The dying child and the family

The physician involved in the care of a child with a fatal disease has an obligation not only to give the best possible medical care to the child but also to provide emotional support and guidance for the family and the patient. Many emotional problems can be resolved or prevented by discussions with the parents and by encouraging them to express their anxieties and questions. The death of a child is the ultimate tragedy, and everything should be done to prevent further problems which add to the anguish the parents must endure. Support of the parents begins when the diagnosis is first presented, must be continued throughout the child's course, and should often extend beyond the death of the child. Understanding the child's reactions to death is important and helps the physician respond appropriately to the child's questions. Some older children wish to discuss their disease with the physician and in such cases their questions should be answered honestly, while at the same time offering hope.     

Child-feeding strategies are associated with maternal concern about children becoming overweight, but not children's weight status

BACKGROUND: Research suggests that parents use specific child-feeding strategies to influence their child's weight based on perceptions and concerns about their child's overweight risk, but limited data are available on ethnically diverse low-income populations. OBJECTIVE: This cross-sectional study examined associations between mothers' perception and concern about children's weight, child-feeding strategies, and child overweight in an ethnically diverse population. SUBJECTS: Mothers of preschool children (n=967) who participated in a federally funded nutrition program were asked how they fed their child, how they perceived child's weight, and whether or not they were concerned about their child becoming overweight. STATISTICAL ANALYSES PERFORMED: Logistic regression to calculate odds of maternal perception/concern given child weight, feeding strategy given maternal perception/concern, and child overweight given feeding strategy. RESULTS: Only 21% (n=23/108) of overweight preschoolers were perceived as overweight. Maternal perception of overweight was not associated with feeding strategies. About 53% (n=76/144) of Hispanic, 42% (n=23/55) of African-American, and 29% (n=223/768) of white mothers reported concern about their child becoming overweight. Mothers reporting concern were more likely to restrict child's intake of select foods (odds ratio 5.94; 95% confidence interval 1.74 to 20.28) and less likely to pressure child to eat (odds ratio 0.39; 95% confidence interval 0.15 to 0.99); however, these strategies did not predict child overweight. CONCLUSIONS: Mothers concerned about their child becoming overweight were more likely to restrict children's intake of specific foods and less likely to pressure their child to eat; however, this study did not detect an association between feeding strategies and child overweight.     

Measuring feeding in low-income African-American and Hispanic parents

Current feeding measures have been developed based on the premise that a child's obesity risk is increased when parents exert high levels of control over feeding. Although these measures provide useful ways to assess parental restrictiveness in feeding, they do not capture other important aspects of feeding that describe the behavior of parents not overly concerned about child obesity. Alternative measures are important to develop, especially for minority populations where concerns about child obesity are often not a significant determinant of parental feeding practices. The current study describes a culturally informed method used to develop a broader assessment of parental feeding strategies across two low-income ethnic groups. To be able to accurately measure cultural differences associated with feeding, qualitative and quantitative methods were used to assure conceptual, linguistic, and measurement equivalency across African-American and Hispanic parents. Based on responses from 231 parents, mean differences in feeding strategies were found with Hispanic parents reporting significantly more parent-centered/high control and child-centered feeding strategies compared to African-Americans. Furthermore, the relationship between children's weight status and parental feeding strategies varied by the two ethnic groups and child gender. Implications of these results for understanding the role of parental socialization in the development of child obesity are discussed.     

Low vision: mobility and independence training for the early years child

It is generally acknowledged that a child's primary caregiver acts as a spring board to independence. By encouraging the child to explore their world, parents and guardians are instrumental in developing the child's sense of self-esteem, self-worth and sociability. Less fortunate, however, are the increasing numbers of young children born with a visual impairment. Lacking visual cues, the child with a visual impairment requires specialist training to develop mobility and independent living skills. The primary aim of this paper is to outline the advantages mobility training has for young children. It also seeks to explore issues pertinent to the availability and extent of this training.     

Parental Feeding Practices in the United States and in France: Relationships with Child's Characteristics and Parent's Eating Behavior

Given the role of parental feeding practices in establishing children's eating habits, understanding sources of individual differences in feeding practices is important. This study examined the role of several psychological variables (ie, parental perceived responsibility for child's eating, parental perceptions of the child's weight, and parents' own eating patterns) in individual differences in a variety of feeding practices. Parents of preschool-aged children completed surveys in a cross-sectional study. Two cultural contexts (ie, United States, n=97 parents; and France, n=122 parents) were included to assess the cross-cultural generalizability of the findings. Monitoring was associated with parental perceived responsibility for child's eating, parental restrained eating, and parents' desire for their child to be thinner, especially in France. Restriction for weight reasons was more prevalent in France and was associated with parents' perceived responsibility for child's eating, perception of child's body weight, and parental restrained eating. Parental use of foods for nonnutritive purposes was more prevalent in the United States and was associated with parental uncontrolled or emotional eating. Finally, parents' perceived responsibility for child's eating was strongly related to child control over feeding, teaching about nutrition, encouragement of balance, and variety and modeling. These associations between psychological variables and parental feeding practices shed light on the sources of individual differences in feeding practices and suggest possible opportunities for intervention when feeding practices are suboptimal.     

Parent use of food to soothe infant/toddler distress and child weight status. An exploratory study

The aim of the present study was to explore the parent feeding practice of using food to soothe infant/toddler distress and its relationship to child weight status. Seventy eight families with infants and toddlers (43 males) ranging in age from 3 to 34 months (M = 14 mos, SD = 9 mos) completed a survey which included questions on their use of food to soothe, questionnaires on parent feeding practices, parenting self-efficacy, child temperament and child's weight and length at the time of their last well-baby visit. Results revealed the use of food to soothe to be a valid construct. In addition, mothers who used food to soothe rated themselves lower in parenting self-efficacy and their children higher in temperamental negativity. Analyses examining weight status as the outcome variable revealed that mothers who reported the use of food to soothe had heavier children, however, this relationship was stronger for children rated as high in temperamental negativity.     

Maternal child feeding practices and obesity: a discordant sibling analysis

BACKGROUND: The relationship between maternal feeding practices and weight status of 7-12 year-old obese and nonobese siblings was evaluated in 18 families using a discordant sibling design. METHOD: Mothers completed measures of concern and perception of children's weight and eating behavior, their control over child feeding, and maternal eating behavior. RESULTS: Intraclass correlations suggested similarity between obese and nonobese siblings in maternal control over feeding. Mothers perceived differences between their obese and nonobese children's eating regulation. Mothers' weight status was positively associated with disinhibition of their own eating as well as concern about both their obese and nonobese children's weight and health. DISCUSSION: These findings fail to support the hypothesis that maternal control over child feeding is related to childhood obesity, but highlight the impact of maternal weight history and eating habits on her impression of children's future weight and health independent of the child's weight status.     

Caregivers' responses to an intervention to improve young child feeding behaviors in rural Bangladesh: a mixed method study of the facilitators and barriers to change

Behavior change communications regarding child feeding have met with mixed success. The present study analyzes responses of 34 Bangladeshi caregivers seven months after they received a responsive feeding intervention. The intervention communicated and demonstrated five feeding interactions: hand-washing, self-feeding, verbal responsivity, managing refusals non-forcefully, and dietary diversity. Seventeen caregivers who adopted key behaviors addressed by the intervention and 17 who did not were compared in terms of socio-demographic variables, but more importantly in terms of their recall of the messages, their reported practice, and reported facilitators and barriers. Both those who changed and those who did not reported similar facilitators and barriers to practicing the new behaviors; there was also no difference in recall or in socio-demographic variables. Key themes identified through a constant comparative analysis helped to focus on common features of the lives of caregivers that made it easy or difficult to perform the practices. Some of these were household constraints such as poverty, shortage of time in which to complete chores, and avoiding waste and messiness; others related to the child's demands. Many caregivers misinterpreted instructions about talking to one's child in response to signals, as opposed to more common forms of supervision. Facilitators such as the child's evident pleasure and the caregiver's satisfaction did not always outweigh the barriers. Recommendations for improving interventions include helping caregivers solve problems tied to barriers and including more family members in the intervention.     

A follow-up study of parent education in pediatric office practices: impact at age two and a half.

The relationship between physician efforts to educate mothers of first born children about child behavior and development, and various outcome measures of mother and child functioning has been extended from 18 months to a time period of two and a half years. As was found earlier, there was a modest relationship between physician effort and mother gain in knowledge about child development, her feeling of being supported by the practice in her child-rearing role, and the frequency of her participation in affectional and cognitively stimulating activities with her child. These relationships, however, did not significantly increase in strength over time. At the end of 30 months there were still no significant positive relationships between teaching input and the child's developmental status, and mothers receiving care form physicians who taught more continued to report more behavior problems with their child than mothers receiving care from physicians who taught less. A content analysis of a small sample of the visits of high and low scoring physicians indicated that neither focused their teaching efforts on ways that mothers could interact with their children in more affectionate and cognitively stimulating ways. It is suggested that more focused teaching in this area might lead to better child development outcomes.     

Toddler-feeding practices among Mexican American mothers. A qualitative study

Little is known about toddler feeding practices, particularly among Mexican American mothers. A convenience sample of 18 Mexican-American mothers with toddlers participated in individual in-depth interviews. In determining what to feed her child, mothers tended to cater to the child's preferences rather than exposing the child to different foods or repeating attempts to feed previously unaccepted foods. In deciding when to feed food or beverage, more than half said the child's cue was primary. Findings indicate that an indulgent feeding style may dominate compared to other styles in the toddler developmental stage in Mexican-American mothers.     

Transition from Tube Feedings to Feedings by Mouth in Children: Preventing Eating Dysfunction

Tube feeding provides a temporary means of improving nutritional status and growth until a child can be nourished by mouth. Children in transition from tube to oral feeding typically display oral-motor, sensory, and developmental feeding problems and behaviors that make weaning difficult. A smooth transition benefits the child's health immediately by ameliorating eating difficulties and prevents dysfunction later in life. The weaning process from tube to oral feeding is best thought of in developmental terms. A four-step process is suggested to ensure a smooth transition: promote a positive feeding relationship between caregiver and child; determine feeding readiness; normalize feeding, including oral stimulation, eating-related behaviors, environment, and regulation; and initiate a behavioral feeding plan. The awareness and anticipatory guidance of nutrition professionals before this transition maximizes oral-feeding success for the formerly tube-fed child. J Am Diet Assoc. 1996; 96:277-281.     

Childhood eating disorders

Eating is a sensitive barometer of emotional state and parent-child interaction. Psychosocial distortions often appear first to the health worker and are referred to the dietitian as distortions in eating. At times, the distortion is severe enough to be called an eating disorder. An eating disorder of childhood is the misuse of feeding in an attempt to solve or camouflage family problems of living that seem otherwise insoluble. The childhood eating disorder might take the form of failure to thrive, obesity, excessive finickiness, or, most commonly, vehement and protracted struggles between parent and child about eating. An eating disorder is a biopsychosocial problem. It is based on characteristics and distortions in physical, physiological, psychological, and social factors. The dietitian who is to be helpful with families referred to her for correction of eating difficulties must be able to detect the disordered situation and differentiate it from one that is simply problematic. If an eating disorder exists, it is unlikely that the situation will change without psychotherapeutic intervention into family functioning. An appropriately conducted symptom management approach to correct the eating distortion is a helpful and potentially successful adjunct to psychotherapy. Such a component should be constructed around the restoration of a positive feeding relationship.     

Maternal distress, child behaviour, and disclosure of psychosocial concerns to a paediatrician

BACKGROUND: Despite the availability of effective screening measures, primary care providers continue to fail to identify and manage many children with psychosocial problems. One of the best predictors of identification by a primary care physician is whether mothers disclose concerns about their child's psychosocial functioning to their child's physician. This study examined if maternal distress and child behaviour predicted whether mothers had and discussed concerns about their child's behaviour and emotions with paediatricians. METHODS: Participants were 138 mothers who accompanied their 4-12-year-old children to a health supervision visit at an urban teaching hospital. Mothers completed a demographic questionnaire, the Pediatric Symptom Checklist, the Beck Depression Inventory, and an exit questionnaire. Results Logistic regression correctly classified 97.3% of mothers who did not disclose child problems. Only 34.5% of mothers who did disclose were correctly classified. CONCLUSIONS: The results supported the hypothesis that mothers' psychosocial functioning is significantly related to concern about child behaviour and disclosure of concerns to the paediatrician. The inability of child behaviour and maternal functioning to predict which mothers were concerned and disclosed concerns supports the hypothesis that disclosure and identification of psychosocial problems in primary care is complex and requires a multifactor model.     

Controlling Maternal Feeding Practices Associated with Decreased Dieting Behavior in Sixth-Grade Children

Controlling maternal feeding practices have been linked to increased caloric intake, disinhibited eating, and obesity in children. Its relationship to child dieting behavior, however, is unknown. Using the National Institute of Child Health and Human Development Study of Early Child Care and Youth Development, this study examined whether controlling feeding practices are associated with increased or decreased dieting behavior in children. Controlling maternal feeding practices were assessed in third grade with the question, “Do you let your child eat what he/she feels like eating?” Answers ranged from 1 to 4; higher scores were reverse-coded to indicate greater control. Child dieting behavior was assessed in sixth grade and dichotomized into “any dieting behaviors” vs “none.” Multiple logistic regression was used to investigate the relationship between controlling maternal feeding practices and dieting behavior and included the covariates of sex, race, maternal education, maternal weight status, child weight status in third grade, and change in body mass index z score between third and sixth grade. In sixth grade (n=776), 41.5% of children engaged in dieting behavior. In the multivariate analysis, greater maternal control over child eating predicted lower odds of child dieting in sixth grade (odds ratio=0.79; 95% confidence interval: 0.64 to 0.97). There was no interaction between controlling maternal feeding practices and child's sex or baseline obesity status. Exerting more control over what a child eats in third grade may protect against future dieting behavior in children, independent of child's weight status or rate of weight gain. Further work is needed to better define which controlling feeding practices are beneficial for the child.     

An evaluation of efforts to educate mothers about child development in pediatric office practices.

The efforts expended by pediatricians in a variety of private practice settings to educate mothers of first-born children about child behavior and development were examined in relation to various outcome measures of mother and child functioning over a time period of one-and-a-half years. Mothers learned more about child development in group settings than in solo practice settings, but differences between medical groups with and without nurse practitioners were not significant. Mothers receiving care from pediatricians who made at least a moderate effort to teach, learned more about child development, described more use of positive contact with their children, and felt they were helped more in their childrearing efforts than did mothers receiving care from pediatricians who made little effort to teach. However, there were no significant differences in measures of the child's developmental status related to physician teaching input, and mothers exposed to higher levels of teaching input reported more behavioral problems with their children. The most important predictor of the child's developmental status at 18 months of age was the amount of positive contact between mother and child at one year. It is suggested that the effects of changing the frequency of well-child visits on the mothers' interaction patterns with their children and on their feelings of being supported by the physician be ascertained before making recommendations about the optimal number of such visits.     

Pregnancy Wantedness and Child Attachment Security: Is There a Relationship?

Objectives Few studies examine the consequences of unwanted pregnancy on child development, and most of those that do, use measures of pregnancy intention. Here we use measures of pregnancy wantedness, together with measures of maternal motivation, to examine the potential effect of wantedness on the child's attachment relationship with its mother. Methods Using data collected from 78 primiparous Black women who had applied for an Early Head Start program in a Midwestern city and who had completed a pregnancy acceptance questionnaire, we created four measures: Pregnancy Wantedness, Positive Maternal Motivation, Negative Maternal Motivation, and Social Reinforcement for the pregnancy. Each child had been assessed at about 11 months of age for Difficult Temperament and at about 14 months of age for Attachment Security. We then tested both regression and linear structural equation models in order to predict the child's attachment security with the remaining variables. Results Pregnancy Wantedness is predicted with an R (2) of .198 by Negative Maternal Motivation and Social Reinforcement but does not predict Attachment Security, which is predicted with an R (2) of .375 by Positive Maternal Motivation, Negative Maternal Motivation, and Difficult Temperament. Conclusions Our analyses indicate that in a multivariate context there is no relationship between the wantedness of a pregnancy and the subsequent attachment security of the child for this sample of low-income Black primiparous mothers. This finding is related to some conceptual and measurement issues of pregnancy wantedness, the irrelevance of some aspects of wantedness to parent-child interaction, and the powerful effect of maternal motivations on child attachment security.     

Responsive complementary feeding in rural Bangladesh

It is now widely recognized that malnutrition can partly be attributed to caregiver-child interaction during feeding episodes. Current conceptual frameworks emphasize the importance of responsiveness (including active and social behaviour), psychomotor abilities of the child to self-feed, and a non-distracting feeding environment. The present observational study had three main objectives: (1) to define operationally key terms such as responsive and active feeding and observe their frequency in a rural Bangladesh sample; (2) to examine whether self-feeding, responsive and active behaviours of the mother and child varied with child's age and amounts eaten; and (3) to determine associations between mother and child behaviours. Fifty-four mother-child pairs were observed during one feeding episode and behaviours were coded for 5 categories, namely self-feeding, responsive, active, social and distracting behaviours. Children were between 8 and 24 months of age. Results indicated that the five behaviours could be observed and reliably coded. Two-thirds of mothers had an active feeding style but only a third were responsive; the two styles did not overlap. With older children, mothers encouraged more eating and more self-feeding, but children did not feed themselves more; instead older children were more negatively responsive (refusing offered food). Positively responsive mothers tended to have active children who explicitly signaled their desire for food or water, and who ate more mouthfuls of food. Positively active mothers adopted different strategies to encourage eating, such as verbally directing the child to eat, focusing, and temporarily diverting. These mothers tended to have children who were negatively responsive and refused food. Children accepted on average 5.31 mouthfuls of food and rejected 2.13. Mothers who used intrusively active strategies (e.g. force feeding) tended to have children who were both positively and negatively responsive, thus partially reinforcing her forceful behaviour. Thus, the responsive feeding framework, once operationalized, has the potential to identify specific behaviours that support or impede mother-child interaction during complementary feeding.     

Child feeding practices and perceptions of childhood overweight and childhood obesity risk among mothers of preschool children

Aim: The present study assessed the relationship between maternal attitudes, beliefs and child feeding practices. It was hypothesised that: (i) maternal control over feeding would increase when mothers perceived their children as over‐ or underweight and were concerned about the weight status of their children; and (ii) mothers would express more concern about their daughters' weight, and report higher levels of control over feeding as a result. Methods: Participants included 112 mothers and their children aged 2–6 years who were attending swim lessons at a Central Coast swim school. Mothers completed the Child Feeding Questionnaire to assess maternal attitudes, beliefs and control over child feeding. Child and maternal body mass indexes were measured. Correlational analyses, t‐tests and multiple regression analyses were performed. Results: Mothers reported a high overall level of control in child feeding, and a low level of concern for child weight. Child overweight and obesity were marginally lower than reported in previous studies. Mothers reported more concern for their daughters' weight, but did not report increased control over feeding based on child gender. Pressure to eat was negatively associated with maternal education, suggesting a link between socioeconomic status and child feeding practices. Mothers displayed higher levels of parental control over obese than normal‐weight children, suggesting that they accurately assessed the weight status at the obese level. Conclusion: Mothers may be able to detect obesity in their children, but not overweight. Mothers may also be unconcerned about their sons' weight, and this discrepancy should be investigated in clinical and educational settings. Nutrition education and child obesity prevention and treatment programs should take maternal attitudes, perceptions and child feeding practices into account when planning interventions.     

Risk factors for the development of persistent diarrhoea and malnutrition in Burmese children.

To identify socioeconomic and behavioural risk factors for development of persistent diarrhoea and malnutrition in children, a case-control study was carried out in Burma. Cases were 67 children 1-59 months old hospitalized for diarrhoea lasting > 14 days and complicated by severe malnutrition; for each case, a healthy control child was selected who was age- and sex-matched from the same neighbourhood. Homes of cases and controls were visited for interviews and for direct observation of household child-care practices. Risk factors were catalogued and calculations made for relative risk and etiologic fractions. Risk factors that were associated with persistent diarrhoea and malnutrition included low family income, low education of mothers, unhygienic latrines, flies in the house and on the child, dirty appearance of child and mother, mother not using soap and water when washing child's hands, defaecation of child on floor, breastfeeding on demand, child eating food from floor, not feeding recommended weaning foods, and lack of knowledge by mother about causes of diarrhoea and about foods that prevent malnutrition. These results indicated that persistent diarrhoea and malnutrition in Burma is caused by a complex of several interrelated socioeconomic factors, unsanitary behaviour pertaining to personal hygiene, the practice of demand breastfeeding and lack of certain weaning foods, and low education of mothers who showed less knowledge about causes of diarrhoea and prevention of malnutrition.     

Permissive parental feeding behavior is associated with an increase in intake of low-nutrient-dense foods among American children living in rural communities

Parents play an important role in shaping children's eating habits. Few studies have evaluated the influence of both parenting style and parenting practices on child outcomes such as dietary intake. During spring 2007, 99 parent-child dyads from four rural US areas participated in this cross-sectional study. Child food intake was reported during two interviewer-administered, parent-assisted 24-hour recalls. Diet quality was defined as the average number of low-nutrient-dense (LND) foods consumed. Validated questionnaires were used to assess parental feeding practices and feeding style. Pearson correlations identified relationships among child food intake, parental feeding style typologies, and covariates. Regression analyses were used to predict child diet quality. Sixty percent of children and 76% of parents were overweight or obese. A permissive feeding style, which is highly responsive to a child's requests and sets few demands on him or her, was the most common (n=37) parental feeding style. This feeding style was associated with child intake of LND foods (r=0.3; P<0.001) and moderated the relationship between parental feeding practices and child intake of LND foods. In the presence of a permissive feeding style, higher levels of monitoring were associated with child intake of LND foods (β=.69; P<0.05). Parental feeding style may alter the effectiveness of parental feeding practices on children's food intake. More research is needed to understand the parent-child feeding relationship in the context of parental feeding styles and practices.