1. FEEDING AND EATING
DISORDERS OF INFANCY AND
EARLY CHILDHOOD

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

3. 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.

4. 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.

6. 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.

7. 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.

8. 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.

9. 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.

10. 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

11. 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.

12. 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.

13. 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.

14. 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.

15. 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.

16. 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.

17. 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.

18. 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.

19. 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.

20. Rumination
Disorder

21. 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.

22. 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

23. 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.

24. 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

25. 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.

26. 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.

27. 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

28. 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.

29. 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.

30. 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

31. 0 metoclopramide (Reglan),
0 cimetidine (Tagamet)
0 antipsychotics such as haloperidol (Haldol) and
thioridazine (Mellaril) have been cited to be helpful