Author(s): Suzinne Pak-Gorstein, MD, PhD (R-3 Pediatric Resident); Elinor A. Graham MD, MPH, Medical Director of Harborview Children and Teen Clinic

Date Authored: July 1, 2004

Toddler receiving health care from professional.
Photo by World Bank Photo Collection (cc license)

Summary of Results

Problem Addressed: 

Around 2000, providers in the Harborview Children and Teen Clinic began to notice an increased frequency of developmentally and physical normal infants and toddlers of immigrant families presenting with a history of refusing to eat or take the breast or bottle for feeding. In some cases this was associated with a significant oral aversion resulting in poor weight gain and failure to thrive. Some patients had extensive evaluations for intestinal problems without definitive findings and included management with feeding tubes for an extended period of time. This quality improvement project was carried out to determine if there were common patterns found in the history and presentation of this apparent “epidemic” of non-organic failure to thrive and if underlying cultural factors might be influencing this condition. It was hoped that this information would lead to more effective intervention and prevention strategies.


1. Quantitative Study Design: Reviews of computerized charts of patients served at Harborview Children and Teen Clinic between the years 2002 and 2004 identified by ICD coding to have problem with growth (failure to thrive, poor weight gain, feeding problems) were undertaken. Emphasis was placed on those patients of Somali descent as this population was observed by medical providers to have a high prevalence of feeding problems. Standardized questionnaires were developed for data extraction. Human subjects review committee authorization was obtained from the University of Washington Human Subjects Division for this retrospective medical record review.

2. Qualitative data collection: Interviews were conducted with social workers, Somali interpreters, health care providers, community workers, WIC nutritionists, and Somali medical aides working at Harborview as well as Columbia Health Center, which services a large population of Somali families. Site visits at the Somali Community Center and REWA (Refugee Women’s Alliance) offices were carried out to interview staff members regarding their impressions of feeding problems and possible interventions among the Somali population in Seattle.

Sample: 45 charts were reviewed, and a sample of 20 patients were selected for further analysis based on identification of feeding problem and documented weight faltering. Charts of siblings and mothers were reviewed as well in order to glean further pertinent information.

Summary of Data Analysis Results:

A greater percentage of girls were identified to suffer from weight faltering as compared to boys (60% vs 40% respectively), although discussions with workers involved with the Somali community did not reveal any practices or beliefs to explain gender-specific differences in feeding practices.

Children were noted to have growth or feeding problems by a mean of 10 months of age with 65% of these children documented to have problems with oral aversion . Poor weight gain typically lasted for 12 months, although the duration ranged from 4 to 34 months.

Weight faltering, as measured by crossing of 2 major lines on the NCHS growth grids, were identified in 88% of the children., which typically occurred by 11 months of age. As another indicator of weight faltering, approximately half of the children did have measured body weights less than 5 th percentile for age at some time, which typically occurred by 9 months of age.

Height faltering, as an indicator of chronic poor nutrition, was observed in 17% of the children.

One-third of infants were reported to have significant illnesses prior to feeding and growth problems which included frequent ER visits for diarrhea/vomiting or URI symptoms, or frequent treatment for URI at the clinic. Most children (60%) had a diagnosis of atopy (asthma, reactive airway disease, eczema, allergies) being made at some time, and over half had family history of atopy as well.

As another important indicator for feeding problems, 50% of subjects possessed evidence of forced feedings. The high prevalence of forced feedings corresponds well with the impressions from health and community workers that the typical Somali mother, often stressed for various reasons and with great social pressure to have a ‘fat babies’, would be observed to force feed their infants and toddlers, wake them at night or at early morning for feeds, and occasionally feed their infants while the infant was sleeping.

A little over half of the children were born at the University of Washington, and 25% were born overseas. The families had immigrated to US sometime between 1993 and 2000. Although most were born at UW, the breastfeeding education that they may have received at delivery did not persist for very long. While all subjects began breastfeeding at birth, over half had received formula by 1.5 months of age. Workers familiar with the Somali community noted little interest among mothers to continue breastfeeding for fear that their breast milk would be inadequate to provide sufficient calories to produce a plump appearing infant. Frequent observations were made that a distant family member or Somali neighbor would make disparaging comments to the nursing mother that it appeared the baby was not receiving enough breast milk to grow.

The birth history of these infants was overall non-complicated, with average birth weight being 3.4 kilograms. The maternal age at birth ranged between 18 and 33, with the average age being 24.5 years.

In response to perceived problems with nutrition, 40% of infants had documented evidence of formula change, 40% were treated empirically for reflux, 35% actually underwent swallow study or evaluation, 85% were referred to nutrition, and 47% were referred to Community House Calls Program for home visiting. Approximately half of all patients had evidence of parental requests for Pediasure, a commercial formula heavily advertized on television and not available without provider authorization through the WIC nutrition program in which all families were enrolled.

As evidence of underlying and ongoing lack of nutrition education and feeding practices, 38% of the subjects also had siblings who had documented problems with feeding. Most strikingly, over half of subjects, with feeding and weight gain problems, had overweight family member (53%) that included either a sibling or parent. Again, this finding correlates well with the finding from the qualitative interviews that the Somali mothers not only had little concept of a balanced diet for their children or themselves, but actually desired to have their children appear fat as a social indicator of their success as mothers.

These families tend to have multiple stressors. It was found that 10% of mothers were single, 25% were separated, and only 47% had evidence of father being involved with the family. This does fit well with the overall impression from health care workers that the Somali father occasionally had remarried and was supporting a second family in another state. However, it is also noted that often mothers would misreport being single with the impression that more welfare aid would result. Hence, it is likely that these statistics are inflated; however, only by examining a control group of children not suffering from feeding or growth problems can this be delineated with any certainty.

It is clear that other maternal stressors exist in the form of caring for a high number of young children. The birth order of the subjects ranged from 1 to 6 with 50% of children being born 3 rd or more. As a sensitive indicator of child-care burden on the mother, who was the primary care provider in all subjects, the number of siblings aged less than 5 years of age was calculated. Over half of the subjects were born into families in which there were 1 or more siblings who were less than 5 years of age. Only 10% of these subjects had siblings over 11 years of age who could conceivably help with child care.

As further evidence of maternal stressor, 20% of mothers had evidence of symptoms of depression, 33% had visited their health care providers for chronic pain, and 75% had documented lack of family and/or community support. As most of the population were from low socioeconomic levels, it is not surprising that there existed documentation that at least 18% had some type of legal stressors, and 88% had income problems, and 43% had problems with housing.

Of the few subjects with information regarding maternal education, there was quite a bit of variation with a third having had received 1-5 years of education, another third received 6-12 years, and the remaining have received more than 12 years of education.

Although greatly limited by a small sample size, further simple stratified analysis did reveal some interesting results. Most of the infants with forced feedings were girls (58% girls vs 37% boys), while those with no documented evidence of forced feedings were boys (42% girls vs 63% boys). Also, a greater number of infants with oral aversions were from families in which lack of social support was noted (not statistically significant), a sibling was suffering from a medical problem (p=0.02), and in which a family member was identified to be overweight (p=0.08).

Implications for further study and interventions:

Further studies with a control group or with population-based design would be necessary to substantiate these exploratory analyses results. However, these preliminary results do reveal interesting and significant patterns in feeding problems that correlate well with qualitative impressions from community and health workers. High rates of obesity among the Somali immigrant population have been observed in general as well as among these families with infants suffering from poor weight gain. Hence, it is conceivable that social pressures to grow a plump baby, along with lack of basic nutritional concepts, multiple maternal stressors, and paucity of child care support all contribute to the practice of forced feedings. In turn, the forced feedings underlie the problem of poor weight gain with oral aversion and obesity with over feeding.

The success of any future interventions to address obesity as well as poor weight gain, would be better assured by including further ethnographic analysis of the cultural underpinnings related to body image and nutrition. Furthermore, future studies would be well-advised to target maternal nutrition education at an early stage in the growth of the infant.