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This clinical case-study of 50 infants suffering from NOFT (non-organic failure to thrive) and their parents supports the idea that the feeding problem is intimately related to parental disorders. We find a high rate (70%) of parental psychopathology (axis I diagnosis applying DSM-III-R) at the time of referral and a significant reduction (to 37%) during treatment of the infants and their parents. After a year only 12% of the parents were diagnosed with psychiatric disorders. In contrast personality disorders (axis II diagnosis applying DSM-III-R) show more stability and can be regarded as a trait variable, whereas the psychiatric disorders are of a more reactive nature. These conclusions may be influenced somewhat by the strictly hospital based design of our pilot study (infants and parents contacted only after clinical referral) and by inclusion only of firstborn infants. Nevertheless, they point to the psychopathology of parents as a main cause for non-organic failure to thrive. Psychopathological traits such as severe attachment behavior problems and primary bonding difficulties may have been latent and only became manifest due to the task of nurturing an infant for the first time. [ABSTRACT FROM AUTHOR]

Objective: This study was the first of its kind by assessing oral skills development during and after applying the "Graz Model" of tube weaning., Methods: This prospective case series study included data of 67 (35 females, 32 males, treated from March 2018 to April 2019) tube dependent children, who participated in the effective "Graz Model" of tube weaning. Parents filled out the standardized Pediatric Assessment Scale for Severe Feeding Problems (PASSFP) prior to and immediately after completion of the program. Paired sample t tests were conducted to examine pre-to-post changes in the children's oral skills., Results: The study showed that oral skills increased significantly during tube weaning PASSFP score of 24.76 (standard deviation, SD = 12.38) prior to versus 47.97 (SD = 6.98) after completion of the program. Furthermore, significant changes in their sensory and tactile perception and in their general eating behavior were observed. Children also showed reduced oral aversion symptoms and food pocketing, could enjoy their meals, and increased their food repertoire. Mealtime duration could be decreased, and parents were less anxious about their infants' intake and less frustrated because of their children's eating behavior., Conclusion: The results of this study demonstrated for the first time that tube dependent children can improve their oral skills significantly during and after their participation in the child-led approach of the "Graz model" of tube weaning., Competing Interests: The authors report no conflicts of interest., (Copyright © 2023 by European Society for European Society for Pediatric Gastroenterology, Hepatology, and Nutrition and North American Society for Pediatric Gastroenterology, Hepatology, and Nutrition.)

This article is based on the script of my farewell-speech at the University Hospital for Children and Adolescents in 2012. I served for 28 years as Head of the Psychosomatic and Psychotherapeutic unit as part of the Division for General Pediatrics, which was imbedded in the Department for Pediatrics. In these years I learned to focus on the triangle between doctor, parents, and child: To observe and recognize the verbal and non-verbal expressions of the children, the parents, and also his own is one of the doctor's key tasks. Within this process of acting and treating, practising medicine should become part of a commonly lived experience. This requires sensitivity as well as self-criticism and respect for the families, who entrust themselves to us. We have been able to implement this with children who suffer from eating disorders or tube dependency. As a continuation of the long-standing activity at the Medical University of Graz the spin-off firm Notube.com is presented, which offers treatment for children from 0 to 8 years of age suffering from eating disorders of all kinds. The experience of psychosomatic understanding and treatment acquired at the clinic can thus-even after retirement-continue to benefit hundreds of families. By establishing an outpatient clinic and by offering telemedical support to families this is a medicine that points the way to the future, especially in times of the Covid 19 pandemic., (© The Author(s) 2020.)

Background and Objectives: Children who become tube-dependent need specialized treatment in order to make the transition to oral feeding. Little is known about long-term effects of tube weaning programs. This study analyzes long-term effects (outcome, growth, and nutrition data) in a large sample of formerly tube-dependent children 1 to 6 years after participation in tube weaning programs, based on the "Graz model of tube weaning.", Methods: Parents of children who completed a tube weaning program between 2009 and 2014 (N = 564) were asked to complete a questionnaire on their child's growth and nutrition. Data was analyzed using SPSS V22.0 for Windows (SPSS, Chicago, IL)., Results: Response rate was 47.16% (N = 266). Seven children had died between completion of the program and the long-term follow-up. Two hundred and thirty-nine children (92.3%) were still exclusively orally fed 1 to 6 years after completion of the weaning program, 17 children (6.6%) were partially tube-fed. Three children were completely tube-fed (1.1%). Growth data showed no significant changes in zBMI (World Health Organization standards z values for body mass index) between completion of weaning and long-term follow-up. Provided data on nutrition of fully orally fed patients showed that most children (N = 162, 68%) were eating an age-appropriate diet, whereas a small percentage (N = 10, 4%) were fed with a high-caloric formula, a selective diet (N = 12, 5%), or a liquid/pureed diet (N = 55, 23%)., Conclusions: Many children who undergo a tube weaning program based on the "Graz model of tube weaning" are able to stay on full oral feeds in the years after completion of the wean without deterioration of growth.

Background: Enteral nutrition support (ENS) is a standard of care in all NICUs. As a result of long-term ENS, tube dependency can develop. Tube dependency is an inability to make the transition from tube to oral feeds despite the absence of medical reasons for ENS and might lead to symptoms like oral aversion and food refusal. This study aims to evaluate the prevalence of prematurity in a large cohort of tube dependent children., Methods: Prospectively collected data on tube dependent children who participated in a program based on the "Graz Model of tube weaning" from January 2009 to December 2015 was analysed quantitatively., Results: The study cohort consisted of 711 tube dependent children. Using ICD-10 classification, 378 children (53.2%) were born prematurely, with 103 extremely preterm infants (EPI; including children <29 weeks of gestational age and 275 preterm infants (PI; between 29 and 36+6 weeks of gestational age). More than half (55.4%) of all included patients were female, 51.8% were tube fed via a percutaneous endoscopic gastrostomy (PEG-) tube, 45.8% had a nasogastric (NG-) tube and 2.4% were tube fed via Jejunal (J-) tube. 66% of all EPI and 63.3% of all PI were tube fed since birth. 83.5% of all EPI had no additional diagnoses beyond their extreme prematurity. No differences in tube weaning outcomes between preterm and full term infants were shown., Conclusion: Prematurity, especially extreme prematurity, is associated with an increased risk for development of tube dependency. Preventive measures for this specific group of children should be considered.

A pre-post design including 22 females was used to evaluate the effectiveness of neurofeedback in the treatment of adolescent anorexia nervosa. Resting EEG measures and a psychological test-battery assessing eating behavior traits, clinical symptoms, emotionality, and mood were obtained. While both the experimental (n = 10) and control group (n = 12) received their usual maintenance treatment, the experimental group received 10 sessions of individual alpha frequency training over a period of 5 weeks as additional treatment. Significant training effects were shown in eating behavior traits, emotion regulation, and in relative theta power in the eyes closed condition. Although the results are limited due to the small sample size, these are the first empirical data demonstrating the benefits of neurofeedback as a treatment adjunct in individuals with anorexia nervosa.

Anorexia nervosa has been related to alterations in brain activity in terms of hyperactive EEG patterns. This case report illustrates the principles and results of a five-week neurofeedback treatment in a 29-year-old woman suffering from anorexia nervosa. A neurofeedback protocol to enhance alpha activity (8 - 12 Hz) was developed and conducted additionally to the standardized treatment for eating disorders in training sessions twice a week. Pre- and post-test measurements included resting state EEG measurements and a psychological test battery. The results show improvements from pre- to post-test in eating disorder psychopathology including psychological wellbeing, emotional competence, and eating behavior traits. In addition, a decrease in theta power (4 - 7 Hz), a well-known trait marker of anorexia nervosa, was measured. However, our data should be interpreted with caution because this is a single case study. Nevertheless, this report documents the practicability and method of neurofeedback as treatment adjunct in eating disorders from the clinical perspective. Although the use of neurofeedback in the treatment of anorexia nervosa is recommended in literature, empirical studies are still lacking. Randomized controlled trials to evaluate short- and long-term effects of neurofeedback are needed., (© Georg Thieme Verlag KG Stuttgart · New York.)

Background: The aim of this paper was to evaluate anthropometry and subcutaneous body fat on long-term enterally-fed children during tube weaning through a prospective cohort study with a pre-post-test design., Methods: The LIPOMETER, an optical device, was used to measure the thickness of subcutaneous adipose tissue (SAT) layers (in mm). The specification of 15 evenly-distributed body sites allows for a precise measurement of subcutaneous body fat distribution, known as subcutaneous adipose tissue topography (SAT-Top). Anthropometry and SAT-Top were determined in long-term enterally fed children in the pre- and post-tube weaning phase of a 3-week tube weaning program. The results of the SAT-Top measurements are presented on three levels: 15 body sites, four body regions and SAT-total., Results: The sample size consisted of 30 long-term tube-fed children (13 girls and 17 boys). Both sexes demonstrated a clear decrease of anthropometry and subcutaneous body fat during tube weaning. Girls lost -26.1 mm, -30.7%, (P=0.002) of their initial fat mass and boys -12.5 mm, -18.4%, (P<0.001). In general, girls had thicker SAT layers in all SAT-Top measurements and a higher reduction of subcutaneous body fat during the intervention. At the end of the tube weaning program girls and boys demonstrated similar results of subcutaneous body fat on the three observed levels: 15 body sites, four body regions and SAT-total. Upon discharge, total subcutaneous body fat of girls and boys was 58.9 mm and 55.5 mm, respectively., Conclusion: This study presents a basic documentation of changes in anthropometry and subcutaneous body fat during tube weaning and could potentially be used to help create guidelines for safe tube weaning.

Objectives: The present study highlights the occurrence of unintended adverse effects of enteral nutrition in infancy and childhood, as viewed and reported from a parental perspective., Methods: Quantitative analysis of a standardized questionnaire, filled out online by parents of enterally fed children. The questions focused on the nutritive and nonnutritive adverse effects, and other medical and biometric data. Data were collected from January 1, 2009 to December 31, 2013., Results: The study cohort consisted of 425 infants and children with different underlying medical conditions and an average age of 2.17 (median = 1.63) years. Nasogastric tubes were used in 44.2% of all the patients, and 55.8% of the children were fed by percutaneous endoscopic gastrostomy tube. Nearly all of the children have been tube-fed since birth. A total of 56.0% of all tube-fed children showed regular gagging and retching episodes, 50.0% vomited frequently, 14.8% experienced nausea, 7.5% experienced extreme nervous perspiration during the feeding, 45.2% showed loss of appetite, 5.2% experienced local granulation tissue, and 1.9% had other skin irritations. No significant correlations could be found between age, sex, medical diagnoses, type of feeding tube, feeding schedules (bolus or continuous), and parental and child's behavior regarding the feeding situation and duration of tube feeding., Conclusions: Enteral nutrition affects the child and the whole family system on more than just nutritional level. It is suggested that children and their families should be followed-up by health professionals periodically for nutritional optimization, growth documentation, and other aspects of tube management.

In the context of enteral feeding in children the influence on growth and the question of fat resorption is of great interest. We, therefore, measured the thickness of subcutaneous body fat in a sample of long-term enterally fed toddlers and healthy controls. In 33 long-term enterally fed toddlers (10 girls, 23 boys) and 275 healthy controls (128 girls, 147 boys) subcutaneous body fat was measured by means) of the optical device Lipometer. All participants were divided into three age groups (infants, toddlers and children). The height (p=0. 014, -11.7 cm, -12.5%) and weight (p=0.012, -3.0 kg, -21.9%) of long-term enterally fed female toddlers were significantly lower than healthy controls, while male enterally fed toddlers had lower values in all anthropometric measures compared to healthy controls: height (p=0.003, -8.0 cm, -8.4%), weight (p<0.001, -3.5 kg, -24.8%), BMI (p=0.004, -1.3 BMI), Z-score BMI (p=0.001, -1.2 Z-score BMI), upper arm circumference (p<0.001, -1.6 cm, -10.1%) and waist circumference (p<0.001, -6.2 cm, -12.5%). Tube fed toddlers showed a similar body fat distribution when compared to healthy controls, but demonstrated significantly lower values of anthropometric measurements. The results indicate that long-term enterally fed children have ample fat stores but lack physical development.

Current literature suggests an increased attentional bias toward food stimuli in eating-disordered individuals compared to healthy controls. In line with these research efforts, the present study aims to investigate the processing of food stimuli (enriched by emotional stimuli) between patients diagnosed for anorexia nervosa (AN) and healthy controls by means of electroencephalography. Twenty-two female adolescents (eleven AN patients vs. eleven healthy controls) were investigated. Positive event-related potentials "P300" and "late positive potential" (LPP) reflecting attentional processing (caused by motivationally relevant stimuli) were investigated during passive viewing of the food cue picture stream. This method was used for the first time in a sample of individuals with AN. As a main result, AN patients exhibited a higher amount of attentional bias in P300 and LPP, while watching food stimuli. Moreover, AN patients rated food stimuli as less pleasant. For a conclusion, there is substantial evidence pointing to an abnormal attentional brain reactivity to food pictures in AN. Therefore, food stimuli seem to be more motivationally relevant for AN patients than for healthy controls. By broadening existing knowledge, these findings might bear some implications for the treatment for AN. However, further research is recommended in order to confirm the results coming from rather limited data.

Numerous sexual disorders, which were previously in the foreground, have in fact disappeared due to our changing society. This broad field today includes repressed sexual disorders of adolescents who cannot or do not want to go along with the changes either for familial or personal reasons. Immigrant background, religious beliefs, and peer pressure may play a role here. As a dialog partner for adolescents, the competent physician must take into consideration the interplay of sexual desire, ethical beliefs, morals, and parental expectations, which requires interest, intuition, and tact.

This study investigates the outcome of an intervention program to establish oral feeding after prolonged tube feeding in children. The intervention is based on supervised reduction of enteral formula within a few days supported by a 3-week program of speech therapy, occupational therapy, psychoanalytically based eating therapy, physical therapy, psychodynamic coaching, and nutritional counseling of the infant and his or her parents. Two hundred twenty-one cases were included in this study. All patients had been severely ill or were handicapped and had been exclusively fed by tube for most of their lives. The major outcome variable was complete discontinuation of tube feeding with sufficient oral feeding after treatment, defined as the child's ability to sustain stable body weight by self-motivated oral feeding. Two hundred three patients (92%) were completely fed orally after treatment. Tube feeding was discontinued completely within 8 days in mean, and mean in-patient treatment time was 21.6 days. The current method can be used by a trained and experienced team to wean tube-dependent children from prolonged tube feeding. Tube weaning should be addressed from the beginning of tube feeding in all children who are expected to restore oral feeding after the phase of nutritional stabilization. Since successful programs are rare, we were motivated to present our results of this elaborate program in this article., (Copyright © 2010 Michigan Association for Infant Mental Health.)

Two children were weaned from long-term tube feeding after liver transplant because of Alagille syndrome. The children were successfully weaned, one in seven days and the other in 13 days, using our standard and highly specialized intensive treatment protocol. Normal feeding behavior and stabilization of body weight were established. Children fed by long-term enteral tubes can be weaned from enteral feeding even after a long period of treatment. The return to age-appropriate self-feeding should be introduced as early as possible. Our weaning program time is brief and effective and can be recommended generally to improve quality of life and withhold unintended side-effects of enteral nutrition.

The case history of a 15 1/2-year-old boy is presented who suffers from screaming fits during the night and epilepsia. The problem has existed since he was eight. He lives alone with his mother in a "partner-like" relationship. The previous diagnosis, namely epilepsy, has masked any possible psychodynamic element. Our diagnostic instruments were: 1. Standardized diagnostics with DSM III-R; 2. psychoanalytically oriented psychodiagnostics; 3. long term EEG-video-monitoring, which eventually succeeded in differentiating his multiple symptoms. Using these methods we were able to differentiate a sleep disorder (somnambulism) from his grandmal epilepsy. We changed his anticonvulsive pharmacological therapy and introduced an individual psychotherapy ("Katathymes Bilderleben"). This kind of psychotherapy is applied for the first time as a therapy for somnambulism. By using this therapeutic concept we cured our patient from his symptoms.

Feeding baby's is mostly a gratifying activity for mothers. But when difficulties arise, they can develop into a serious pediatric issue: The so-called non organic failure to thrive (NOFT). In these cases the feeding difficulties are one aspect of the disturbed relation between the mother and her child. Conventional pediatric therapy often fails to achieve weight gain, the babies seem emotionally disturbed and upset during all feeding procedures. Phenomenologically oriented documentation of the quality and type of the diadic interactions allow a diagnosis of the relationship itself and cleans up with terms like "unreliable" mother or "difficult" babies. We present the first review of theoretical background, diagnostic nomenclature and therapeutic concepts in german and wish to address colleagues with a interest in psychotherapeutic methods.

Psychosomatic reactions and disturbancies occur frequently in adolescence. Their dramatic presentation is characteristic for the inner feeling of uniqueness, instability and loneliness of this phase of life. Grownups seem far away and unable to understand what is really going on. The pediatrician being consulted needs special interest and knowledge of the specific dynamics of adolescence and should remember his own youth. He should avoid involving the patient into unnecessary and harmful physical examinations, because they tend to aggravate and fixate the symptom. He must succeed as competent listener without reminding the youngster of the wellment advises of parents and teachers. Often he will feel entangled into a voyage through a jungle of emotions and somatic signals where his function will be to guide and accompany his young patient safely out into the light of adulthood. This paper presents a pediatric and psychodynamic approach to some frequent psychosomatic disorders of adolescence. It discusses Anorexia Nervosa, Bulimia Nervosa, Somatisation Syndrome, Conversion Syndrome, suicidal attempt and physical conditions affected by psychological factors.

The results of a standardized evaluation of the occurrence of depression in a group of 34 children suffering from cancer are presented. The children (13 male, 21 female) were admitted to the oncological unit of the Department of Pediatrics at the University of Graz, Austria, during a 14 months-course (January 1987-March 1988). We rated each child 4 times in 4 weekly intervals after admission and start of induction chemotherapy. To access the occurrence and severity of depression and to monitor progress during treatment we performed a psychiatric interview and also applied the psychiatric rating scale CDRS (Children's Depression Rating Scale) by Poznanski et al 1979 and SCMDD (Self-Report Symptom Checklist for Major Depressive Disorders) by Kashani et al 1985 derived from DSM III. 340 diagnostic ratings were performed by 3 raters; two of them were psychotherapeutically trained pediatricians (M. D., P. J. S.) and one psychologist (L. W.). A "clearcut" depression was found in 25 of the 340 ratings i.e. in 6 of the 34 children, demonstrating that the occurrence of depression in pediatric cancer patients was lower than primarily assumed.

We present the second description of an early diagnosed state of Hallervorden-Spatz disease (HSD) verified clinically and by means of magnet resonance imaging. Since the magnet resonance shows HSD specific transformations brain biopsy can be relinquished. In our case the early confirmation of a neurodegenerative disease (versus the presumption of a severe adjustment disorder as the case was presented) brought much relief in respect of the feelings of guilt to the family, although the long term prognosis is poor. The distinction between neurodegenerative diseases, demyelinisating diseases and HSD was possible considering the clinical signs and using the magnet resonance, which showed various pigments within the globus pallidum.

37 children (aged 4 1/2-15 1/2 years) with encopresis were seen at the psychosomatic outpatient unit of the university children's hospital of Graz in the course of two years, comprising 1.8% of all our outpatients of that time (n = 2037). They had been referred to us by pediatricians general practitioners, welfare institutions and the local children's surgical hospital. Based an our observations and data-analysis of this heterogenic group we would like to suggest a subdivision of the new classification group of "elimination disorders" (307.70/307.60 DSM III-R) into three main subgroups; according to the use of the fifth digit in the DSM III-R (e.g. mood disorders 296.xx) we define: 307.71: primary infantile encopresis (group I); 307.72: primary reactive encopresis (group II a); 307.73: secondary reactive encopresis (group II b); 307.74: late "neurotic" encopresis (group III); 307.70: not otherwise specified NOS. Moreover, we hope to draw attention to the specific psychodynamics of this functional disorder, since we believe this to be a fundamental prerequisite for any successful therapeutic intervention.

We present outcome data of 171 children with psychosomatic and child-psychiatric disorders and discuss the pros and cons of two standardized multiaxial diagnostic systems (DSM III and the Multiaxial System of Rutter 1975). Results and arguments were considered until a clearcut choice fell for the DSM-III. As a major conclusion we introduce the BAT-Index, a factor derived by comparing the psychosocial stressors (Axis 4 DSM III) to the highest level to adaptive functioning past year (Axis 5 DSM III) which can be helpful in estimating the to be expected changes and complications in therapeutic settings and gives us a good prognostic assessment of the patient.