ral other influences, including societal expectations and maternal and family characteristics for child weight and type of food eaten, that contribute to the development of negative feeding patterns and poor growth in the child. Clearly, as evidenced by Ramsay’s thoughtful review, child feeding problems extend beyond the child’s specific characteristics and reflect the influence of several external or environmental factors simultaneously affecting the young child at multiple levels. Therefore, discerning the specific contributors to a young child’s feeding impairment is challenging, given that problematic feeding patterns may be the result of physiologic or functional feeding problems (e.g. limited hunger, poor sucking) but can later become conditioned through learned association with external or environmental cues (e.g. parent feeding practices and beliefs). As Ramsay notes, all of these factors can have a detrimental impact on a child’s feeding behaviours, mealtime interactions and growth.
Echoing Ramsay’s comments, Black further illustrates the impact of the child-caregiver interaction on the development of child feeding patterns and mealtime behaviours. The child’s contributions to subsequent feeding problems may include inconsistent or disruptive communication of verbal and nonverbal cues regarding hunger and satiety. In turn, caregivers may have difficulty recognizing or interpreting their child’s feeding cues, which can lead to mealtime conflicts. Black reviews several strategies by which caregivers can promote the feeding process, such as modelling positive eating behaviours, establishing consistent and predictable mealtime routines and emphasizing the value of offering nutritionally balanced foods within a positive mealtime atmosphere. Black, however, underscores the importance of the need for multilevel interventions to promote healthy feeding patterns in children, including environmental changes in which restaurants need to include nutritious, yet appealing, food choices for children, and family and individual education that fosters caregiver mealtime management and increases awareness of healthy eating behaviour. These interventions are equally important for children who are underweight or overweight.
While Black’s paper provides direction for multilevel interventions to promote the development of healthy eating behaviours for all children spanning the entire weight continuum, Piazza and Carroll-Hernandez focus their review of the research solely on children who are underweight and/or fail to thrive. Similar to Ramsay’s and Black’s reviews, the authors note the complex causes of pediatric feeding disorders, which can include both biological and environmental factors that are further exacerbated by caregiver management. Demonstrating the effectiveness of intensive, interdisciplinary day-treatment services that are primarily behaviourally-based, the authors provide empirical support for behavioural feeding treatment through outcomes-based data. In their own work, the authors document the fact that children with long-standing feeding problems, many of whom required supplemental feedings via naso-gastric or gastrostomy tubes, were able to meet 70% or greater of their oral feeding goals in the treatment program, with 100% of cases being able to transfer treatment to the home and community. Follow-up data up to 24 months post-discharge from the treatment program reveal that 85% of children continued to make progress toward age-typical feeding.
Implications for Development and Policy
In combination, these three papers illustrate the complexity of feeding development and the mechanisms by which feeding problems emerge in young children. Clearly, pediatric feeding disorders do not have a single origin, but involve several interacting components that result in atypical feeding patterns that ultimately affect the child, family and society as a whole. Outcomes-based data is critical to understanding the most effective strategies to use when addressing feeding problems in children, and the authors have provided compelling