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Guideline Summary
Guideline Title
Best evidence statement (BESt). Parent-infant interaction and non-organic failure to thrive.
Bibliographic Source(s)
Cincinnati Children's Hospital Medical Center. Best evidence statement (BESt). Parent-infant interaction and non-organic failure to thrive. Cincinnati (OH): Cincinnati Children's Hospital Medical Center; 2011 Jun 28. 7 p. [27 references]
Guideline Status

This is the current release of the guideline.

Scope

Disease/Condition(s)

Non-organic failure to thrive

Guideline Category
Management
Clinical Specialty
Family Practice
Nutrition
Pediatrics
Intended Users
Advanced Practice Nurses
Dietitians
Nurses
Occupational Therapists
Physician Assistants
Physicians
Social Workers
Speech-Language Pathologists
Guideline Objective(s)

To evaluate, among formula-fed infants admitted for inpatient hospitalization with non-organic failure to thrive and their primary caregivers, if focused parent-child interaction education in addition to standard care compared with standard care improves weight gain within 4-8 weeks

Target Population

Formula-fed infants (birth to 1 year) with non-organic failure to thrive and their primary caregivers

Interventions and Practices Considered
  1. Evaluation of caregiver-child attachment/bonding for concerns that may impact feeding and developmental interaction
  2. Evaluation of caregiver-child attachment/bonding in infants and children admitted with non-organic failure to thrive
  3. Evaluation of oral-motor/feeding skills and caregiver-infant behaviors during feeding interaction
  4. Caregiver education regarding child cues, behavioral states, state modulation, and feeding
Major Outcomes Considered

Weight gain

Methodology

Methods Used to Collect/Select the Evidence
Searches of Electronic Databases
Description of Methods Used to Collect/Select the Evidence

Search Strategy

  • Keywords: Parent-infant interaction, infant feeding, parent education, failure to thrive, non-organic failure to thrive, feeding strategy, feeding practices, feeding technique, management of failure to thrive
  • Databases: Medline, CINAHL, PubMed, Cochrane, Google Scholar
    • Limits: English language
    • Search date: August, 2010 through February 15, 2011.
  • National Association of Children's Hospitals and Related Institutions (NACRHI) electronic mailing list.
Number of Source Documents

Not stated

Methods Used to Assess the Quality and Strength of the Evidence
Weighting According to a Rating Scheme (Scheme Given)
Rating Scheme for the Strength of the Evidence

Table of Evidence Levels

Quality Level Definition
1a† or 1b† Systematic review, meta-analysis, or meta-synthesis of multiple studies
2a or 2b Best study design for domain
3a or 3b Fair study design for domain
4a or 4b Weak study design for domain
5 or 5a or 5b Other: General review, expert opinion, case report, consensus report, or guideline

†a = good quality study; b = lesser quality study

Methods Used to Analyze the Evidence
Systematic Review
Description of the Methods Used to Analyze the Evidence

Not stated

Methods Used to Formulate the Recommendations
Expert Consensus
Description of Methods Used to Formulate the Recommendations

Not stated

Rating Scheme for the Strength of the Recommendations

Table of Recommendation Strength

Strength Definition
"Strongly recommended" There is consensus that benefits clearly outweigh risks and burdens (or vice-versa for negative recommendations).
"Recommended" There is consensus that benefits are closely balanced with risks and burdens.
No recommendation made There is lack of consensus to direct development of a recommendation.
Dimensions: In determining the strength of a recommendation, the development group makes a considered judgment in a consensus process that incorporates critically appraised evidence, clinical experience, and other dimensions as listed below.
  1. Grade of the body of evidence (see note above)
  2. Safety/harm
  3. Health benefit to patient (direct benefit)
  4. Burden to patient of adherence to recommendation (cost, hassle, discomfort, pain, motivation, ability to adhere, time)
  5. Cost-effectiveness to healthcare system (balance of cost/savings of resources, staff time, and supplies based on published studies or onsite analysis)
  6. Directness (the extent to which the body of evidence directly answers the clinical question [population/problem, intervention, comparison, outcome])
  7. Impact on morbidity/mortality or quality of life
Cost Analysis

A formal cost analysis was not performed and published cost analyses were not reviewed.

Method of Guideline Validation
Peer Review
Description of Method of Guideline Validation

Reviewed against quality criteria by 2 independent reviewers.

Recommendations

Major Recommendations

The strength of the recommendation (strongly recommended, recommended, or no recommendation) and the quality of the evidence (1a-5b) are defined at the end of the "Major Recommendations" field.

  1. It is recommended that caregiver-child attachment/bonding be evaluated to determine if there are concerns that are impacting the feeding and developmental interaction (Coolbear & Benoit, 1999 [3a]; Ward, Lee, & Lipper, 2000 [3a]; Benoit et al., 1997 [4a]).

    Note: There are distinct differences in attachment/bonding between mothers and children with failure to thrive (Coolbear & Benoit, 1999 [3a]; Ward, Lee, & Lipper, 2000 [3a]; Benoit et al., 1997 [4a]) and these differences in attachment were related to their child's nutritional status (Ward, Lee, & Lipper, 2000 [3a]).

    Level of evidence for attachment: moderate.

  2. It is recommended that caregiver-infant interaction be evaluated in infants and children admitted with non-organic failure to thrive. The findings from this additional evaluation will serve to guide additional supports the caregiver-child dyad might benefit from to support overall feeding interactions (Coolbear & Benoit, 1999 [3a]; Leitch, 1999 [3a]; Lindberg et al., 1996 [3a]; Wolke, Skuse, & Mathisen, 1990 [3a]; Ammaniti et al., 2004 [4a]; Feldman et al., 2004 [4a]; Hagekull, Bohlin, & Rydell, 1997 [4a]; Reilly et al., 1999 [4a]; Jung et al., 2007 [4a]; Drotar et al., 1990 [4a]).

    Note: There were significant differences found in maternal-child interactions in groups with children with failure to thrive and feeding disorders (Coolbear & Benoit, 1999 [3a]; Leitch, 1999 [3a]; Lindberg et al., 1996 [3a]; Wolke, Skuse, & Mathisen, 1990 [3a]; Ammaniti et al., 2004 [4a]; Feldman et al., 2004 [4a]; Hagekull, Bohlin, & Rydell, 1997 [4a]; Reilly et al., 1999 [4a]; Jung et al., 2007 [4a]; Drotar et al., 1990 [4a]). These differences were associated with reduced social-emotional and cognitive growth fostering behaviors and were also associated with differences in feeding.

    Level of evidence for caregiver-child interaction: moderate.

  3. It is recommended that oral-motor/feeding skills and caregiver-infant behaviors during feeding interaction be evaluated (Ramsay et al., 2002 [3a]; Wright, Parkinson, & Drewett, 2006 [4a]; Ammaniti et al., 2004 [4a]; Wright & Birks, 2000 [3a]; Ramsay, Gisel, & Boutry, 1993 [4a]; Mathisen et al., 1989 [4a]; Raynor & Rudolf, 1996 [4b]).

    Note: There are differences in feeding behaviors in children with failure to thrive and maternal response to feeding behaviors that may perpetuate difficulties with weight gain and caregiver-child interaction (Ramsay et al., 2002 [3a]; Wright, Parkinson, & Drewett, 2006 [4a]; Ammaniti et al., 2004 [4a]; Wright & Birks, 2000 [3a]; Ramsay, Gisel, & Bountry, 1993 [4a]; Mathisen et al., 1989 [4a]; Raynor & Rudolf, 1996 [4b]).

    Level of evidence for feeding behaviors: moderate.

  4. It is recommended that caregiver education regarding child cues, behavioral states, state modulation, and feeding be incorporated into plan of care with infants admitted with non-organic failure to thrive (Leitch, 1999 [3a]; Jung et al., 2007 [4a]).

    Note: Specific education regarding child cues, behavioral states, state modulation, and feeding results in increased sensitivity to cues and overall feeding and interaction (Leitch, 1999 [3a]; Jung et al., 2007 [4a]).

    Level of evidence for caregiver education: moderate.

Definitions:

Table of Evidence Levels

Quality Level Definition
1a† or 1b† Systematic review, meta-analysis, or meta-synthesis of multiple studies
2a or 2b Best study design for domain
3a or 3b Fair study design for domain
4a or 4b Weak study design for domain
5 or 5a or 5b Other: General review, expert opinion, case report, consensus report, or guideline

†a = good quality study; b = lesser quality study

Table of Recommendation Strength

Strength Definition
"Strongly recommended" There is consensus that benefits clearly outweigh risks and burdens (or vice-versa for negative recommendations).
"Recommended" There is consensus that benefits are closely balanced with risks and burdens.
No recommendation made There is lack of consensus to direct development of a recommendation.
Dimensions: In determining the strength of a recommendation, the development group makes a considered judgment in a consensus process that incorporates critically appraised evidence, clinical experience, and other dimensions as listed below.
  1. Grade of the body of evidence (see note above)
  2. Safety/harm
  3. Health benefit to patient (direct benefit)
  4. Burden to patient of adherence to recommendation (cost, hassle, discomfort, pain, motivation, ability to adhere, time)
  5. Cost-effectiveness to healthcare system (balance of cost/savings of resources, staff time, and supplies based on published studies or onsite analysis)
  6. Directness (the extent to which the body of evidence directly answers the clinical question [population/problem, intervention, comparison, outcome])
  7. Impact on morbidity/mortality or quality of life
Clinical Algorithm(s)

None provided

Evidence Supporting the Recommendations

References Supporting the Recommendations
Type of Evidence Supporting the Recommendations

The type of supporting evidence is identified and graded for each recommendation (see the "Major Recommendations" field).

Benefits/Harms of Implementing the Guideline Recommendations

Potential Benefits

Admission to an inpatient unit is costly. Incorporating caregiver education to increase feeding interaction may improve caregiver-infant interaction and overall weight gain. In addition, there may be a long term benefit to this education including increased attachment behaviors that support appropriate development.

Potential Harms

Not stated

Qualifying Statements

Qualifying Statements

This Best Evidence Statement addresses only key points of care for the target population; it is not intended to be a comprehensive practice guideline. These recommendations result from review of literature and practices current at the time of their formulation. This Best Evidence Statement does not preclude using care modalities proven efficacious in studies published subsequent to the current revision of this document. This document is not intended to impose standards of care preventing selective variances from the recommendations to meet the specific and unique requirements of individual patients. Adherence to this Statement is voluntary. The clinician in light of the individual circumstances presented by the patient must make the ultimate judgment regarding the priority of any specific procedure.

Implementation of the Guideline

Description of Implementation Strategy

An implementation strategy was not provided.

Institute of Medicine (IOM) National Healthcare Quality Report Categories

IOM Care Need
Getting Better
IOM Domain
Effectiveness

Identifying Information and Availability

Bibliographic Source(s)
Cincinnati Children's Hospital Medical Center. Best evidence statement (BESt). Parent-infant interaction and non-organic failure to thrive. Cincinnati (OH): Cincinnati Children's Hospital Medical Center; 2011 Jun 28. 7 p. [27 references]
Adaptation

Not applicable: The guideline was not adapted from another source.

Date Released
2011 Jun 28
Guideline Developer(s)
Cincinnati Children's Hospital Medical Center - Hospital/Medical Center
Source(s) of Funding

Cincinnati Children's Hospital Medical Center

Guideline Committee

Not stated

Composition of Group That Authored the Guideline

Group/Team Leader: Brenda K. Thompson, MA, CCC-SLP, Speech Pathologist II, Division of Speech-Language Pathology

Support Personnel: Mary Ellen Meier, MSN, RN, CPN, EBP Mentor, Center for Professional Excellence in Research and Evidence Based Practice

Financial Disclosures/Conflicts of Interest

Not stated

Guideline Status

This is the current release of the guideline.

Guideline Availability

Electronic copies: Available from the Cincinnati Children's Hospital Medical Center External Web Site Policy.

Print copies: For information regarding the full-text guideline, print copies, or evidence-based practice support services contact the Cincinnati Children's Hospital Medical Center Health James M. Anderson Center for Health Systems Excellence at EBDMInfo@cchmc.org.

Availability of Companion Documents

The following are available:

Print copies: For information regarding the full-text guideline, print copies, or evidence-based practice support services contact the Cincinnati Children's Hospital Medical Center Health James M. Anderson Center for Health Systems Excellence at EBDMInfo@cchmc.org.

Patient Resources

None available

NGC Status

This NGC summary was completed by ECRI Institute on November 18, 2011.

Copyright Statement

This NGC summary is based on the original full-text guideline, which is subject to the following copyright restrictions:

Copies of this Cincinnati Children's Hospital Medical Center (CCHMC) External Web Site Policy Best Evidence Statement (BESt) are available online and may be distributed by any organization for the global purpose of improving child health outcomes. Examples of approved uses of the BESt include the following:

  • Copies may be provided to anyone involved in the organization's process for developing and implementing evidence based care
  • Hyperlinks to the CCHMC website may be placed on the organization's website
  • The BESt may be adopted or adapted for use within the organization, provided that CCHMC receives appropriate attribution on all written or electronic documents; and
  • Copies may be provided to patients and the clinicians who manage their care

Notification of CCHMC at EBDMInfo@cchmc.org for any BESt adopted, adapted, implemented or hyperlinked by the organization is appreciated.

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