Eating Disorders in Infants and Toddlers

2
Antonia Parmeggiani and Jacopo Pruccoli

2.1 Introduction

Parents frequently refer to medical attention reporting that their children eat poorly.
Commonly this trouble does not represent a severe problem; however, in a small
percentage of cases, children may present significant feeding difficulties.
Paediatricians and child neuropsychiatrists should be informed about these disor-
ders in order to support parents by offering appropriate guidance and treatments.
In this chapter, the authors will consider feeding disorders (FD) and eating disor-
ders (ED) in infants and toddlers and describe their main features and variables.
They will also describe the characteristics of ED in a neurodevelopmental disorder,
namely, autism spectrum disorder [1].

2.2  utrition, Eating Behaviour and

N
Feeding Difficulties/Disorders

Eating behaviour, together with sleep, represents an important function of regula-

tion in infancy. The development of adequate feeding and eating functions relies on
the proper integration of a range of physical and psychological competencies.
Feeding represents a critical source of interaction between caregivers and their child
in the first years of life, particularly for children with neuropsychiatric disabilities
[2]. FD in infancy result from impairments in developmental milestones needed to

A. Parmeggiani (*) · J. Pruccoli

IRCCS Istituto delle Scienze Neurologiche di Bologna, Centro Regionale per i Disturbi della
Nutrizione e dell’Alimentazione in Età Evolutiva, Child Neurology and Psychiatry Unit,
Bologna, Italy
Dipartimento di Scienze Mediche e Chirurgiche (DIMEC), Università di Bologna,
Bologna, Italy
e-mail: [email protected]; [email protected]

© Springer Nature Switzerland AG 2022 5

E. Manzato et al. (eds.), Hidden and Lesser-known Disordered Eating Behaviors
in Medical and Psychiatric Conditions,
https://doi.org/10.1007/978-3-030-81174-7_2
6 A. Parmeggiani and J. Pruccoli

achieve proper eating skills [3]. FD might be the result of a lack of balance among
parents’ feeding style, organic causes, and child behaviour. FD present themselves
on a clinical spectrum from mild to severe and are characterized by food refusal,
lower amount of food intake or a more significant food selectivity than that appro-
priate for the age. FD have a prevalence among children in western countries around
20–30%, including cases misperceived by parents [4], and they represent a risk fac-
tor for severe long-lasting physical and psychosocial morbidity. Recurrence of
severe FD/ED during lifetime is around 1–5% [5].
Problems of feeding in children encompass a broad range of conditions. Notably,
paediatric patients display malnourishment more quickly than adults, causing nega-
tive effects of prolonged malnutrition on their growth and development. Physicians
should consider that a FD in infancy could lead up to an ED in adolescence and in
adulthood.
Nowadays, in developed countries, nutrient deficiencies may be a consequence
of inflammatory bowel diseases, chronic diarrhoea, cystic fibrosis, congenital heart
defects, prematurity, intestinal failure, liver diseases, chylothorax, cancer, poor
wound healing, metabolic dysfunction, food allergies, gastroesophageal reflux dis-
ease, esophagitis, macroglossia, etc. [5, 6]. But they may also be a consequence of
an inappropriate dietary intake in children without a balanced support of mineral/
vitamins [7]. Feeding problems or dysphagia is seen in up to 25% of all children in
developed countries. Prematurely born children present an increased prevalence of
swallowing disorders, developmental disorders and cerebral palsy [8–10].
Literature reports a number of medical definitions for feeding difficulties, such
as neophobia (food rejection), picky eating (fussy children) and avoidant/restrictive
food intake disorder (ARFID), a newly introduced diagnosis in the DSM-5 [11].
An exhaustive medical approach to patients reporting FD should include a
detailed anamnesis, physical and neurological examinations, dietary assessment
and appropriate exams regarding possible organic failure. Dysphagia or swallowing
in children with premature birth, cerebral palsy or metabolic diseases should always
be considered. Once organic disorders have been ruled out, physicians should con-
sider non-organic aetiologies: incorrect feeding behaviours as selective intake, fear
of feeding, low food intake or even food refusal may be present. Behavioural prob-
lems may coexist. Clinicians should investigate early depressive mood or psychoso-
cial deprivation, including maternal depression. Physicians should examine the
interaction between child and caregivers during mealtimes, postpartum depression
of the mother, selective food intake in parents and mood disorders. Whenever a
patient is diagnosed with a FD, physicians should provide a thorough assessment by
a multidisciplinary team, including paediatricians, child neuropsychiatrists, nutri-
tionists, psychologists and speech pathologists.

2.3 Classification of FD and ED in Infants and Toddlers

Classifications of FD in infancy have formerly established a rigorous dichotomy

between organic and nonorganic failure to thrive [12] by separating medically diag-
nosable causes from infant and maternal psychopathology. Later studies have raised
2 Eating Disorders in Infants and Toddlers 7

concerns regarding this distinction as being misleading and rarely possible in

­practice [13, 14].
In 1994, the DSM-IV presented “Feeding Disorder of Infancy and Early
Childhood” as a new diagnostic category, not modified in the DSM-IV-TR [15].
This disorder was defined by persistent failure to eat adequately, with significant
failure to gain weight or significant loss of weight over at least 1 month. This
disturbance was not caused either by an associated gastrointestinal or other medi-
cal condition or accounted another mental disorder or lack of available food. The
onset was before the age of 6 [16]. In 2002, Chatoor expanded this diagnostic
entity and identified six subgroups of “Feeding Behaviour Disorders” in the first
3 years of life [17]. This new classification was adopted by the Diagnostic
Classification of Mental Health and Developmental Disorders of Infancy and
Early Childhood (DC:0-3) [18], recently updated to a new version (DC:0-5). In
DC:0-5, eating disorders are distinguished according to observed pathologic eat-
ing behaviours, rather than to hypothetic aetiologies, and eating disorders of
infancy/early childhood are classified as overeating disorder, undereating disorder
and atypical eating disorder (hoarding, pica and rumination) [19]. The target of
this classification system is to evidence developmental differences in psycho-
pathological descriptions and to separate pathological conditions from transient,
age-related behaviours [20].
In 2013, the DSM-5 presented “Feeding and Eating Disorders” in one chapter,
providing diagnostic criteria for pica, rumination disorder, ARFID, anorexia ner-
vosa, bulimia nervosa, binge-eating disorder, other specified feeding or eating dis-
order and unspecified feeding or eating disorder [11]. In infancy and in childhood,
these eight categories of FD/ED may all occur. In fact, cases in individuals younger
than 13 years of age are reported in literature [21]. With regard to FD in infancy, the
main innovation brought by DSM-5 consists in replacing the former DSM-IV-TR
“Feeding Disorder of Infancy and Early Childhood” with ARFID as an entirely new
diagnosis. The diagnosis of ARFID has no age restriction. Consistent with the
DSM-5, the latest version of the International Classification of Diseases and Related
Health Problems (ICD 11) includes ARFID as a new diagnosis, replacing the former
ICD 10 “Feeding disorder of infancy and childhood” [22]. ARFID being a relatively
newly defined diagnostic category, further research should provide deeper knowl-
edge about the disorder and potential subtypes [21].

2.3.1 ARFID

The main diagnostic feature of ARFID is avoidant or restrictive eating behaviour,

with persistent difficulty in meeting nutritional needs. Patients with ARFID mani-
fest a series of clinical features as a result of their eating behaviour disturbance.
Notably, ARFID is associated with significant weight loss, or infants may show
failure to achieve weight or height as expected from their developmental trajectory.
Clinical and laboratory assessments may reveal significant nutritional deficiencies
causing anaemia, hypothermia, bradycardia and low bone mineral density [23].
Patients frequently develop dependence on enteral feeding or oral nutritional
8 A. Parmeggiani and J. Pruccoli

supplements, involving hospitalization. The DSM-5 criteria require that ARFID

should not be explained with lack of available food or associated cultural practices.
Different from anorexia nervosa, a diagnosis of ARFID requires physicians to rule
out a significant disturbance in body weight or shape perception. Lastly, no medical
or psychiatric condition should provide a better explanation of the eating distur-
bance [11, 22, 24].
Literature does not report data on population-based incidence and prevalence
rates for ARFID in infants and toddlers. A review conducted in 19 paediatric gastro-
enterology clinics in the United States found 33 patients out of 2231 (1.5%) meeting
diagnostic criteria for ARFID [25]. Further studies investigated prevalence of
ARFID among clinical settings specific for ED. The introduction of ARFID as a
new diagnosis dramatically reduced the former number of eating disorders not oth-
erwise specified (EDNOS) as classified in DSM-IV [16]. A review of 177 patients
treated for ED in Switzerland revealed that 22.5% subjects met DSM-5 criteria for
ARFID; in line with other studies, all of these patients would have previously been
diagnosed with EDNOS [26]. Literature consistently reports that patients diagnosed
with ARFID are younger and male and present greater psychiatric and medical
comorbidity compared to another ED [27, 28, 29]. Many studies report higher rates
of generalized anxiety, obsessive-compulsive, autism and learning disorders [28,
30]. Congenital malformations, very low birth weight, cerebral palsy and diseases
of the gastrointestinal tract may also be associated with a picture similar to
ARFID. Consequences of any underlying medical or psychiatric condition may
have triggered food aversion. Moreover, DSM-5 criteria neither presuppose nor
exclude any aetiology previously and assume that ARFID may occur concurrently
with medical or comorbid psychiatric diagnoses, if the feeding or disturbance
implies clinical attention beyond that expected for the co-occurring illness [11, 25].
For this reason, to distinguish between medical conditions and ARFID is frequently
challenging [31].
When food refusal dominates the clinical picture, a relevant differential diagno-
sis should be made between ARFID and pervasive refusal syndrome (PRS).
Pervasive refusal syndrome is a rare, potentially life-threatening condition, charac-
terized by the following: partial or complete refusal in eating, mobilization, speech
and/or personal care; active resistance to help; social/school withdrawal; and clini-
cal conditions requiring hospitalization, in the absence of co-occurring organic or
psychiatric conditions. Pervasiveness of symptoms in different domains and rejec-
tion of any offer of help may distinguish this condition from ARFID [32].

2.3.2 Autism Spectrum Disorders and FD

Infants with autism spectrum disorders (ASD) experience a variety of developmen-

tal, cognitive, medical and behavioural problems. Among these difficulties, FD
implicate significant social and biological distress. Ledford and Gast [33] presented
the first literature review of FD in ASD, describing rates of prevalence of problem-
atic feeding behaviours from 46% to 89%. The latest meta-analysis on this topic has
2 Eating Disorders in Infants and Toddlers 9

been published by Sharp, Berry and colleagues [34]. Findings from their study show
that children with ASD are five times more likely to manifest FD than their peers
without ASD. Recently, possible links between ASD symptomatology and the clini-
cal picture of eating and feeding disorders have been documented in literature.
Autistic traits in infancy have been reported by parents of patients with anorexia
nervosa (AN). This evidence may suggest that autistic features, documented in
patients with AN, pre-exist to the occurrence of eating disorder symptomatol-
ogy [35].
FD in children with ASD may include deficient motor skills (handling, chewing
and swallowing), abnormal sensory processing, gastrointestinal disorders, behav-
ioural problems (obsessive-compulsive or repetitive behaviours, imitation impair-
ment and limited interests), maladaptive mealtime behaviours and food selectivity
[1, 36]. FD as selective or scarce feeding may represent a warning early sign sug-
gesting an ASD and are frequently associated with delay or stagnation of develop-
ment [37]. Earliest alterations may be evident since the 6th month of life [38]. Food
selectivity represents the most predominant feeding problem in ASD, affecting
approximately 70% of patients; texture, taste, smell and temperature of foods may
be involved. Carbohydrates, snack foods and processed foods are usually preferred
over vegetables and fruit [39]. Abnormalities in sensory integration, as well as
social and familial factors, could play a role in determining feeding difficulties; no
definite causal relationship between feeding disorders and ASD, however, has been
demonstrated so far [40]. Feeding difficulties among children with ASD have been
positively related to parent-reported autism core symptoms, behavioural disorders,
sleep difficulties and parental stress [41].
Clinical monitoring of FD among infants with ASD has prominently focused on
growth impairment. Yet, literature reports no significant disparity between children
with and without ASD concerning height, weight and BMI. Energy intake, as con-
sumption of carbohydrates and fats, is not usually impaired, despite feeding diffi-
culties. Exhaustive nutritional analysis, however, reveals significant distinctive
deficits, e.g. lower calcium and protein intake, and suggests susceptibility to multi-
ple long-term complications. Deficits of vitamins A, B12 and D have been docu-
mented as well. Thus, relying only on classic anthropometric measurements in
children with ASD may reveal regular health status and cover underlying specific
nutritional deficits [35].
Recent studies attest to a growing interest in dietary manipulation (e.g. gluten-­
free casein-free diet, GFCF) for children with ASD. Elimination diets, based on the
removal of complex carbohydrates and processed foods, have been documented as
well. These interventions have been reported to contribute to dietary insufficiencies
and nutritional deficits in children with ASD [42].
Based on this evidence, clinicians should regularly assess nutritional conditions
of patients with ASD. Feeding difficulties should be systematically investigated and
considered together with the analysis of anthropometric parameters and nutritional
deficits or excesses. Furthermore, physicians should inform parents about the
­potential risks involved in putting children with ASD on an elimination diet or diet
modifications [43].
10 A. Parmeggiani and J. Pruccoli

2.3.3 Treatment

FD/ED in infancy show heterogeneous clinical pictures, which encompass medical,

behavioural and psychological factors and thus entail individualized and multidisci-
plinary treatment programmes. Since unaddressed FD frequently persist into ado-
lescence and adulthood, causing multiple complications, early referral for diagnosis
and treatment is mandatory.
Currently, literature confirms behavioural therapy as the main empirically sup-
ported treatment for FD in paediatrics. Comparative studies have revealed its mark-
edly greater efficacy in improving oral intake, when compared to other
non-behavioural interventions [44–46]. Non-behavioural treatments include sen-
sory integration [47], oral-motor exercises and nutritional manipulation [48].
Literature concerning such interventions currently lacks empirical support [49]. A
few recent studies have investigated the efficacy of pharmacologic interventions on
FD in infancy; low-dose olanzapine [50], cyproheptadine [51] and D-cycloserine
[52] have shown promising results. Nonetheless, research on this topic remains lim-
ited, and pharmacotherapies continue to be considered as adjunct treatments to
behavioural interventions [50].
Concerning ARFID as a specific condition, the recent Canadian guidelines for
the treatment of eating disorders indicate that day treatment may provide weight
restoration. Cognitive behavioural therapy and atypical antipsychotics represent
promising treatments, requiring further research [53]. Concerning PRS, literature
lack official guidelines for treatment; a recent report has described the case of a
patient successfully treated with cognitive behavioural strategies like prompting,
fading, modelling and task analysis [54].
In conclusion, at present, behavioural interventions represent the mainstay of
treatment for FD in infancy. Considering the high prevalence of these conditions
among paediatric population, additional studies are needed to provide stronger
empirical evidence for existing interventions.

2.3.4 Conclusion and Take-Home Message

Feeding represents a complex regulation system. It is one of the most important inter-
actions between a caregiver and a child, which can be affected by many variables.
Clinicians should never underestimate feeding difficulties in childhood. They should
always carefully consider the medical, dietary and psychosocial history of their young
patients to determine any underlying causes for feeding disorders and should utilize
anthropometric measurements. Early diagnosis is crucial because FD in infancy may
lead up to ED in adolescence and in adulthood and may represent a warning early sign
suggesting ASD. Management of a child with FD requires collaborative care of a
multi-professional team. Early referral for diagnosis and treatment is mandatory. At
present, behavioural therapy is the main supported treatment for FD in childhood.
Although recent studies have investigated the efficacy of some drugs, additional stud-
ies are needed to provide further evidence for existing treatments.
2 Eating Disorders in Infants and Toddlers 11

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