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Caloric Intake and Eating Behavior in Infants and Toddlers With Cystic Fibrosis

Scott W. Powers, PhD^*,, Susana R. Patton, PhD^*, Kelly C. Byars, PsyD^*,, Monica J. Mitchell, PhD^*,, Elissa Jelalian, PhD, Mary M. Mulvihill, PhD^||, Melbourne F. Hovell, PhD^¶ and Lori J. Stark, PhD^*,

^* Children’s Hospital Medical Center, Cincinnati, Ohio
University of Cincinnati College of Medicine, Cincinnati, Ohio
Department of Psychiatry and Human Behavior, Rhode Island Hospital, Brown University School of Medicine, Providence, Rhode Island
^|| Department of Pediatrics,University of California, San Diego Medical Center, San Diego, California
^¶ Graduate School of Public Health, San Diego State University, San Diego, California

--> Objective. Infants and toddlers with cystic fibrosis (CF) are at risk for poor growth. Controlled behavioral assessment studies have not focused on this population. This study compared calorie intake, percentage of Recommended Daily Allowance (RDA) per day and per kilogram, and percentage of calories from fat, protein, and carbohydrates between infants and toddlers with CF and healthy peers. Also, eating behaviors, such as meal duration, bites and sips per minute, percentage of meal spent eating, children’s problematic eating behaviors, and parents’ perceptions of mealtime behaviors were compared between infants and toddlers with CF and controls. Five hypotheses were tested. 1) Infants and toddlers with CF would be comparable to controls on the number of calories consumed per day and the percentage of calories from fat. 2) Infants and toddlers with CF would not meet the CF dietary guidelines for the percentage of RDA for calories or the percentage of calories from fat. 3) Infants and toddlers with CF would have longer meal durations than healthy peers, but would not differ on the pace of eating, the number of calories consumed during the meal, or the percentage of time spent eating during the meal. 4) Parents of infants and toddlers with CF would perceive more problematic mealtime behavior than controls. 5) Parents’ perceptions of children’s mealtime behavior would positively correlate with meal duration and negatively correlate with the number of calories consumed during the meal.

Design. A 2-group comparison study.

Setting/Sample. A clinical sample of 35 infants and toddlers with CF (M = 18.6; standard deviation = 8.1 months; range = 7–35 months) and a community sample of 34 healthy peers matched for age, gender, socioeconomic status, and number of parents and siblings present during mealtimes.

Measurement and Main Results. Children’s calorie intake was measured using 3-day diet diaries. The 2 groups did not differ on the total number of calories consumed per day, the percentage of calories derived from fat, or the percentage of RDA consumed per day. Infants and toddlers with CF were not meeting the CF dietary recommendations of 120% to 150% RDA for energy with 40% of calories coming from fat. Using the Dyadic Interaction Nomenclature for Eating, a behavioral coding system, videotaped recordings of children’s dinner meals were scored for meal duration, number of bites and sips per minute, number of calories per bite or sip, and the percentage of 10-second intervals with bites and sips. The CF sample had significantly longer mealtimes (20.2 minutes) than the control group (16.4 minutes), but did not differ on calories consumed at the meal, bites and sips per minute, calories per bite and sip, or time spent eating during the meal. On the Behavioral Pediatrics Feeding Assessment Scale, a measure of parental perceptions of mealtime behavior that was completed by a subset of families (39 families), parents of infants and toddlers with CF endorsed a greater number of mealtime behaviors as problems and a higher occurrence of problems than did parents of controls. Examples of these behaviors for the CF sample included problems with their child’s willingness to try new foods (48%), eat vegetables (48%), and observations that their child has a poor appetite (32%) and would rather drink than eat (32%). Parents of children with CF chose a greater number of mealtime strategies and feelings as problems and reported more frequently using problematic strategies at mealtimes than did parents of controls. Examples of problematic strategies and feelings for parents of infants and toddlers with CF included feeling anxious/frustrated when feeding their children (37%), not feeling confident that their child eats enough (32%), and using coaxing to get their child to take a bite (26%). For the entire sample, a positive correlation of 0.29 was found between the number of mealtime behavior problems reported by parents and meal duration, suggesting the co-occurrence of problematic mealtime behavior with longer meal duration. No relationship was found between the number of child mealtime behavior problems reported by parents and the number of calories consumed during the filmed meal. For the CF sample, a correlation of -0.26 between children’s weight percentile for age and the filmed meal duration was found, suggesting a tendency for meal duration to increase as children’s weight for age decreases. Post-hoc analyses were conducted comparing infants and toddlers with previously reported samples of preschool and school-aged children on meal duration. Results demonstrated that in each group, children with CF had longer meals than age-matched controls.

Conclusions. Our findings reveal significant deficits in achieving dietary recommendations for many families of infants and toddlers with CF. Only 11% of infants and toddlers with CF met the CF dietary recommendation of at least 120% of the RDA/day for energy. In addition, infants and toddlers were found to derive only 34% of their daily calories from fat, compared with the recommended 40% needed for a moderate to high fat diet. These results underscore the need for intervention in families of infants and toddlers with CF, who in addition to being at increased risk for malnutrition, may also experience a hastening in the decline of their pulmonary status because of poor nutritional status. Currently, there is limited programmatic research on nutritional and feeding interventions for toddlers and infants with CF. One study, which used a hospital-based behavioral education program to increase the caloric intake of 3 children (ages 10–20 months) who were below the fifth percentile for weight for length, found at least a 54% increase in calories for each child after treatment. Similarly, preliminary findings of 2 parent-based interventions, a nutrition education curriculum and a nutrition education plus behavior parent-training curriculum, found a 22% and 32% increase in daily calories, respectively, at treatment completion. A large-scale clinical trial is needed to evaluate the efficacy of any nutritional intervention before widespread dissemination. Additional assessment-focused research is also needed to identify patients’ who may be at greatest risk for malnutrition and to guide the development of interventions to treat them.

Key Words: nutrition • chronic illness • dietary adherence • parenting • pediatric psychology

Abbreviations: CF, cystic fibrosis • RDA, Recommended Daily Allowance • SD, standard deviation • SES, socioeconomic status • BPFAS, Behavioral Pediatrics Feeding Assessment Scale

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