4.2 EATING DISORDER

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• Physical causes

- Hunger/feeding difficulties

- Wet diapers

- Unpleasant hot/cold

- Noisy environment

- Insect bites

• Emotional stress

- Loneliness, separation from mother

- stranger anxiety, etc.

- Overstimulation: Lack of sleep

• Painful illnesses

- Blocked nose

- Ear infection (Eustachian tube block)

- Stomach pain, e.g. evening colic

- Teething/ toothache

- Gastroesophageal reflex

- Constipation

- Undetected injury

- Headache, CNS infections

• Developmental issues

- Autistic spectrum disorders

or painful underlying illnesses, (c) reassurance to the parents, and (d) training them simple tricks to calm the baby, e.g. cuddling, swaddling, soothing sounds, e.g. humming, gentle rocking or calming motions. However, interventions, e.g. over-feeding or use of pacifiers should be avoided.

Evening colic (Infantile colic, three-month colic) is well- recognized entity of unknown etiology, characterized by unexplained crying spells in infants below 3-4 months of age during evenings with flexion of thighs and flushing of face. Each spell lasts for 2-3 hours and recurs with consistent regularity for many evenings (gt;3 days a week), before gradual cessation by 3-4 months of age.

Incidence: Infantile colic of variable severity is reported in ~5-20% of infants, more common in first-born, active babies of anxious parents.

Etiology is uncertain, probably related to aerophagia and intestinal colic, as evident from gurgling sounds and increased peristaltic movements in some cases. Crying further aggravates aerophagia, to form colic-cry­colic cycle.

Diagnosis depends on exclusion of other causes and typical presentation with regular periodicity and timing of spells, in an otherwise healthy and well-fed child.

Management includes—(a) reassurance to parents about benign nature of the problem, (b) training them to comfort the baby by rocking, cuddling and burping during the spell, and (c) counseling the mother about the proper feeding position and burping after feeds, anti-spasmodic drops and probiotics might be useful in some cases, though should preferably be avoided.

Minor feeding problems, e.g. refusal to eat, slow-feeding, picky-eating, spitting while feeding, etc. are common in infants and young children, reported by ~25-40% parents. Most of them are transient, self-limiting and are of little consequence, if the child is developing and growing normally. No intervention is required in these cases, except reassurance and guidance to parents.

Some common behavioral feeding problems in early childhood are discussed here, while others like anorexia nervosa and bulimia are largely seen in adolescents and discussed elsewhere (Ch 13.3).

4.2.1 PICKY-EATING___________________________________

Picky-eating (Fussy, Faddy or Choosy-eating) is a common behavior in early childhood but may cause considerable stress to parents. It is characterized by an unwillingness to eat familiar foods or to try new foods, as well as strong food preferences.

Incidence: Estimated prevalence of picky-eaters varies widely from 5-50% of infants, due to lack of consistency in definition or assessment. Incidence gradually starts increasing from 18-24 months of age and peaks at ~5-6 years, before declining. Picky-eating is more common in single children of young-inexperienced parents.

Etiology is uncertain, but factors like delayed or inappropriate introduction of complimentary feeding, forced feeding, choosy dietary habits of the family itself and babies' own personality trait seem to be important among picky-eaters. Maternal eating behavior and food preferences have been also suggested to influence child's food habits.

Consequences: While energy intake in picky-eaters is usually adequate, these children are at-risk for undernutrition due to poor dietary diversity and micronutrient deficiencies. Constipation is common and some may develop serious behavioral problems, e.g. anorexia nervosa, in later life.

Some picky-eaters are also at rare risk to develop Avoidant/restrictive food intake disorder (ARFID), a serious mental health problem in older children or adolescents, characterized by the overall lack of interest in food and/ or aversion to eat large number of foods.

Management involves reassurance to parents, avoidance of force-feeding, encouragement or rewards to improve dietary diversity (positive reinforcement) and assessment for underlying behavioral problems in child as well as in family.

4.2.2 PICA______________________________________________

Pica, i.e. perverted appetite, is the commonest eating disorder, defined as “a pattern of eating non-nutritive non­food substances for-(a) at least one month (b) inappropriate to the child's developmental level, and (c) not a part of culturally supported or socially normative practice” (DSM V criteria).

Substances commonly ingested in pica are clay, dirt and mud (geophagia); paint, pencil-lead (plumbophagia), ice (pagophagia), starch (amylophagia), feces (coprophagia), hair (trichophagia), plaster, ash, wool/ cloth, leaves, coal, soap, etc.

Incidence: Pica is a normal developmental behavior till 24 months of age, as infants have a tendency to mouth all objects grasped by their hands. Persistence of pica beyond this age is abnormal, estimated to be present in ~20-30% in toddlers and ~10% in older children. Incidence is relatively higher in low-socioeconomic status, similar family history and institutionalized children.

Etiology: While Pica is largely a behavioral disorder, it has been associated with: (a) mental retardation,

(b) emotional neglect, (c) iron and zinc deficiency, and (d) worm infestations (? cause?? effect).

Complications: Children with pica are at risk for: (a) GIT problems, e.g. recurrent abdominal pain, diarrhea or worm infestation, (b) chronic lead poisoning and (c) iron deficiency anemia. Rarely, these cases may develop bezoars, intestinal obstruction or perforation.

Diagnosis is clinical, though investigations, e.g. hemo­gram (for anemia and infections) and stool examination (for worm infestations) are indicated in all cases.

D/D of pica includes more serious psychological disorders, e.g. autism, schizophrenia, and physical disorders, e.g. Kline-Levine syndrome.

Management of pica includes:

a. Treatment of predisposing/ complicating factors, e.g. iron deficiency anemia, helminthiasis and lead poisoning;

b. Parental counseling regarding -(i) benign and self­limiting nature of problem, (ii) need to provide emotionally stimulating environment to the child and (iii) supervision to keep potentially dangerous substances out of the reach of child;

c. Behavioral modification strategies, e.g. positive rein­forcement, occasional negative reinforcement or mild aversion therapy.

Rumination is a rare but severe vegetative disorder in infants (3-12 months), characterized by self-induced or spontaneous regurgitation of food after feeding (akin to anorexia nervosa/bulimia in adolescents). It is more common in males and emotionally deprived children, often leading to severe failure to thrive and occasionally death.

Severe feeding disorders of infancy or early childhood are defined as persistent feeding disturbance with: (a) failure to gain weight or significant weight loss for at least one month,

(b) no significant medical conditions, mental disorder or lack of available food, and (c) age of onset less than 6 years (DSM-IV criteria).

Incidence: Severe feeding disorders are seen in only ~1- 2% of under-five children, more common in those born prematurely or having some developmental handicap.

Types: These disorders are classified in many ways, usually into six sub-types: (a) feeding disorder of state regulation-difficulty to maintain a calm state during feeding, e.g. too sleepy or agitated, (b) feeding disorder of social reciprocity-no appropriate response to the care­giver while feeding, e.g. smiling or babbling, (c) infantile anorexia-lack of interest or refusal to eat adequate amounts of food for at least 1 month below 3 years of age, (d) sensory food aversions-refusal to eat foods with specific tastes, textures, or smell, (e) feeding disorder associated with concurrent medical condition, e.g. cleft-palate, and (f) feeding disorder associated with previous insults to the gastrointestinal tract, e.g. choking, severe vomiting, suction, intubation, etc.

Management of these serious feeding disorders requires detailed clinical and behavioral assessment, relevant investigations and a team-approach in management, which is beyond the scope of this book.

4.3