Published on March 20, 2014
FEEDING AND EATING DISORDERS OF INFANCY AND EARLY CHILDHOOD
Introduction 0 Feeding 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 0 Cause 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, 0 3) 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. 0 The behavior must be developmentally inappropriate, not culturally sanctioned, and sufficiently severe to merit clinical attention.
PICA 0 More frequently in young children than in adults. 0 Among adults, certain forms of pica, including geophagia (clay eating) and amylophagia (starch eating), have been reported in pregnant women.
Epidemiology 0 Pica is more common among children and adolescents with mental retardation. 0 A 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. 0 Pica appears to affect both sexes equally.
Etiology 0 lasts for several months and then remits. 0 A higher than expected incidence of pica seems to occur in the relatives of persons with the symptoms. 0 Nutritional deficiencies have been postulated as causes of pica. 0 A high incidence of parental neglect and deprivation has been associated with cases of pica.
Diagnosis and Clinical Features 0 Eating nonedible substances repeatedly after 18 months of age is usually considered abnormal. 0 onset 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, 0 anemia 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 0 No single laboratory test confirms or rules out a diagnosis of pica. 0 Levels 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 0 Pica may disappear when oral iron and zinc are administered. 0 A 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 0 Differential diagnosis of pica includes iron and zinc deficiencies. 0 Pica 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 Diagnosis 0 Psychosocial 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. 0 A 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 0 The 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 0 The first step in the treatment of pica is determining the cause whenever possible. 0 Exposure to toxic substances, such as lead, must also be eliminated. 0 No definitive treatment exists for pica. 0 Treatments emphasize psychosocial, environmental, behavioral, and family guidance approaches.
Treatment 0 When lead is present in the surroundings, it must be eliminated or rendered inaccessible or the child must be moved to new surroundings. 0 The most rapidly successful : mild aversion therapy or negative reinforcement (e.g., a mild electric shock, an unpleasant noise, or an emetic drug). 0 Positive reinforcement, modeling, behavioral shaping, and overcorrection treatment have also been used.
Rumination Disorder 0 Rumination 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. 0 onset of the disorder generally occurs after 3 months of age.
Rumination Disorder 0 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. 0 According to DSM-IV-TR, the disorder must be present for at least 1 month after a period of normal functioning
Epidemiology 0 Rumination is a rare disorder. 0 more 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 0 Rumination and gastroesophageal reflux often coexist 0 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 0 Overstimulation 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. 0 Partially digested food is brought up into the mouth without nausea, retching, disgust, or associated gastrointestinal disorder 0 Usually, the infant is irritable and hungry between episodes of rumination 0 Although spontaneous remissions are common, severe secondary complications can develop, such as progressive malnutrition, dehydration, and lowered resistance to disease.
Diagnostic Criteria for Rumination Disorder0 A) Repeated regurgitation and rechewing of food for a period of at least 1 month following a period of normal functioning. 0 B)The behavior is not due to an associated gastrointestinal or other general medical condition (e.g., esophageal reflux). 0 C)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 0 No specific laboratory examination is pathognomonic of rumination disorder. 0 Rumination 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 0 Pyloric 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. 0 Rumination disorder can occur in patients with other eating disorders, such as bulimia nervosa.
Treatment 0 Sometimes, 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. 0 This practice appears to be the most rapidly effective treatment, with rumination reportedly eliminated in 3 to 5 days.
0 Rumination may be decreased by the technique of withdrawing attention from the child whenever this behavior occurs. 0 Treatments 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
0 metoclopramide (Reglan), 0 cimetidine (Tagamet) 0 antipsychotics such as haloperidol (Haldol) and thioridazine (Mellaril) have been cited to be helpful
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