This assessment should ideally be done by a health visitor in the UK primary care setting, but could be done by a paediatrician, GP, psychologist or social worker, depending on the child’s circumstances. The important principle of the assessment is to look globally at the child and family in relation to feeding and establish the current situation before giving any advice. In general this assess-ment will be most informative if at least part of it is undertaken in the family home. While home visits can be time consuming, they supply a wealth of infor-mation, much of which can never be obtained in the lengthiest of office-based consultation.
The first question to ask in any assessment is what the family perceive the problem to be.
· Are they worried about their child’s growth, feeding or both and why are they worried?
· Have they always felt that there was a problem with their child’s feeding or growth, or has their anxiety been raised solely as a result
of health professionals telling them that their child is not gaining weight?
The next issue to rule out or contextualize is the possible role of medical issues.
· Have there been important health problems in the past such as prematurity or severe chronic illness?
· Are there currently any symptoms suggestive of illness?
If so, a paediatric assessment will be needed at an early stage. However even if medical problems are identified usually the general management approach will be the same, so it is still important to proceed to a broader assessment of the child’s feeding. This needs to consider everything about food and eating sys-tematically, rather than merely concentrating on, for example, what was reported as being eaten the day before. The food chain (Figure 10.2) illustrates the general areas needing to be considered.
THE FOOD CHAIN EXAMPLES OF ISSUES THAT MAY BE UNCOVERED Money & Knowledge Family in the grip of a loan shark
Purchase No car, no local supermarket Preparation Living in one room without a cooker
Giving Mum depressed and force feeding
Using Rapid growth in hospital Taking Eats walking around room Absorbing Coeliac disease
Figure 10.2 The food chain
The sorts of questions you might ask would be:
· What are the family circumstances? Do the family know what food they should be giving their child and have they the money to buy it? How do they shop and where, and can they cook?
· What sorts of foods are given? This assessment is easier if the family complete a three-day food diary, which is far more informative than relying on parental recall. The family may have an inappropriately restrictive diet due to religious beliefs or ideas about food
intolerance, both of which can lead to a very low-energy diet. Some children are genuinely food intolerant, most commonly of milk, and this may greatly restrict what they can eat. Milk intolerance should never be diagnosed in a child without assessment by a paediatrician, and such children should always be under the supervision of a paediatric dietician.
· How is the food given to the child and where, and how does the child react to it? Are there meals or settings or types of food that the child will eat better? This part of the assessment is made much easier if a meal can actually be witnessed or viewed via a video made by parents.
· Finally, it is important to examine the child’s growth pattern over time and link events in their life to periods of poor weight gain or catch-up. If there was a period of particularly poor weight gain, what was happening then? If the child showed a period of rapid recovery, what precipitated this and why did the improvement not continue? Sometimes the information from the growth chart may in effect contradict all the remainder of the assessment. For example a child may be presented as eating very well at home and yet show much more rapid weight gain during a brief admission to hospital.
Similarly, a child’s poor weight gain may coincide very precisely with major family upsets or changes in the organization of care.
Intervention
Once the whole picture is outlined, obvious areas capable of change may have been identified which clearly explain the poor weight gain. More often things are not that clear, but there are aspects that, if changed, should result in improved intake. Commonly the assessment itself results in improved intake, as the parents spontaneously develop a clearer view of what needs to be changed, though this is not always shared explicitly.
When it comes to offering advice, as in any area of behavioural change, it is important to remember three basic principles.
1. Reinforce and commend whatever is already going well. Families often feel demoralized and may only need help in recognizing where to concentrate their efforts. In other circumstances it may be very difficult to find anything worthy of praise, but without some positive reinforcement it will be difficult to engage families in changing any other behaviours.
2. Discuss possible changes with the family and identify those which are most important and achievable. The family should then implement a limited number, ideally no more than two or three at any one time.
3. If possible put this advice in writing to the family with copies to all others working with the family, to ensure a consistent message to the family.
The sort of advice that might be given depends very much on the individual child. Generally, dietary advice would aim to maximize the energy content of the food given: for example adding butter or cream to foods, using full-fat dairy products, offering a sweet as well as a savoury course at each meal and encour-aging solid foods – which have the most energy – over pureés or drinks. It may also be important to widen the range of food types given or make them more age appropriate.
Other advice commonly relates to mealtime routine. There should be regular meals and snacks (a toddler must eat five times a day to meet their high dietary requirements), yet constant grazing on snack foods, or drinking large volumes of fluids should be avoided. Suitable seating can make a big difference, as can meals shared with parents or other children. A vital behaviour to advise against is coercion of any kind in relation to food, particularly force-feeding since it can have such an adverse effect on the child’s experience of meals. Many parents probably resort to force-feeding at some stage in these circumstances, so it is a sensible precaution to advise explicitly against it in advance.
Advice is most likely to be successfully implemented if it is followed up within 1–2 weeks. At this contact progress can be discussed and the advice restated if necessary. Actual changes in weight gain take longer to identify: at least a month in a child under one year and two to three months in toddlers. It is important to check progress, but not to weigh too often, as over short periods of time random variations can mislead.