Feeding Disorder of Infancy
A feeding disorder of infancy is the failure of a young child to gain weight over time because he or she does not take in the proper amount of nutrients. However, no medical condition is causing the problem. Feeding disorder of infancy is a disorder in which an infant or a child under 6 years old refuses to eat enough to be healthy. It is not due to a medical condition such as a stomach problem. As a result of feeding disorder, the infant or child fails to gain weight normally and to get proper nutrition. He or she may lose enough weight to cause harm.
Range of problem feeding and eating presentations seen in infants and children. In diagnostic terms some fall under the category of “feeding disorder,” whereas others are childhood presentations of the eating disorders “anorexia nervosa,” “bulimia nervosa,” and atypical forms of these. Several other commonly occurring presentations that are difficult to fit into existing diagnostic categories are additionally described here, including “selective eating,” “food avoidance emotional disorder,” “food phobias,” “functional dysphagia,” and “food refusal.”
Poor feeding is a nonspecific symptom seen in newborn and young infants. It can result from many conditions, including infection, metabolic disorders, genetic disorders, structural problems, and neurological disorders. Poor feeding is not a sign of the severity of the disease, but it requires close watching of the infant.
Poor feeding is not the same as “picky” eating. Many children between ages 2 and 4 are picky eaters. Parents only need to give children what they like to eat at this age. However, children must continue to drink milk or an appropriate milk substitute.
The last version of the Diagnostic Classification of Mental Health and Developmental Disorders of Infancy and Early Childhood-Revised – DC: 0-3R by Zero-To-Three1 introduced a classification of feeding behavior disorders for infants and young children. Different clinical pictures are included depending on the developmental period in which they appear, their clinical symptoms and their possible association with coexisting medical conditions.
The cause of feeding disorder is unknown, but the disorder results in bonding problems between the child and the caregiver. There also can be problems with the child’s sleep-wake patterns. Infants or children who do not get enough sleep may not have the energy to eat or interact. Problems with feeding may also be a symptom of a developmental disability.
Feeding disorders are diagnosed when the infant or young child appears malnourished and the problem is not caused by a medical condition (such as cleft palate, congenital heart disease, or long-term lung disease), or a disorder that causes mental retardation. The cause of these disorders is often unknown, but they can result from a variety of factors such as poverty, dysfunctional child-caregiver interactions, or parental misinformation about appropriate diet to meet the child’s needs.
- Any disorder that causes damage to the nervous system or causes muscle weakness
- Beckwith-Wiedemann syndrome
- Birth-acquired herpes
- Congenital hypothyroidism
- Group B streptococcal septicemia of the newborn (late)
- Hypoplastic left heart
- Infant botulism
- Infection of the tissue covering the brain and spinal cord (meningitis)
- Newborn jaundice
- Patent ductus arteriosus
- Premature infant
- Tetralogy of Fallot
- Total anomalous pulmonary venous return
- Tracheoesophageal fistula, a birth defect in which there is a connection between the trachea and the esophagus
- Transposition of the great vessels
- Truncus arteriosus
- Viral gastroenteritis
If symptoms occur repeatedly for at least a month, the child may have feeding disorder. An infant with feeding disorder:
- is cranky while eating
- shows little emotion
- acts withdrawn, is not social
- fails to develop physically and emotionally at the normal rate
- does not eat enough to gain weight
- does not get enough restful sleep because of a problem with the sleep-wake cycle
- throws up a lot
- Excessive crying
- Excessive sleepiness (lethargy)
- Poor weight gain
- Weight loss
The healthcare provider will do a physical exam and take a medical history to rule out other medical conditions. He or she will ask about the child’s eating and sleeping patterns, overall mood, mood while eating, and history of weight loss. A trained specialist, usually a nurse, will watch the caregiver feed the infant or child. Depending on how severe the symptoms are, the healthcare provider will decide how best to treat the child. The child may need to be treated in the hospital.
The child will be evaluated for any medical illness that could cause or contribute to the problem. Evaluation of the growth curves for height, weight, and head circumference is important in any evaluation of feeding or weight problems.
Laboratory and imaging studies may be used to complete the medical workup but often are normal in children with growth problems.
Two sets of diagnostic criteria are commonly used for infants and children with feeding disorders. The Feeding Disorder of Infancy or Early Childhood system from the DSM-IV-R contains the following criteria:
- Criterion A. Persistent failure to eat adequately, as reflected in significant failure to gain weight or significant weight loss over at least 1 month.
- Criterion B. The disturbance is not due to gastrointestinal or other general medical condition (e.g., esophageal reflux).
- Criterion C. The disturbance is not better accounted for by another mental disorder (e.g., rumination disorder) or by lack of available food.
- Criterion D. The onset must be before age 6.
Chatoor’s Diagnostic Classification of Feeding Disorders, which has been edited and included in DC: 0-3R, states: The diagnosis of feeding behavior disorder, the symptoms of which may become evident at different stages of infancy and early childhood, should be considered when an infant or young child has difficulty establishing regular feeding patterns—that is, when the child does not regulate his or her feeding in accordance with physiological feelings of hunger or fullness. If these difficulties occur in the absence of hunger or interpersonal precipitants such as separation, negativism, or trauma, the clinician should consider a primary feeding disorder.
The six subcategories of feeding behavior disorder are summarized in DC: 0-3R as follows:
- Feeding disorder of state regulation. The infant has difficulty reaching and maintaining a calm state during feeding (e.g., the infant is too sleepy, too agitated, or too distressed to feed). This disorder starts in the newborn period.
- Feeding disorder of caregiver-infant reciprocity. The infant or young child does not display developmentally appropriate signs of social reciprocity (e.g., visual engagement, smiling, or babbling) with the primary caregiver during feeding.
- Infantile anorexia. The infant or young child refuses to eat adequate amounts of food for at least 1 month. The onset of the food refusal occurs before the child is 3 years old. The infant or young child does not communicate hunger and lacks interest in food, but shows strong interest in exploration or interaction with caregiver, or both.
- Sensory food aversions. The child consistently refuses to eat foods with specific tastes, textures, or smells. The onset of the food refusal occurs during the introduction of a novel type of food (e.g., the child may drink one type of milk but refuse another, may eat carrots but refuse green beans, may drink milk but refuse baby food). This child eats without difficulty when offered preferred foods, and the food refusal causes specific nutritional deficiencies or a delay of oral-motor development.
- Feeding disorder associated with concurrent medical condition. The infant or young child readily initiates feeding, but shows distress over the course of feeding and refuses to continue feeding. The child has a concurrent medical condition that the clinician judges to be the cause of the distress.
- Feeding disorder associated with insults to the gastrointestinal tract. Food refusal follows a major aversive event or repeated noxious insults to the oropharynx or gastrointestinal tract (e.g., choking, severe vomiting, reflux, insertion of nasogastric or endotracheal tubes, suctioning). This infant or young child consistently refuses food in one of the following forms: bottle, solids, or both. Reminders of the traumatic event(s) cause distress, and are manifested by anticipatory distress.
Treatment usually involves a team approach. The team always includes the caregiver and may include a pediatrician, a nutritionist, a social worker, child psychiatrist, and a physical or occupational therapist. The goal of the team is to enhance the bond between the child and the caregiver.
The infant or child may need to be fed through an IV (a tube placed in a vein) or an NG tube (a tube placed in the nose) until he or she can eat normally.
It is important to stay in touch with the healthcare provider to inform him or her about any significant changes in the child’s feeding behavior
Depending on the severity of the condition, the following measures may be taken:
- Increase the number of calories and amount of fluid the infant takes in
- Correct any vitamin or mineral deficiencies
- Identify and correct any underlying physical illnesses or psychosocial problems
A short period of hospitalization may be required to accomplish these goals.
There is no quick cure for the majority of infants and children with feeding disorders. Most feeding disorders are mild and self-limited. A multidisciplinary approach involving pediatricians, outreach nurses, dietitians, social workers, behavior specialists, and parents is needed to improve the child’s well-being and nutritional status.
Childhood malnutrition can permanently stunt mental and physical development if it is severe and long-lasting. Early treatment can prevent such complications.
Following recommended guidelines for nutrition can help ensure adequate caloric and fluid intake for an infant. Regular well-child visits to your pediatrician can help identify any feeding and growth problems early and can prevent permanent damage related to malnutrition.
Feeding disorders of infants, toddlers, and preschoolers must be taken seriously. Treatment is best done in the context of the whole family, with assessment and treatment by a multidisciplinary team. The presentation of eating problems in early childhood or eating disorders in adolescence is a strong indicator of risk for eating disorders in young adulthood. Practitioners who treat adults of reproductive age with a history of eating disorders, or those who see young children with feeding disorders should be aware of the risks involved. Whelan and Cooper have shown that mothers of children with feeding problems had a markedly increased rate of both current and past eating disorders themselves.It is crucial for pediatricians and for physicians in general to be aware of the child at risk and to interact effectively with child mental health caregivers. Primary care physicians should be alert not only to those children who “fall off the growth curve” but also to children of adults with eating disorders or children whose parents show persistent difficulty feeding them. In collaboration with professional colleagues, physicians can interact effectively to prevent feeding disorders in early life. This should have a primary preventive effect on the incidence of eating disorders of young adulthood
- Massimo Ammaniti, Loredana Lucarelli, Silvia Cimino, Francesca D’Olimpio, Irene Chatoor. Feeding disorders of infancy: A longitudinal study to middle childhood. International Journal of Eating Disorders. Volume 45, Issue 2, pages 272–280, March 2012
- Chatoor I,Ammaniti M. A classification of feeding disorders in infancy and early childhood. In: Narrow WE,First MB,Sirovatka PJ,Regier DA, editors. Age and Gender Considerations in Psychiatric Diagnosis: A Research Agenda for DSM-V. Arlington, VA: American Psychiatric Association, 2007, pp. 227–242.
- Marchi M,Cohen P. Early childhood eating behaviors and adolescent eating disorders. J Am Acad Child Adolesc Psychiatry 1990; 29: 112–117.
- Nicholls D, Bryant-Waugh R. Eating disorders of infancy and childhood: definition, symptomatology, epidemiology, and comorbidity. Child Adolesc Psychiatr Clin N Am. 2009 Jan;18(1):17-30.
- Chatoor I.Feeding disorders in infants and toddlers: diagnosis and treatment. Child Adolesc Psychiatr Clin N Am. 2002 Apr;11(2):163-83.