Carolyn Steinberg, MD, FRCPC

Feeding disorders of , toddlers, and preschoolers

Failure to thrive should not be the only diagnostic criterion used when considering whether a young has a feeding disorder.

ABSTRACT: Feeding disorders in in- 6 rom the moment of birth, failure rather than a diagnosis itself. fancy are common and, when severe, a child begins to assert in- Feeding disturbances can occur even in can be life-threatening. The child dependent functioning. No the absence of problems with nutri- needs adequate to satisfy F longer receiving nutrients tional intake. the demands of growth and permit passively through the umbilical cord, An excellent new classification brain development. For feeding to the now needs to receive nutri- system for feeding disorders in infants succeed, the and infant need ents by the process of being fed. This andtoddlers was publishedby Chatoor to be supported adequately, both 7 involves at least two people, sur- in 2002. This classification system socially and emotionally. As the in- Diag- rounded by the family network, has since been adopted by the fant develops, he or she needs to as- nostic Classification of Mental Health which in turn is embeddedin a socio- sume more physical and emotional in- and Developmental Disorder of Infan- cultural context. Not only does the dependence. There are many places cy and Early Childhood DC: 0-3R 8 child have to be aware of and signal ( ). along this path where feeding can go his or her needs, the caregiver has to It subclassifies feeding disorders awry. Knowledge of the historical recognize these signals and respond according to various organic and background to the development of appropriately. nonorganic causes and encompasses a our understanding of internally reg- The negotiations between parent broader understanding of the etiology ulated feeding and diagnostic clas- and child around feeding are a harbin- of these disorders. sification systems and various as- ger of how other tasks will be negoti- sessment and treatment strategies Development of internally ated. Approximately 25% of normally for feeding disorders can help pri- regulated feeding developing infants and up to 80% of mary care physicians in the care of those with developmental delays have According to Chatoor, an important families and may also have a pre- 1,2 Diag- feeding problems. Both the task of the first years of life is the ventive effect on the incidence of nostic and Statistical Manual of Men- eating disorders in young adulthood. tal Disorders DSM-IV-TR 3 Dr Steinberg is an infant and preschool child ( ) and the International Statistical Classifica- psychiatrist. She recently began working at tion of Diseases ICD-10 4 Richmond Hospital, where she is develop- ( ) describe ing an infant mental health program. Previ- feeding disorders in early childhood as ously she consulted to the Feeding and encompassing nutritional intake prob- 5 Swallowing Team, Home Nutrition Support lems. As Maldonado-Duran has indi- Program, and the Stollery Children’s Hospi- cated, feeding disturbances or disorders tal in Edmonton, Alberta, as well as the are not synonymous with failure to Regional Neonatal Intensive Care Unit. thrive or stunted growth. is a descriptive term for growth

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development of autonomous internal fants become more active socially. order) or by lack of available food. 9 regulation of feeding. A child should Interactions with the parent become • Criterion D. The onset must be be able to recognize his or her increasingly reciprocal in nature. Body before age 6. and satiety cues and respond appropri- language signaling hunger and satiety In my experience, the requirement ately. The key to this is the develop- may become more clear, so interac- of significant failure to gain weight or ment of a parent-infant communica- tions between infant and parent re- significant loss of weight in this gen- tion system that requires the child to garding the process of feeding become eral definition has limitations. Such a signal hunger and satiety states and more mutually regulated. For exam- requirement excludes children with the parent to respond accordingly. ple, the infant may signal hunger and adequate caloric intake but maladap- The parent then supports the infant’s on seeing the parent, anticipate the up- tive feeding patterns. emerging skills and teaches the infant coming feeding and stop the signals. Chatoor’s Diagnostic Classifica- 7,8 Between 6 months and 3 years of tion of Feeding Disorders, which has DC: 0-3R, age, children progress through a de- been edited and included in velopmental process called separation states: 10 The diagnosis of feeding behavior and individuation. The child becomes The presentation disorder, the symptoms of which may increasingly physically and emotion- become evident at different stages of of eating problems ally independent and develops some infancy and early childhood, should autonomy. The parent and infant have in early childhood be considered when an infant or young to negotiate who is going to put the child has difficulty establishing regu- or eating disorders food in the infant’s mouth. The parent lar feeding patterns—that is, when the needs to consider how he or she feeds in adolescence is a child does not regulate his or her feed- the child and whether the offered food ing in accordance with physiological strong indicator is for nutritional needs or emotional feelings of hunger or fullness. If these needs. If the infant signals poorly, the of risk for eating difficulties occur in the absence of parent may become confused and hunger or interpersonal precipitants disorders in young attempt to override the child’s cues. such as separation, negativism, or This can result in a battle of wills. adulthood. trauma, the clinician should consider This stage, as with the others, can pre- a primary feeding disorder. cipitate maladaptive feeding patterns, depending on both infant and parent The six subcategories of feeding characteristics. behavior disorder are summarized in DC: 0-3R appropriate responses to these internal Diagnostic criteria as follows: signals by example, thus helping the • Feeding disorder of state regulation. infant to regulate his or her eating in Two sets of diagnostic criteria are The infant has difficulty reaching and response to hunger and satiety. This commonly used for infants and chil- maintaining a calm state during feed- prepares the infant for the transition to dren with feeding disorders. The Feed- ing (e.g., the infant is too sleepy, self-feeding. ing Disorder of Infancy or Early Child- too agitated, or too distressed to DSM-IV-R3 Chatoor proposes that the initial hood system from the feed). This disorder starts in the new- stage in this developing process is to contains the following criteria: born period. 9 achieve homeostasis. During this • Criterion A. Persistent failure to eat • Feeding disorder of caregiver-infant time the infant has to establish basic adequately, as reflected in significant reciprocity. The infant or young child cycles and rhythms of sleep and wake- failure to gain weight or significant does not display developmentally fulness, feeding and elimination. The over at least 1 month. appropriate signs of social reciproc- infant must maintain a calm state of • Criterion B. The disturbance is not ity (e.g., visual engagement, smil- alertness for feeding. If the infant is due to gastrointestinal or other gen- ing, or ) with the primary too irritable or sleepy, feeding may be eral medical condition (e.g., esopha- caregiver during feeding. impeded. The parent may needto work geal reflux). • Infantile . The infant or with the child to maintain this calm, • Criterion C. The disturbance is not young child refuses to eat adequate alert state in order for feeding to occur. better accounted for by another men- amounts of foodfor at least 1 month. By 2 to 4 months of age, most in- tal disorder (e.g., rumination dis- The onset of the food refusal occurs

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before the child is 3 years old. The basis for difficulties in feeding. tory of Crohn’s disease. She describes infant or young child does not com- Assessment herself as always having had a small municate hunger and lacks interest appetite, having hadstruggles over eat- in food, but shows strong interest in Assessment requires access to a multi- ing with her own , and being exploration or interaction with care- disciplinary team whose members can quite a fussy eater. She indicates that giver, or both. bring their expertise to bear on the spe- she still has difficulties with food and • Sensory food aversions. The child cific function that has gone awry. Ide- clothing textures. consistently refuses to eat foods ally, this team should include the fol- Johnny is the result of a planned with specific tastes, textures, or lowing: pregnancy, and had a normal birth. smells. The onset of the food refusal • A psychodynamically informed psy- However, his mother has always found occurs during the introduction of a chiatrist or clinical psychologist to him “difficult to feed.” He had a sys- novel type of food (e.g., the child (1) assess parental characteristics temic infection at about 6 months of may drink one type of milk but re- such as mental status, attachment age andhadto change to a different for- fuse another, may eat carrots but system, and temperamental charac- mula, which he refused to take. refuse green beans, may drink milk teristics in the context of relation- Despite this, he did make a successful but refuse ). This childeats ship to partner and society; (2) transition to table food, although his without difficulty when offered pre- observe the parent-infant interac- mother recognized that he did not like ferred foods, and the food refusal tions to assess temperamental fit and jarred baby food and wondered if the causes specific nutritional deficien- communication. texture bothered him. By age 11/2, cies or a delay of oral-motor devel- • A pediatrician to assess the infant’s Johnny and his mother were making opment. physical health. regular visits to the pediatrician. Even • Feeding disorder associatedwith con- • A dietician to assess the infant’s though Mom complained that Johnny current medical condition. The infant height, weight, head circumference, did not eat very much, Johnny main- or young child readily initiates feed- food intake, and nutritional status. tainedhis growth curve. Shortly there- ing, but shows distress over the • A speech-language pathologist or after, Johnny had some gagging epi- course of feeding and refuses to con- occupational therapist (or both) to sodes, was diagnosed with reflux, and tinue feeding. The child has a con- assess the infant’s oral-motor devel- put on thickened fluids. Over the en- current medical condition that the opment. suing year and a half, Mom became clinician judges to be the cause of • A clinical psychologist to assess the increasingly worried about Johnny’s the distress. infant’s development. low food intake and nutritional status. • Feeding disorder associated with • An occupational therapist to assess She believed that she needed to “make insults to the gastrointestinal tract. the infant’s sensory processing. him eat,” and would employ a variety Food refusal follows a major aver- Treatment of coaxing strategies to feed him. sive event or repeated noxious in- Johnny was allowedto graze whenever sults to the oropharynx or gastroin- Just as a team of professionals can best he wanted. As Johnny slowly slipped testinal tract (e.g., choking, severe establish the cause of the feeding dis- off his growth curve, Mom continued vomiting, reflux, insertion of naso- turbance, so too can a variety of mo- trying to introduce new foods and new gastric or endotracheal tubes, suc- dalities be used to treat these disorders techniques to get him to eat. Eventu- tioning). This infant or young child most effectively. I have found both ally, mealtimes became a source of consistently refuses food in one of conjoined interventions and staged great stress and tears for both mother the following forms: bottle, solids, interventions to be of benefit. The fol- andchild. When finally admittedto the or both. Reminders of the traumatic lowing case provides an example of hospital, Johnny was lethargic and event(s) cause distress, and are man- this. showed some evidence of micronutri- ifested by anticipatory distress. Johnny is a 3-year-old boy who ent deficiency. In my own clinical practice, this was admitted to hospital after failing In looking at Johnny in the con- classification system has been extreme- to maintain his growth curve. Johnny text of the development of internally DSM- ly useful in going beyond the lives at home with two older siblings, regulatedfeeding, the assessment team IV-TR phenomenological requirement neither of whom has had an eating foundthat he was able to achieve basic of “failure to gain weight,” and has problem. His mother, however, comes cycles of feeding andelimination early allowed me to look at the etiologic from a family with a longstanding his- on and that he emitted clear satiety

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Int J Eat Disord 1991;10:395-405. cues. He may also have shown evi- and Johnny continues to thrive. 2. Reilly SM, Skuse DH,Wolke D, et al. Oral- dence of a regulatory disorder of sen- Another developmental task, - 8 motor dysfunction in children who fail to sory processing with formula refusal ing, has been successfully negotiated. thrive: Organic or non-organic? Dev Med and fussiness about texture and tastes. Conclusions Child Neurol 1999;4:115-122. Mom’s many attempts to help him 3. Diagnostic and Statistical Manual of may have been affected by her own Feeding disorders of infants, toddlers, Mental Disorders: DSM-IV-TR. Washing- early history of poor negotiation over and preschoolers must be taken seri- ton, DC: American Psychiatric Associa- food with her own mother. Interviews ously. Treatment is best done in the tion; 2000. 943 pp. revealed that Mom had considerable context of the whole family, with 4. International Statistical Classification of anxiety about the development of gas- assessment and treatment by a multi- Diseases and Related Health Problems. trointestinal problems and is tempera- disciplinary team. The presentation of 10th revision. Geneva: World Health mentally a rather inflexible person. eating problems in early childhood or Organization; 1992. She succumbed to feeling that she eating disorders in adolescence is 5. Maldonado-Duran JM. A new perspec- neededto do more to get Johnny to eat. a strong indicator of risk for eating dis- 11 tive on failure to thrive. Bulletin of Zero to Because Johnny is temperamentally orders in young adulthood. Practi- Three 2005;21:15. rigid as well, a battle between mother tioners who treat adults of reproductive 6. Goldblum R. Growth in infancy. Pediatri andchildensued. In desperation, Mom age with a history of eating disorders, Rev 1987;9:57-61. let Johnny eat whenever he signaled or those who see young children with 7. Chatoor I. Feeding disorders in infants any hunger. This probably contributed feeding disorders should be aware of and toddlers: Diagnosis and treatment. to his poor intake. It didnot help when the risks involved. Whelan and Coop- Child Adolesc Psychiatr Clin North Am Johnny was diagnosed with reflux, er have shown that of children 2002;2:163-183. which may well have made eating with feeding problems had a markedly 8. Diagnostic Classification of Mental more uncomfortable for him, made increased rate of both current and past 12 Health and Developmental Disorders of him more uncooperative, and made eating disorders themselves. It is cru- Infancy and Early Childhood (DC: 0 - 3R). Mom rely more on coaxing. cial for pediatricians andfor physicians Washington, DC: Zero to Three Press; Assessment involved a multidisci- in general to be aware of the child at 2005. 75 pp. plinary team with each expert con- risk and to interact effectively with 9. Chatoor I, Ganiban J. Assessment and tributing to thedescription of theprob- child mental health caregivers. Prima- classification of feeding disorders. In: lem outlinedabove. Treatment for this ry care physicians should be alert not DelCarmen-Wiggins R, Carter A (eds). case involved: only to those children who “fall off the Handbook of Infant, Toddler, and • Sessions for Mom to help her under- growth curve” but also to children of Preschool Mental Health Assessment. stand the reasons for the problems. adults with eating disorders or children NewYork: Oxford University Press; 2004. • Nutritional supplementation for whose show persistent diffi- 560 pp. Johnny. culty feeding them. In collaboration 10. Mahler M, Pine F, Bergman A. The Psy- • Treatment for Johnny’s reflux. with professional colleagues, physi- chological Birth of the Human Infant. • Parent-infant therapy to address the cians can interact effectively to pre- NewYork: Basic Books; 1975. 308 pp. feeding process. vent feeding disorders in early life. 11. Kotler LA, Cohen P,Davies M, et al. Lon- • Family therapy to address one sib- This shouldhave a primary preventive gitudinal relationships between child- ling’s coercive behavior toward effect on the incidence of eating disor- hood, adolescent, and adult eating disor- Johnny. ders of young adulthood. ders. JAmAcad ChildAdolesc Psychiatry • Occupational therapy assessment to Acknowledgments 2001;40:1434-1440. determine the extent of Johnny’s reg- I would like to acknowledge the help of Dr 12. Whelan E, Cooper PJ. The association ulation disorder of sensory process- Paul Steinberg in the preparation of this 8 between childhood feeding problems ing and strategies to work on his paper. and maternal eating disorder: A commu- sensitivities. Competing interests nity study. Psychol Med 2000;30:69-77. As Johnny began to thrive, Mom None declared. was able to address her own rigidity in other areas of her relationship with References Johnny. One year after treatment, this 1. Lindberg L, Bahlin G, Hagekull S. Early dyad has a much healthier relationship feeding problems in a normal population.

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