Stopping Sam from starving

When a child refuses to eat, the effects can be devastating. Chris Mowbray reports on an experimental project that is helping anxious parents

The scene is only too familiar. The food has long gone cold in the dish. The owner of the stomach for which the meal was intended has not the smallest intention of eating it and this has been going on for half an hour.

Imagine, then, what it is like to have a small child who refuses to eat for days at a time. Now the remorseless weeping of the infant is accompanied by the real and justified anxiety of the parents and, for the mother particularly, guilt.

It is the overriding emotion shared by all parents in such a situation because they feel that they are failing and that the blotchy-faced, wailing child in the highchair is a living proof of that failure.

It was such an experience that came close to shattering the well-ordered life of Carol Maskrey and turned every mealtime into a nightmare. Her guilt was greatly intensified by the fact that she is a senior nurse.

"I used to dread meal-times. Sam would end up crying, having tantrums, sometimes throwing food about and moving away from the table," says Miss Maskrey, aged 35, who works in intensive care at the Bath Royal United Hospital in Wiltshire.

"We would force him to sit down again and that would make matters worse and everyone would end up in tears. Both I and my partner [Barry Taylor] used to get very argumentative with him and then with each other," she said.

As a professional "coper" in a demanding job, Carol was used to having instant answers to problems and being a support for her patients. Suddenly she found herself faced with a problem in her own life that she could not solve.

An estimated 185,000 children in Britain have serious feeding problems, which can threaten their health and, in extreme cases, lead to drip-feeding in hospital.

Sam was a normal, healthy baby who was raised and weaned without difficulties for the first 18 months of his life. Then he started showing an increasing reluctance to eat, which gradually got worse until he was eating virtually nothing.

"I was riddled with guilt because, as a nurse, I felt that I should know what to do - but I didn't. I also felt a lot of pressure from other people, especially from members of the family. I was given plenty of advice, but no one understood what we were going through.

"I was angry, frustrated and, above all, fearful for Sam's survival. We consulted a doctor and he was sympathetic, but he couldn't do anything because there was nothing medically wrong with Sam. He had not even lost a large amount of weight."

At the end of nearly three months, Sam went through an entire week without eating a single piece of solid food, and Carol and Barry, a psychiatric nurse, realised that the time had come for drastic action.

It was pure luck that they lived in Wiltshire and that their health visitor had heard of an experimental project launched in the county by the Children's Society aimed at dealing with just this problem. Staff from the society's Infant Support Project worked with the couple for nine months to find a way of breaking the cycle of self-imposed starvation, and slowly Sam started to eat again.

The type of condition that Sam experienced was first recognised six years ago by the Children's Society. It commissioned research from the University of Bath, which found that one child in every 20 under school age is "malnourished" because of food refusal that has no medical cause. The Infant Support Project was established in 1991 and has dealt with 170 cases. Its seven workers, based in two teams at Trowbridge and Swindon, can only help Wiltshire residents because it is funded by the county's Social Services Department and the Bath and Wiltshire Health Commission.

"Children's failure to thrive is usually envisaged as affecting only families who live in poverty or who neglect their children, but that is not the case," says Di Hampton, the project leader.

"It is a widespread problemaffecting anyone from aristocrats in stately homes to families living in the most ordinary streets. Nor is it simply caused by parental inexperience because, although it often does affect first-born children, we have also found it in the third or fourth child in a family.

"We never attach blame to anyone because it is the fault of neither parents nor child.''

She says that the solutions differ from child to child because the cause of the problem varies from family to family. The common factor is that when "something goes awry", the family falls into a spiral of difficult behaviour at meal-times.

The first thing the project worker assigned to a case does is to hear what the parents have to say about the problem and then to attend two or three main meal-times as an observer. If the parents agree, the scene is also recorded on video so they can watch how they and their child behave.

They are asked to keep a diary of exactly what their child eats at every meal in the minutest detail. This enables project staff to estimate the number of calories the child is in fact taking in and whether there is a serious shortfall.

The parents are then given ideas on how meal-times might be handled differently and are set targets. One way of breaking the pattern might be to include the child in parents' own meal-times rather than feeding the child separately. The project worker also shows parents how to handle their child's tantrums.

"The original cause of the problem can be something as simple as the child having difficulty reaching the table because the chair is too low or because the parents are sitting uncomfortably close to the child," Ms Hampton says.

"Occasionally, parents feel unable to stay the course because they are not prepared to make the changes we recommend, and we have to respect their wishes. They may believe, for example, that their child should not have a pudding if the main meal has not been eaten, but we do not see a pudding as a reward - only as a source of calories.

"Regrettably, the Children's Society is not in a position to extend the project around the country. We are looking to social services departments and health authorities to establish their own schemes, and we would be happy to advise them."

Carol Maskrey says: "The society pulled us back into gear, made us look at the problem objectively and helped us to draw up sensible guidelines for solving it.

"They suggested simple things such as always eating our meals with Sam instead of eating by ourselves later. They advised us always to praise him when he behaved well and to ignore bad behaviour.

"We have found a way of coping with it and I still use some of the techniques the society taught us. I do not really know what caused it because the whole thing is very complex, but I think Sam was a naturally faddy eater and the situation had something to do with the way we reacted to it."

Sam, now three-and-a-half, is still not a very good eater, but the society's treatment programme, which finished eight months ago, appears to have provided a lasting solution.