Feeding Disorder of Infancy or Early Childhood

Definition and Introduction

Image of a child crying, while refusing food.
Image courtesy of Being Happy Mom Opens in new window

Feeding disorder of infancy, a broadly defined maladaptive pattern of eating behaviors in infants, features the interactive process between caregiver and infant. This disorder has variable components that range from food refusal, food selectivity, eating too little, food avoidance, and delayed self-feeding.

Table X1 | DSM-IV-TR Diagnostic Criteria for Feeding Disorder of Infancy or Early Childhood
A.Feeding disturbance as manifested by persistent failure to eat adequately with significant failure to gain or significant loss of weight over at least 1 month.
B.The disturbance is not due to an associated gastrointestinal or other general medical condition (e.g., esophageal reflux).
C.The disturbance is not better accounted for by another mental disorder (e.g., rumination disorder) or by lack of available food.
D.The onset is before age 6 years.
Source: American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders, 4th ed. Text rev. Washington, DC: American Psychiatry Association

According to DSM-IV-TR Opens in new window, feeding disorder of infancy or early childhood is a persistent failure to eat adequately, reflected in significant failure to gain weight or in significant weight loss over 1 month.

The symptoms are not better accounted for by a medical condition or by another mental disorder and are not caused by lack of food (see Table X1). The disorder has its onset before the age of 6 years.

Children with feeding disorders have been found to display less affectionate touch, more negative touch, and more rejection of mother’s touch than children without feeding problems. In addition, more rejecting maternal responses to the child’s touch have also been observed, and children with feeding disorders are more often positioned out of reach of their mothers’ arms.

Children with feeding disorders are often withdrawn, and touch is diminished during the entire feeding process compared with other children. It is likely that patterns of proximity and touch between mothers and infants during feeding may serve as an index of risk for future feeding difficulties and potential growth failure.

Epidemiology

It is estimated that between 15 and 35 percent of infants and young children have transient feeding difficulties. A recent survey of feeding problems in nursery school children revealed a prevalence of 4.8 percent with equal gender distribution.

Children with feeding problems exhibited more somatic complaints and mothers of affected infants exhibited increased risk of anxiety symptoms. Data from community samples estimate a prevalence of failure to thrive syndromes in approximately 3 percent of infants with approximately half of those infants exhibiting feeding disorders.

Differential Diagnosis

Feeding disorder of infancy must be differentiated from structural problems with the infants’ gastrointestinal tract that may be contributing to discomfort during the feeding process.

Because feeding disorders and organic causes of swallowing difficulties often coexists, it is important to rule out medical reasons for feeding difficulties.

A recent study of videofluoroscopic evaluation of children with feeding and swallowing problems revealed that clinical evaluation was 92 percent accurate in identifying those children at increased risk of aspiration. This type of evaluation is necessary before psychotherapeutic interventions in cases where a medical contribution to feeding problems is suspected.

Course and Prognosis

Most infants with feeding disorders exhibit symptoms within the first year of life and, with appropriate recognition and intervention, do not go on to develop failure to thrive. When feeding disorders have their onset later, in children 2 to 3 years of age, growth and development can be affected when the disorder lasts for several months. It is estimated that about 70 percent of infants who persistently refuse food in the first year of life continue to have some feeding problems during childhood.

Treatment

Treatments for feeding disorders need to be individualized and include interventions aimed at the infant, the mother, and most often targeting the interactions between the infant and mother, or caregiver.

If an infant tries before ingesting an adequate amount of nutrition, it may be necessary to begin treatment with the placement of a nasogastric tube for supplemental oral feedings.

On the other hand, if the mother or caregiver is unable to participate in the intervention, it may be necessary to include additional caregivers to contribute to feeding the infant. In rare cases, an infant may require hospitalization until adequate nutrition on a daily basis is accomplished.

Most interventions for feeding disorders are aimed at optimizing the interaction between the mother and infant during feedings, and identifying any factors that can be changed to promote greater ingestion. The mother is helped to become more aware of the infant’s stamina for length of individual feedings, the infant’s biological regulation patterns, and when the infant is fatigued, with a goal of increasing the level of engagement between mother and infant during feeding.

A transactional model of intervention has been proposed by Irene Chatoor, M.D., a leading expert in the field, for infants who exhibit the “difficult” temperamental traits of emotional intensity, stubbornness, lack of hunger cues, irregular eating and sleeping patterns, strong will in refusing to eat a sufficient amount, and who are intensely interested in noneating exploration of their environment.

The treatment includes education for the parents regarding the temperamental traits of the infant, exploration of the parents’ anxieties about the infant’s nutrition, and training for the parents regarding changing their behaviors to promote internal regulation of eating in the infant. Parents are encouraged to feed the infant on a regular basis at 3- to 4-hour intervals, and offer only water between meals.

The parents are trained to deliver praise to the infant for any self-feeding efforts, regardless of the amount of food ingested. Furthermore, parents are guided to limit any distracting stimulation during meals and give attention and praise to positive eating behaviors rather than intense negative attention to inappropriate behavior during meals.

This training process for parents is recommended to be done in an intense manner within a short period of time. Many parents are able to facilitate improved eating patterns in the infant in a short period of time.

For older children with severe feeding disorders resulting in failure-to-thrive syndromes, hospitalization and nutritional supplementation is necessary before optimal psychotherapeutic interventions.

Medication is not a standard component of treatment for feeding disorders, although several anecdotal reports have suggested benefit with adjunctive pharmacologic agents.

One recent case report indicated that several preadolescents with failure-to-thrive and feeding disorders who received enteral nutritional interventions and were comorbid for anxiety and mood symptoms, the addition of risperidone (Risperdal) was observed to be associated with an increase in oral intake and accelerated weight gain.

See also:
  1. Araujo CL, Victora CG, Hallal PC, Gigante DP. Breastfeeding and overweight in childhood: Evidence from the Pelotas 1993 birth cohort study. Int J Obes. 2005;30(3):500.
  2. Berger-Gross P, Colettoi DJ, Hirschkorn K, Terranova E, Simpser EF. The effectiveness of risperidone in the treatment of three children with feeding disorders. J Child Adolesc Psychopharmacol. 2004:14:621.
  3. Chatoor I, Feeding and eating disorders of infancy or early childhood. In: Sadock BJ, Sadock VA, eds. Kaplan & Sadock’s Comprehensive Textbook of Psychiatry. 8th ed. Vol. 2. Baltimore: Lippincott Williams & Wilkins; 2005:3217.
  4. Cohen E, Rosen Y, Yehuda B, Iancu I. Successful multidisciplinary treatment in an adolescent case of rumination. Isr J Psychiatry Relat Sci. 2004;41:222.
  5. DeMatteo C, Matovich D, Hjartarson A. Comparison of clinical and videofluoroscopic evaluation of children with feeding and swallowing difficulties. Dev Med Child Neurol. 2005;47:149.
  6. Esparo G, Canals J, Ballespi S, Vinas F, Domenech E. Feeding problems in nursery children: prevalence and psychosocial factors. Acta Pediatr 2004;93:663.
  7. Feldaman R, Keren M, Gross-Rozval O, Tyano S. Mother-child touch patterns in infant feeding disorders: Relation to maternal, child, and environmental factors. J Am Acad Child Adolesc Psychiatry. 2004;43:1089.
  8. Hughes SO, Anderson CB, Power TG, Micheli N, Jaramillo S, Nicklas TA. Measuring feeding in low-income African-American and Hispanic parents. Appetite. 2006;46(2):215.
  9. Jacobi C, Agras WS, Bryson S, Hammer LD. Behavioral validation, precursors, and concomitants of picky eating in childhood. J Am Acad Child Adolesc Psychiatry. 2003;42:76.
  10. Lewinsohn PM, Holm-Denoma JM, Gau JM, Joiner TE Jr. Striegel-Moore R, Bear P, Lamoureux B. Problematic eating and feeding behaviors of 36-month old children. Int J Eat Disord. 2005;38(3):208-219.
  11. Linscheid TN. Behavioral treatments for pediatric feeding disorders. Behav Modif. 2006;30:6-223.