When Does the Association Exist Between Anthropometric Failure and Behavioral Feeding Problems?
The association between anthropometric failure and behavioral feeding problems exists primarily in early childhood (ages 9 months to 4 years), where behavioral feeding issues significantly increase the risk of malnutrition, though the relationship is complex and not always direct. 1, 2
Critical Age Window and Risk Quantification
The strongest evidence for this association comes from early childhood:
Children aged 9 months to 4 years with behavioral feeding problems show significantly higher rates of anthropometric failure, with total behavioral frequency scores ≥85 increasing malnutrition risk 3.7-fold, child behavioral scores ≥62 increasing risk 2.6-fold, and parental behavioral scores ≥21 increasing risk 4.8-fold 2
The relationship is bidirectional: behavioral feeding problems can lead to anthropometric failure, but children with low appetite or disinterest in food may also trigger compensatory active feeding behaviors from caregivers that don't necessarily improve growth 3
Context-Dependent Associations
The association varies significantly by underlying condition and context:
In Children with Specific Medical Conditions
Esophageal atresia-tracheoesophageal fistula (EA-TEF): 25% of patients whose parents were anxious about feeding developed moderate to severely disturbed eating habits, with behavioral difficulties regarding food directly linked to growth problems 4
Skeletal dysplasias: Feeding difficulties (aspiration, gastroesophageal reflux, loss of appetite) correlate with failure to thrive in conditions like rhizomelic chondrodysplasia punctata, where 50% required enteral nutrition due to feeding problems 4
Shwachman-Bodian-Diamond syndrome: 48-73% presented with feeding difficulties as neonates requiring enteral nutrition, with failure to thrive documented in 62-79% 4
In Otherwise Healthy Children
The association is weaker and more complex in general pediatric populations without underlying medical conditions 5
Food intake deficiencies show weak-to-null correlation (Pearson correlation -0.013 to 0.147) with anthropometric failures in population studies, suggesting behavioral feeding problems alone may not directly cause anthropometric failure without other contributing factors 5
Important Clinical Caveats
When the Association May NOT Exist
In children with adequate compensatory mechanisms: Active caregiver feeding behaviors may successfully compensate for child disinterest in food, preventing anthropometric failure despite behavioral feeding problems 3
In conditions with primary organic causes: When pancreatic insufficiency, malabsorption, or metabolic complications are present, anthropometric failure may occur independent of behavioral feeding issues 4
Single anthropometric measurements have poor predictive value: 27% of infants meet one or more failure-to-thrive criteria, but most are identified by only one criterion with positive predictive values ranging from 1-58%, indicating behavioral feeding problems don't reliably predict anthropometric failure across all definitions 6
Assessment Strategy
Use the Composite Index of Anthropometric Failure (CIAF) rather than single measurements to capture the full spectrum of growth failure (height-for-age, weight-for-height, weight-for-age, and combined failures) when evaluating the relationship with feeding problems 1
Employ observational assessment rather than questionnaires alone, as videotaped mealtime observations provide superior data to self-report measures, though they are more resource-intensive 1
Screen for neurodevelopmental disorders (particularly ADHD, where feeding problems are 3-4 times more prevalent) when evaluating underlying conditions contributing to both behavioral feeding problems and anthropometric failure 1
Treatment Implications
When the association is confirmed, combined behavioral therapy with nutritional support produces significant improvement in both anthropometric measurements and feeding behavior scores in children with primary malnutrition 2
The treatment approach must address both components: nutritional support alone without behavioral intervention may fail to address the root cause when behavioral feeding problems are primary 2