Relationship Between Composite Index of Anthropometric Failure and Behavioral Pediatric Feeding Assessment Scale in Children
Children with feeding behavior problems, as measured by the Behavioral Pediatrics Feeding Assessment Scale, demonstrate significantly lower anthropometric measurements including BMI, tri-ponderal mass index, upper middle arm circumference, and triceps skinfold thickness, indicating a direct association between feeding difficulties and composite anthropometric failure. 1
Understanding the Composite Index of Anthropometric Failure (CIAF)
The CIAF provides a more comprehensive assessment of undernutrition than conventional single indicators like underweight alone, capturing the overall extent of anthropometric failure through six mutually exclusive measurements combining height-for-age, weight-for-height, and weight-for-age. 2 This composite approach reveals that nearly 48% of children under 5 years demonstrate some form of anthropometric failure, with 6% showing all three forms simultaneously. 3
The key advantage of CIAF over traditional weight-for-age measurements is that it provides an unequivocal statement on the direction and degree of change in undernutrition over time, whereas single indicators can sometimes provide contradictory information about nutritional status. 2
Direct Association with Feeding Behavior Problems
Evidence from Specific Learning Disability Population
In children with specific learning disability, feeding behavior problems were present in 39.5% of cases, with clear anthropometric correlates. 1 Binary logistic regression demonstrated significantly higher frequency of feeding problems in children with:
- Lower BMI (adjusted odds ratio: 0.841,95% CI: 0.722-0.979) 1
- Lower tri-ponderal mass index (AOR: 0.738,95% CI: 0.585-0.933) 1
- Lower upper middle arm circumference (AOR: 0.772,95% CI: 0.649-0.918) 1
- Lower triceps skinfold thickness (AOR: 0.890,95% CI: 0.808-0.980) 1
Evidence from ADHD Population
Children with ADHD demonstrate even more pronounced associations between feeding problems and anthropometric failure. 4 Specifically:
- 11.1% had wasting and 1.9% had severe wasting compared to no wasting in typically developing children 4
- More than half had mid-upper arm circumference below the 5th percentile, indicating undernutrition, versus 35.2% of controls 4
- More than one-third had feeding problems compared to only 9.3% of typically developing children 4
Significant negative correlations existed between feeding problems and bodyweight (r = -0.338, P = 0.012), BMI (r = -0.322, P = 0.017), and MUAC (r = -0.384, P = 0.004). 4 Nearly half of ADHD children had suboptimal nutrition compared to 11.1% of controls. 4
Clinical Mechanism: Active Feeding as Compensation
An important nuance emerges from observational feeding studies: active feeding behaviors by caregivers often represent compensation for child disinterest in food rather than enhancement of growth trajectory. 5 This suggests that:
- Caregiver encouragement and active feeding attempts may mask underlying feeding problems when assessed through questionnaires alone 5
- The Behavioral Pediatrics Feeding Assessment Scale captures child disinterest and feeding difficulties that correlate with poor anthropometric outcomes 1, 4
- Observational methodology reveals feeding behaviors that participants may not self-report, providing more accurate assessment than questionnaires subject to social desirability bias 6
Practical Assessment Algorithm
Step 1: Screen for Anthropometric Failure
Calculate CIAF using WHO growth standards to capture:
- Height-for-age (stunting) 3
- Weight-for-height (wasting) 3
- Weight-for-age (underweight) 3
- Combined failures 2, 3
Step 2: Administer Behavioral Pediatrics Feeding Assessment Scale
Identify specific feeding behavior problems including:
- Child disinterest in meals 5, 1
- Inability to sit through meals 4
- Mealtime behavioral difficulties 1, 4
Step 3: Measure Specific Anthropometric Indicators
When feeding problems are identified, obtain:
- BMI and tri-ponderal mass index as primary indicators 1
- Mid-upper arm circumference to detect undernutrition 4
- Triceps skinfold thickness for body composition 1
Step 4: Evaluate for Underlying Conditions
Consider screening for:
- Neurodevelopmental disorders (ADHD, specific learning disability) where feeding problems are 3-4 times more prevalent 1, 4
- Avoidant/Restrictive Food Intake Disorder (ARFID) when significant nutritional deficiency with marked psychosocial interference is present 7
- Failure to thrive requiring comprehensive evaluation including feeding history, swallowing dysfunction, and gastroesophageal reflux 8
Important Clinical Caveats
The relationship between feeding problems and anthropometric failure is bidirectional but not always linear. 5 Active caregiver feeding may temporarily maintain weight despite underlying feeding difficulties, masking the problem until more severe anthropometric failure develops. 5
Observational assessment provides superior data to self-report measures for capturing feeding behaviors, though it is more resource-intensive. 6 When feasible, videotaped mealtime observations should complement standardized feeding assessment scales. 6
Maternal factors contribute substantially to the rich-poor gap in CIAF, including maternal underweight status, high parity, and lack of media exposure. 3 Intervention programs must address these maternal covariates to reduce overall burden of undernutrition. 3