involvement of a pediatrician/pediatric gastro-
enterology specialist, a nutritionist (e.g. assessment, diagnosis and
treatment of diet and nutrition deficiencies), speech and language
therapists (e.g. assessment of physical swallowing capability,
design and implementation of swallowing management plan);
occupational therapists (e.g. assessment of physical feeding capa-
bility and sensory sensitivities, implementation of environmental
modifications to improve feeding skills); and play therapists (e.g.
assessment and treatment of sensory sensitivities). The goals of
management of NOFTT are the following: a) nutritional rehabili-
tation (provision of adequate calories, protein, and other nutrients),
b) nutritional and feeding behavior modification, c) education of
the family on nurturing and behavior techniques, d) monitoring of
growth and nutritional status and e) supportive economic/social
assistance, when needed. An essential member of the multidisci-
plinary feeding team treating children with NOFED is the clinical
pediatric psychology specialist, in charge of “case” assessment
(development and behavior evaluation, construction, imple-
mentation and supervision of behavior modification plan. Irre-
spective of the etiology, all children with NOFTT need a high-calorie
diet for catch-up growth. Children with FTT need 150% of recom-
mended daily caloric intake, based on their expected, and not
actual, weight for height. It is not reasonable to expect a child to eat
twice the usual amount of food. Thus the diet can be fortified by
increasing the formula concentration with addition of complex
carbohydrates and/or oil. Concentrating the formula has the
advantage of providing all nutrients and not only calories and
usually does not affect osmolarity significantly. Appetite-enhancing
medications, such as cyproeptadine, has been used with contra-
dicting and usually short lived results [48]. In severe malnutrition,
and when all these attempts fail, nasogastric tube feeding and
gastrostomy should be considered. Significant catch-up growth in
weight and height following gastrostomy has been demonstrated
in children older than 2 years of age. Nasogastric tube is usually a
hospital-based intervention, but it can be used also in community.
In children with FTT due to NOFED this type of nutrition have the
disadvantage of secondary loss of oral feeding skills and the danger
of worsening food aversion. The multidisciplinary hunger provo-
cation protocol can be used to reduce dependency from tube
feeding [49] and use of the tricyclic antidepressant as amitriptyline
can be added to reduce meal caused discomfort secondary to
gastric distension after prolonged tube feeding [50].
5. Behavior modification intervention
Behavioral modification intervention remains the corner stone
for the treatment of pediatric feeding disorders [51]. Williams et al.
identified 38 intervention studies (published between 1979 and
2008) targeting children with food refusal, defined as refusing to
eat all or most foods resulting in a failure to meet caloric needs or
reliance on supplemental tube feedings [52]. In all 38 studies, im-
provements in oral intake were reported, more than half of the
children who received some form of supplemental tube feeds being
weaned from these feedings. Treatments were primarily multidis-
ciplinary and involved one or more behavioral interventions
including differential reinforcement, escape extinction, and stim-
ulus fading. The primary focus of infant feeding needs to be
responsive feeding, in particular, responding to infant hunger and
satiety cues; being patient and encouraging the child to eat, but
never forcing them, while experimenting with different food
combinations, tastes, textures. Awareness of developmental
feeding skills is needed so that the tasks presented are appropriate.
Meals should be pleasant, regularly scheduled, and not rushed. It
often helps if the parents eat with the child. Starting with small
amounts of food and offering more is preferable to beginning with
large quantities. Group interventions which provides support and a
shared experience appears to have beneficial effects for mothers of
children with feeding problems and therefore, may offer a
constructive means of supporting this population [53]. Early
studies of FTT were hospital based, but in recent years structured
ambulatory management has been recognized as more cost-
effective. It may also benefit child’ development, is more accept-
able to patients and their families, and is more likely to succeed
[54]. An UK study comparing specialist health visitor intervention
with conventional care in children with NOFTT showed no differ-
ence in weight outcomes, but the intervention group had 50% less
hospital admissions and defaulted fewer hospital and health visitor
appointments [55]. An US intervention trial of weekly home visits
by trained lay home visitors versus follow-up in a multidisciplinary
nutrition clinic showed similar improvements in weight and height
for age in both groups, but the intervention group also showed
better receptive language and cognitive development [56]. Given
the value of outpatient based management, hospitalization is rarely
required, except in very extreme circumstances. Most studies in
children with NOFTT have focused on hospitalized patients and are
in the form of reports [57]. Only few of these attempted to evaluate
the intervention provided rigorously, and neither demonstrated
differences in terms of growth or cognitive outcomes [55,58].
Behavior intervention studies in children with NOFEDs have been
done in hospital inpatient units (43.8% of studies), home/school
 C. Romano et al. / Clinical Nutrition 34 (2015) 195e200
(29.2%), day treatment programs (16.7%), outpatient clinics (10.4%),
and residential facilities (6.3%). A significant proportion of children
with tube (69.7%) and bottle dependence (87%) were treated at
inpatient or day treatment facilities. In contrast, no significant
difference in treatment setting was detected for children treated for
food selectivity [52].
6. Monitoring growth progress and outcome
Close follow up should be performed regularly, including eval-
uation of height and weight. The key measure of improvement
should be weight recovery, catch-up weight, which usually begins
within four to eight weeks of a successful intervention. If such
children are not markedly underweight for their height and their
length/height is progressing steadily, it may have to be accepted
that they are showing a variant pattern of normal growth. There is
consensus that severe, prolonged malnutrition, which is common
in developing countries, can negatively affect a child's future
growth and cognitive development. Evidently, the child's malnu-
trition and subsequent poor growth and development are accen-
tuated in a family context of impoverishment, dysfunctional
relationships and inadequate education [59]. Systematic reviews
have highlighted the paucity of high-quality follow-up studies and
recommended the investigation of a larger range of outcomes,
including attention and emotional development [60].
There is strong evidence that weight faltering is associated with
developmental delay in young children, but the evidence that it is
associated with later intellectual deficits is less consistent [58]. The
anthropometric outcomes and the IQ of children with weight
faltering in infancy have been investigated in the Avon Longitudinal
Study of Parents and Children (ALSPAC) [61]. The analysis of IQ
showed that children whose weight faltered from birth to 9 months
had a total IQ that was significantly lower by an average of 2.71
points at 8 years, equivalent to 0.17 SD. Weight gain from birth to 8
weeks had a positive linear association with child IQ at 8 years, but
weight gain from 8 weeks to 9 months did not show an association
with IQ. A prospective longitudinal study of a large non referred
population from early childhood to young adulthood showed that
picky eating, eating conflicts, struggles with food and unpleasant
meals in early childhood correlate with the diagnosis of anorexia
nervosa in adolescence or young adulthood [62e64]. A study of
longitudinal outcome of untreated infantile anorexia, reported the
persistence of difficulties in eating behavior and emotio-
nalebehavioral adjustment in both, the children and their mothers
[65]. Primary care providers are in a unique position to detect the
onset of NOFED at the earliest stage and to prevents/halt its pro-
gression. Screening for growth/weight faltering and feeding diffi-
culties should be part of regular health check-up. Although there
can be many reasons why a child develops NOFED, Levine et al.
hypothesize that a common pathway involves the interaction be-
tween food refusal and intrusive feedings: generally, intrusive
feeding provokes food refusal with decline of caloric intake [66].
Recognition of deviant behaviors that progress beyond normal
developmental food refusal, and have the potential to facilitate later
development of feeding disorders is vital.
7. Conclusions
Managing children with feeding disorders is a challenge for even
the most experienced pediatric specialists. FTT is present in
40e50% of NOFED patients and it's correlated with a delayed
diagnosis. Pediatricians should be able to identify this condition
early in order to provide useful guidance for parents and thus limit
the risk of intrusive feeding behavior. A simple set of clinical history
and feeding patterns should guide the initial evaluation, saving the
199
more advanced, invasive procedures when a medical condition is
suspected. In children with established NOFED, behavior modifi-
cation intervention plan constructed and supervised by the clinical
psychology specialist, remains at the core of management of chil-
dren with NOFED and is usually accessible only in the outpatient/
inpatient setting.
Conflict of interest
None.
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