Feeding problems, sleep disturbances, and negative behaviors in a toddler

Tiffany, a 3-year-old girl, was referred to the developmental and behavioral pediatrics service for evaluation of significant and persistent negative behaviors associated with refusal to eat at meal time and constant snacking during the past 3 months. She lost 2 pounds, but her weight for her height was at the 50th percentile. Her mother indicated that Tiffany had frequent night awakenings (>10) and late sleep onset (between 12:00 and 1:00 a.m.). Her mother described her as being "easily frustrated," getting upset and angry very quickly. Tiffany was identified at an early intervention program as having mild to moderate developmental delays in pragmatic speech, gross and fine motor skills, and social interaction skills. Tiffany was born at 33 weeks gestation and was hospitalized for 10 days without significant perinatal problems. She was readmitted at 2 months of age when she was diagnosed with gastroesophageal reflux, lactose intolerance, sleep apnea, and bradycardia. She was discharged with an apnea monitor. A seizure disorder was diagnosed at 1 year of age and reactive airway disease at 2 years of age. At the time of the referral to the developmental and behavioral pediatrics service, Tiffany was followed by multiple services, including cardiology, neurology, gastroenterology, psychology, and pulmonary. Pharmacologic therapies included albuterol and cromalyn inhalers, phenobarbital, valproic acid, levocarnitine, ranitidine, and an inhaled steroid. She continued to use the apnea monitor each night, although three sleep studies demonstrated a normal sleep pattern with no evidence of apnea or bradycardia. A recent electroencephalogram was normal. Tiffany lives with her mother and maternal grandparents. Her mother is morbidly obese with a history of asthma and depression. She was infertile for a 10-year period, which she attributed to the stress associated with living with an abusive man. Tiffany was the result of a subsequent, brief relationship with another man; she has not had contact with her father. Her mother is a licensed practical nurse who has not worked as a nurse since Tiffany's birth. An interdisciplinary treatment approach to Tiffany's multiple biological and behavioral problems was implemented by admitting her to a collaborative care unit at a children's hospital.