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

Tiffany, a 3-year-old girl, was referred to the developmental and behaviora l 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 an gry very quickly. Tiffany was identified at an early intervention program a s having mild to moderate developmental delays in pragmatic speech, gross a nd fine motor skills, and social interaction skills. Tiffany was born at 33 weeks gestation and was hospitalized for 10 days wit hout significant perinatal problems. She was readmitted at 2 months of age when she was diagnosed with gastroesophageal reflux, lactose intolerance, s leep apnea, and bradycardia. She was discharged with an apnea monitor. A se izure disorder was diagnosed at I year of age and reactive airway disease a t 2 years of age. At the time of the referral to the developmental and beha vioral pediatrics service, Tiffany was followed by multiple services, inclu ding cardiology, neurology, gastroenterology, psychology, and pulmonary. Ph armacologic therapies included albuterol and cromalyn inhalers, phenobarbit al, valproic acid, levocarnitine, ranitidine, and an inhaled steroid. She c ontinued to use the apnea monitor each night, although three sleep studies demonstrated a normal sleep pattern with no evidence of apnea or bradycardi a. A recent electroencephalogram was normal. Tiffany lives with her mother and maternal grandparents. Her mother is morb idly 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 relation ship 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 biolo gical and behavioral problems was implemented by admitting her to a collabo rative care unit at a children's hospital.