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Difficulties in the Management of Sleep and Eating Disorders 0021-7557/03/79-Supl.1/S43 Jornal de Pediatria - Vol.79, Supl.1 , 2003 S43 Jornal de Pediatria Copyright © 2003 by Sociedade Brasileira de Pediatria REVIEW ARTICLE Difficulties in the management of sleep and eating disorders Isabel R. Madeira,1 Leda A. Aquino2 Abstract Objective: To update the knowledge about anorexia and insomnia in childhood. Sources: Search of Medline database, including articles from1997 to 2002. The key words anorexia, feeding disorders, insomnia, sleep disorders and childhood were used. Some textbooks were also included. Summary of the findings: Definition, main types and causes, diagnosis and treatment of anorexia and insomnia are presented. Conclusions: Anorexia and insomnia are prevalent in childhood. The former is a much more frequent complaint in pediatric visits. The diagnosis is almost always based solely on a good history. Both conditions are generally behavioral and reflect the family dynamics. They are preventable and treated at the primary care level, based upon simple strategies, although sometimes not easily accepted by the patients. J Pediatr (Rio J) 2003;79 Suppl 1:S43-S54: Childhood, anorexia, feeding disorders, insomnia, sleep disorders. Introduction Eating and sleep disorders are quite common in Pediatrics Anorexia, difficulty in falling asleep, and night wakings and may be a natural part of developmental stages in are usually behavioral disorders, provoked by family children. dynamics,1,2,4,7 which are amenable to prevention and The “my-child-won’t- eat” complaint is nearly constant treatment at the primary care level. in appointments with a pediatrician. On the other hand, The approach, although simple, is not easy to adopt sleeplessness complaints are not so frequent as expected, as when a more severe disorder has already developed, since far as the prevalence of sleep disorders is concerned; more it implicates changes in behavior and in family dynamics.4-10 often than not, this occurs because the topic is seldom approached by pediatricians.1-7 “My child won’t eat” This complaint is quite frequent in the pediatrician’s office.10 Those mothers who are too anxious expect 1. MD, Assistant Professor, Universidade do Estado do Rio de Janeiro. 2. MD, Pediatrician, Hospital Municipal Jesus - Rio de Janeiro. rapid solutions and prescription of powerful drugs or S43 S44 Jornal de Pediatria - Vol.79, Supl.1, 2003 Management of sleep and eating disorders - Madeira IR et alii miraculous techniques that produce the desired results.3 From the sixth month of life, it is necessary to supplement Due to the multiplicity and complexity of the issues breastfeeding with other types of food, which should be involved, the problem cannot be easily approached, and introduced slowly and gradually. Some authors say that it is therefore necessary that the pediatrician know exactly infants can determine the adequate amount of food intake what to do and be sensitive when choosing a suitable according to their needs, and establish the interval between management.1 meals. The meal size will be proportional to the time Although eating disorders are commonplace in the interval between the meals. routine of outpatient clinics, they were included in the Around the ninth month, when a new demand for American Psychiatric Association’s Diagnostic Statistical autonomy arises, infants may refuse to eat and also have fits Manual of Mental Disorders, Fourth Edition (DSM-IV,) of anger.14 only in 1994, when well-defined criteria were established At the end of the first year of life and during the second for diagnosis. Up to now, some studies were conducted one, the child shows less appetite, known as physiological by authors who described different problems related to anorexia, because his/her growth slows down. In addition, child nutrition, by using a wide variety of poorly specified the interest in food is easily replaced with the innumerable terms and definitions, which does not allow them to be discoveries the child makes around himself/herself. compared between themselves.2 In addition, other authors approached childhood eating disorders as failure to thrive, At 15 months, the child associates food with play. The which actually is the description of a problem - children child wants to touch and squeeze foods as if they were toys. younger than three years who do not develop At around 17 to 20 months, the child begins to select normally.11,12 foods and wants to eat by himself/herself. It is when he/she Chatoor et al. presented criteria for the diagnosis of wants to participate in the adults’ world. It is important to infantile anorexia in 1998 and showed a strong relationship understand and accept the child’s necessity for autonomy in between eating disorders and several problems involving relation to food so that he/she can develop normally within mother-child interaction, as cited by other authors.2 the family and social context. In spite of the fact that nutrition contemplates survival, At the age of three, the child begins to value the it is basically a way of individuals relating with the world. appearance, color, shape and consistency of foods. Marked The relationship an individual will establish with nutrition preferences and pickiness predominate. This phase should during his/her life reflects the dynamics of his/her first be respected, but the introduction of different foods should relation, as a baby, with the mother, family and the not be neglected. environment.1-3,13 At four, the child feels like helping to prepare foods, For the baby, feeding is the moment of emotional setting the table, and joining the family at the table. The contact with the mother. Hence, the importance of greatest difficulty at mealtime is that the child is quite evaluating the mother-infant interaction and all factors talkative and cannot settle down. that might determine or interfere with this relationship.2 At the age of five, appetite improves, and will be Feeding is essential to infants not only for their growth enhanced by the age of eight.3,8 and development, but also as a source of psychological experience and sociocultural conditioning. Therefore, Anorexia in children solutions are not usually that simple, because mothers are not willing to recognize or get involved with problems Appetite means desire for food, which stems not only related to the mother-infant interaction in the family from the necessity of the body, but also from pleasant context.1,3 sensations associated with eating. Hunger is characterized by the organic, physical and “urgent” desire for food. Taking all these aspects into consideration, the Hunger does not distinguish between types of food. Appetite problems related to child nutrition could be avoided or makes people keep on eating even if they are not hungry, even minimized from the very first moment of life if which not uncommonly leads to obesity. Actually, appetite pediatricians were attentive to the breastfeeding process is plenty of behavior-related events and may considered a and to the establishment of mother-infant interaction. mediator between physiological impulses and/or signs and psychosocial ecological factors. Development-related eating behavior in infants Anorexia or lack of appetite is when the child does not In the first year of life, the infant establishes an oral spontaneously eat the amount of food necessary for his/her relationship with the environment. Feeding represents normal growth and development, that is, there is some affection between him/her and the mother. During exclusive imbalance between satisfying psychological and organic breastfeeding it is the infant who determines breastfeeding needs, which leads to malnutrition in some cases.9,10 time and intervals. This practice is now beginning to be Thus, when mothers complain that their children do not better understood by parents. eat, the pediatrician should observe the child’s weight. Management of sleep and eating disorders - Madeira IR et alii Jornal de Pediatria - Vol.79, Supl.1 , 2003 S45 Cases of children with appropriate-for-age weight and, Diagnosis sometimes, overweight, are a frequent finding. If the It essential that organic causes be immediately ruled out, pediatrician’s observation shows a weight-for-height ratio since an adequate treatment may lead to cure in most cases that is lower than expected on growth curves, it is doubtlessly (Figure 1).2,9,13 Among the organic causes, the most difficult a case of true anorexia, as identified by some authors. If the to treat are those that involve central nervous system child’s growth and development are normal, it is a case of disorders, such as encephalopathies and some genetic false anorexia, which represents the excessive concern of syndromes, and chronic diseases such as AIDS, cancer and the family with overfeeding the child. congenital metabolic disorders. The etiology of infantile anorexia or true anorexia may The anamnesis should be rigorous and detailed, in order be organic or behavioral (Table 1.) to investigate all past histories of the child in every sense. False anorexia is the situation in which the child eats The eating history should include the following questions: too little (in the family’s opinion), but grows and develops What foods are offered,? How are they offered,? How long normally. This situation should be immediately noted by is the interval between meals,? Who feeds the child,? What the pediatrician, so that it will not turn into true anorexia. was breastfeeding and weaning like,? When and how was Pseudo-anorexia is attributed to unwillingness to eat the problem first noticed.? caused by chewing and/or swallowing disorders, presence The clinical examination is based on the verification of of aphthae, cleft palate, stomatitis or other conditions signs on epithelial tissues, such as skin, eyes, hair and the that provoke pain or suffering.9,13 oral mucosa, which are related to adequate nutrition.
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