Eating Disorders of Infancy and Childhood: Definition, Symptomatology, Epidemiology, and Comorbidity

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This article describes a 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.”

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Feeding disorders of infancy and early childhood

The fourth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV)1 distinguishes 3 feeding disorders: a broad diagnostic category named “feeding disorder of infancy or early childhood” (Box 1) and two distinct subtypes; “pica” and “rumination disorder,” discussed separately below. The ICD-10 Classification of Behavioural and Mental Disorders classification system2 also has a broad category called “feeding disorder of infancy and childhood” (Box 2), which includes

Pica

Pica is a term used to denote the persistent eating of nonnutritive substances over an extended period of time. Pica tends to be diagnosed at the time the behavior reaches clinical significance, for example, intervention might be required in relation to the ingestion of toxic substances. It is not usually diagnosed before the age of 18 months (24 months if using ICD-10 criteria). Some clinicians also use the term to include the eating of foodstuffs in a raw or unprepared form, such as flour or

Rumination disorder

Rumination disorder is characterized by the regurgitation of recently ingested food, which is re-chewed before being swallowed again, or in some cases spat out, in a process repeated several times. The experience seems to be pleasurable or soothing, with rumination in infants often being understood as a form of self-stimulation. Some investigators have described a typical posture characterized by an arched back, backward tilt to the head, and contraction of abdominal muscles, representing

Selective eating

Selective eating is a term that has been used to describe extreme faddy eating, which may persist into middle childhood and beyond. Other terms sometimes used include picky or choosy eating,21 or perseverative feeding disorder.22 Variations in terminology make comparisons across the literature difficult, but all these descriptions include two essential features: eating a highly limited range of foods and extreme reluctance to try new foods. Because the preferred foods are often soft

Food avoidance emotional disorder

The term food avoidance emotional disorder (FAED) has been used to describe avoidance of food to a marked degree in the absence of the characteristic psychopathology of eating disorders in terms of weight and shape cognitions.32 It excludes children who are chronically low in weight and is of uncertain nosologic status, other than being clearly distinguishable from anorexia nervosa.33

Unlike patients with anorexia nervosa, children with FAED know that they are underweight, would like to be

Food phobias

Phobias involving food can occur in isolation or as part of a more generalized anxiety disorder. The nature of the specific fear varies with, among other things, the child's developmental stage. Fears that are common are fear of vomiting (emetophobia), fear of contamination or poisoning, fear of choking or swallowing (sometimes known as functional dysphagia – discussed further below), and fear of the consequences of hypercholesterolemia.37 Food phobias are usually secondary events and follow a

Functional dysphagia

Functional dysphagia (also known as globus hystericus or phagophobia [see, for example, Okada and colleagues40]) is a term used to describe swallowing difficulties associated with a fear of choking. It can be found as an isolated symptom of acute onset, often following trauma or as a feature of other disorders. Functional dysphagia is probably more valid as a symptom descriptor than a separate nosologic entity. As a symptom, it needs to be recognized and managed appropriately, through a

Food refusal

Food refusal as an isolated behavior is an experience most parents encounter at some point during their child's development. The behaviors identified with food refusal in toddlers include whining or crying, tantrums, and spitting out food.6 This refusal pattern is often general in nature as opposed to food specific and linked to other types of oppositional behavior. Food refusal in older children is often associated with other defiant behaviors, such as delaying eating by talking, trying to

Anorexia Nervosa

Anorexia nervosa is seen clinically from about age 7 upward. By definition, its presentation is similar to that of older sufferers, with some important developmental differences. Several articles have described these differences in presentation between children and adolescents,33, 44, 45, 46, 47, 48, 49 which lie in psychological, behavioral, and physical domains.

Key psychological and behavioral differences include the fact that children have limited capacity for self-appraisal or reflection

Summary

The authors have described the range of feeding and eating problems presenting clinically in preadolescent children, with the exception of childhood obesity, which is addressed elsewhere. This is a complex area, but also one of overlaps and similarities. Many of the problems described are of uncertain nosologic status and linked to this is a lack of systematic research in the area. Priority areas for future research include epidemiologic studies of childhood problem eating behaviors to enable a

References (67)

  • A. Kent et al.

    Pre-menarcheal bulimia nervosa

    J Psychosom Res

    (1992)
  • L.L. Birch et al.

    Family environmental factors influencing the developing behavioral controls of food intake and childhood overweight

    Pediatr Clin North Am

    (2001)
  • L. Goossens et al.

    Loss of control over eating in obese youngsters

    Behav Res Ther

    (2007)
  • American Psychiatric Association

    Diagnostic and statistical manual of mental disorders—DSM-IV

    (1994)
  • WHO

    ICD-10 classification of mental and behavioural disorders

    (1991)
  • W.H. Davies et al.

    Reconceptualizing feeding and feeding disorders in interpersonal context: the case for a relational disorder

    J Fam Psychol

    (2006)
  • S.M. Reilly et al.

    Oral-motor dysfunction in children who fail to thrive: organic or non-organic?

    Dev Med Child Neurol

    (1999)
  • W. Crist et al.

    Mealtime behaviors of young children: a comparison of normative and clinical data

    J Dev Behav Pediatr

    (2001)
  • K.A. Burklow et al.

    Classifying complex pediatric feeding disorders

    J Pediatr Gastroenterol Nutr

    (1998)
  • S.M. Schwarz et al.

    Diagnosis and treatment of feeding disorders in children with developmental disabilities

    Pediatrics

    (2001)
  • R.L. Babbitt et al.

    Behavioral assessment and treatment of pediatric feeding disorders

    J Dev Behav Pediatr

    (1994)
  • M. Dahl et al.

    Early feeding problems in an affluent society. I. Categories and clinical signs

    Acta Paediatr Scand

    (1986)
  • K.C. Byars et al.

    A multicomponent behavioral program for oral aversion in children dependent on gastrostomy feedings

    J Pediatr Gastroenterol Nutr

    (2003)
  • P.B. Sullivan et al.

    Prevalence and severity of feeding and nutritional problems in children with neurological impairment: Oxford feeding study

    Dev Med Child Neurol

    (2000)
  • J.R. Ledford et al.

    Observational and incidental learning by children with autism during small group instruction

    J Autism Dev Disord

    (2008)
  • M.A. Stein et al.

    Sleep and behavior problems in school-aged children

    Pediatrics

    (2001)
  • C. McAlpine et al.

    Pica in institutionalized mentally retarded persons

    J Ment Defic Res

    (1986)
  • K.W. Olden

    Rumination

    Curr Treat Options Gastroenterol

    (2001)
  • C.L. Birmingham et al.

    Rumination in eating disorders: literature review

    Eat Weight Disord

    (2006)
  • G. Harris et al.

    The nature and management of eating problems in pre-school children

  • B.R. Carruth et al.

    Revisiting the picky eater phenomenon: neophobic behaviors of young children

    J Am Coll Nutr

    (2000)
  • D. Nicholls et al.

    Selective eating: symptom, disorder or normal variant?

    Clin Child Psychol Psychiatry

    (2001)
  • S. Timimi et al.

    Selective eaters: a retrospective case note study

    Child Care Health Dev

    (1997)

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