FEEDING AND EATING DISORDERS OF INFANCY AND EARLY CHILDHOOD

By Nirav PrajapatiZeny Vyas

Introduction

0Feeding disorder is characterized:- food refusal, - food avoidance, - active attempts to reject the feeding process,- delay in self-feeding.

Diagnostic and Statistical Manual of Mental Disorders (DSM-IV-TR) 0 includes three distinct disorders of feeding and

eating: 1) pica, 2) rumination disorder, and 3) feeding disorder of infancy or early childhood.

Additional maladaptive feeding patterns

0Cause impaired nutritional intake that are not included in the DSM-IV-TR include

0 (1) infantile anorexia, 0 (2) feeding disorder of caregiver infant reciprocity, 03) sensory food aversions, and 0 (4) posttraumatic feeding disorder.

PICA

0 In DSM-IV-TR, pica is described as persistent eating of nonnutritive substances for at least 1 month.

0The behavior must be developmentally inappropriate, not culturally sanctioned, and sufficiently severe to merit clinical attention.

PICA

0More frequently in young children than in adults.

0Among adults, certain forms of pica, including geophagia (clay eating) and amylophagia (starch eating), have been reported in pregnant women.

Epidemiology

0Pica is more common among children and adolescents with mental retardation.

0A survey of a large clinic population reported that 75 percent of 12-month-old infants and 15 percent of 2- to 3-year-old toddlers placed nonnutritive substances in their mouth.

0Pica appears to affect both sexes equally.

Etiology

0 lasts for several months and then remits.0A higher than expected incidence of pica seems to

occur in the relatives of persons with the symptoms.0Nutritional deficiencies have been postulated as

causes of pica.0A high incidence of parental neglect and deprivation

has been associated with cases of pica.

Diagnosis and Clinical Features

0Eating nonedible substances repeatedly after 18 months of age is usually considered abnormal.

0onset of pica is usually between ages 12 and 24 months

Diagnosis and Clinical Features

The most serious complications are :0 lead poisoning (usually from lead-based paint), 0 intestinal parasites after ingestion of soil or feces, 0anemia and zinc deficiency after ingestion of clay, 0 severe iron deficiency after ingestion of large

quantities of starch, and 0 intestinal obstruction from the ingestion of hair balls,

stones, or gravel.

DSM-IV-TR Diagnostic Criteria for Pica

1. Persistent eating of nonnutritive substances for a period of at least 1 month.

2. The eating of nonnutritive substances is inappropriate to the developmental level.

3. The eating behavior is not part of a culturally sanctioned practice.

4. If the eating behavior occurs exclusively during the course of another mental disorder (e.g., mental retardation, pervasive developmental disorder, schizophrenia), it is sufficiently severe to warrant independent clinical attention.

Pathology and Laboratory Examination

0No single laboratory test confirms or rules out a diagnosis of pica.

0Levels of iron and zinc in serum should always be determined; in many cases of pica, these levels are low and may contribute to the development of pica.

Pathology and Laboratory Examination

0Pica may disappear when oral iron and zinc are administered.

0A patient's hemoglobin level should be determined; if the level is low, anemia can result.

0 In children with pica, the lead level in serum should be determined; lead poisoning can result from ingesting lead.

Differential Diagnosis

0Differential diagnosis of pica includes iron and zinc deficiencies.

0Pica also can occur in conjunction with failure to thrive and several other mental and medical disorders, including schizophrenia, autistic disorder, anorexia nervosa, and Kleine-Levin syndrome.

Differential Diagnosis0Psychosocial dwarfism, a dramatic but reversible

endocrinological and behavioral form of failure to thrive, children often show bizarre behaviors, including ingesting toilet water, garbage, and other nonnutritive substances.

0A recent case report presented an association of pica with hypersomnolence, lead intoxication, and precocious puberty.

0 In certain regions of the world and among certain cultures, such as the Australian aborigines, rates of pica in pregnant women are reportedly high.

Course and Prognosis

0The prognosis for pica is usually good, because in children of normal intelligence it generally remits spontaneously within several months.

0 In childhood, pica usually resolves with increasing age; in pregnant women, pica is usually limited to the term of the pregnancy.

0 In adults who are mentally retarded,it lasts for years.

Treatment

0The first step in the treatment of pica is determining the cause whenever possible.

0Exposure to toxic substances, such as lead, must also be eliminated.

0No definitive treatment exists for pica.0Treatments emphasize psychosocial, environmental,

behavioral, and family guidance approaches.

Treatment

0When lead is present in the surroundings, it must be eliminated or rendered inaccessible or the child must be moved to new surroundings.

0The most rapidly successful : mild aversion therapy or negative reinforcement (e.g., a mild electric shock, an unpleasant noise, or an emetic drug).

0Positive reinforcement, modeling, behavioral shaping, and overcorrection treatment have also been used.

Rumination Disorder

Rumination Disorder0Rumination can be observed in developmentally normal infants

who put their thumb or hand in the mouth, suck their tongue rhythmically, and arch their back to initiate regurgitation.

0onset of the disorder generally occurs after 3 months of age.

Rumination Disorder0 rare in older children, adolescents, and adults.0 It varies in severity and is sometimes associated with medical

conditions, such as hiatal hernia, that result in esophageal reflux. In its most severe form, the disorder can be fatal.

0According to DSM-IV-TR, the disorder must be present for at least 1 month after a period of normal functioning

Epidemiology

0Rumination is a rare disorder. 0more common among male infants, and emerges

between 3 months and 1 year of age. 0 It persists more frequently among children and adults

who are mentally retarded. Adults with rumination usually maintain a normal weight.

Etiology

0Rumination and gastroesophageal reflux often coexist0 In those who are mentally retarded, the disorder may

be attributed to self-stimulatory behavior.0 Psychodynamic theories hypothesize various

disturbances in the mother-child relationship as a contributing factor in the development of rumination disorder

0Overstimulation and tension have also been suggested as causes of rumination

Diagnosis and Clinical Features

0 the essential feature of the disorder is repeated regurgitation and rechewing of food for a period of at least 1 month after a period of normal functioning.

0Partially digested food is brought up into the mouth without nausea, retching, disgust, or associated gastrointestinal disorder

0Usually, the infant is irritable and hungry between episodes of rumination

0Although spontaneous remissions are common, severe secondary complications can develop, such as progressive malnutrition, dehydration, and lowered resistance to disease.

Diagnostic Criteria for Rumination Disorder0A) Repeated regurgitation and rechewing of food for a

period of at least 1 month following a period of normal functioning.

0B)The behavior is not due to an associated gastrointestinal or other general medical condition (e.g., esophageal reflux).

0C)The behavior does not occur exclusively during the course of anorexia nervosa or bulimia nervosa. If the symptoms occur exclusively during the course of mental retardation or a pervasive developmental disorder, they are sufficiently severe to warrant independent clinical attention.

Pathology and Laboratory Examination

0No specific laboratory examination is pathognomonic of rumination disorder.

0Rumination disorder can be associated with failure to thrive and varying degrees of starvation.

0 Thus, laboratory measures of endocrinological function (thyroid function tests, dexamethasone-suppression test), serum electrolytes, and a hematological workup help determine the severity of the effects of rumination disorder

Differential Diagnosis

0Pyloric stenosis is usually associated with projectile vomiting and is generally evident before 3 months of age, when rumination has its onset.

0 Rumination has been associated with various mental retardation syndromes in which other stereotypic behaviors and eating disturbances, such as pica, are present.

0Rumination disorder can occur in patients with other eating disorders, such as bulimia nervosa.

Treatment

0Sometimes, an evaluation of the mother-child relationship reveals deficits that can be influenced by offering guidance to the mother.

0 Behavioral interventions, such as squirting lemon juice into the infant's mouth whenever rumination occurs, can be effective in diminishing the behavior.

0This practice appears to be the most rapidly effective treatment, with rumination reportedly eliminated in 3 to 5 days.

0Rumination may be decreased by the technique of withdrawing attention from the child whenever this behavior occurs.

0Treatments include improvement of the child's psychosocial environment, increased tender loving care from the mother or caretakers, and psychotherapy for the mother or both parents

0 If an infant is malnourished and continues to lose most nutrition through rumination, a jejunal tube may need to be inserted

0metoclopramide (Reglan),

0 cimetidine (Tagamet)

0antipsychotics such as haloperidol (Haldol) and thioridazine (Mellaril) have been cited to be helpful