Young infants spend between a half and a third of their waking time feeding, making the outcome of the feeding situation important, not just in terms of nutrition, but also in the establishment of the relationship between the caregiver and the child (Wolke, Skuse and Reilly, 2006). Feeding problems are common amongst infants and young children. The reported prevalence of feeding disorders is 5-10% (Lindberg et al, 2006), with 20-25% of parents reporting feeding problems at some time in the first two years (Wolke, 2003). Considering that there were 669,601 live births inEnglandandWalesin 2006 (Office of National Statistics) up to 167,000 will experience some form of feeding problem in their first two years of life. The most prevalent feeding problem is refusal to eat, with only 14% of cases being linked to some form of physicaldisorder (Wolke, 1994).

One serious consequence of feeding problems in young children can be failure to thrive, or growth faltering, as it is coming to be known. Failure to thrive has been defined as the rate of weight gain being significantly below the weight gain on population standards and persisting for more than three months (Wolke, Skuse and Reilly, 2006). The prevalence of failure to thrive is 3-5 % of the population in Western countries (Corbett and Drewett, 2004). A conditional weight gain criterion has been used to define growth faltering, which takes weight and gestational age at birth into account to identify the slowest 5% of infants to gain weight ( Drewett et al, 2004; Blair et al, 2004; Emond et al, 2007). Corbett and Drewett (2004) conducted a review and meta-analysis and concluded that "failure to thrive in infancy is associated with adverse intellectual outcomes sufficiently large to be of importance at a population level".

However, the majority of those with feeding disorders do not fail to thrive (Lindberg et al, 2006), and feeding problems and failure to thrive are separate phenomena (Rydell and Dahl, 2005). It is necessary to look at the long-term consequences of feeding problems where there is no failure to thrive as distinguished from any consequences that are the result of the severity of the effects on growth. There are a few studies that have looked at the long-term outcome of feeding problems with and without growth faltering (e.g. Lindberg et al, 2006; Dahl et al, 1994; Rydell and Dahl, 2005; Marchi and Cohen, 1990; Kotler et al, 2001). However, the community samples have been usually small and most studies are based on clinically referred populations more likely to suffer multiple regulatory problems (Wolke, 2003; Papousek et al, 2008).

Previous work using ALSPAC

Motion et al (2001) reported on persistent early feeding difficulties and subsequent growth and early development outcomes using the ALSPAC data. Persistent difficulties were defined by reference to weak sucking at 4 weeks and great difficulties feeding at 4 weeks, 6 months and 15 months of age. Persistent feeding difficulties were associated with significant developmental impairments in motor, language and behaviour at 18 months, with weight gain being a continuing problem. Behavioural outcomes were temper tantrums and frequent meal refusal at 18 months.

Emond et al (2005) investigated the relationship between feeding symptoms and early growth faltering in ALSPAC. They reported that growth faltering between birth and 8 weeks was associated with infant sucking problems regardless of the type of milk, and after 8 weeks of age the most significant post-natal influences on growth were the efficiency of feeding, the ability to successfully take solids, and the duration of breastfeeding. A subsequent study (Emond et al 2007) found that growth faltering in infancy was associated with persisting deficits in IQ at 8 years. Multivariate analysis showed that reduction in IQ was linked with growth faltering before 8 weeks and associated feeding problems.

There is a surprising paucity of investigations of the long-term consequences of feeding problems on behavioural outcome and continued eating disorder in childhood (Micali, 2005). Little is known about whether the chronicity of feeding problems increases the risk for other behavioural maladaptations. No previous study has taken into account whether any long-term consequences of feeding difficulties may be impacted by co-morbidity with other infant problems such as crying or sleeping problems (Wolke et al. 1995; Wolke et al., 2002;Von Hofacker & Papousek, 1998). ALSPAC provides an excellent dataset for investigating the longitudinal trajectories of feeding problems, and the interaction with other problems, both those intrinsic to the infant and factors in the family and wider environment.

The research questions to be addressed by the proposed project are:

1. What is the impact of feeding problems in infancy and the toddler years on the development of behavioural and psychiatric problems in childhood? Do early feeding problems predict later eating disorder?
2. Are the long-term consequences due to feeding problem behaviour, or are these a consequence of multiple regulatory problems in infancy (i.e. crying, sleeping problems) or social and family problems?