Feeding Disorders of Infants and Toddlers:

Infantile Anorexia

 Alice Lawrence

Penn State College of Medicine

2003

 

Feeding disorders can occur in infants secondary to many different causes. These disorders can lead to failure to thrive in the infant, and thus associated with significant developmental risks. Failure to thrive is generally defined as a child whose weight is below the 5^th percentile for age or whose weight is <80% of the ideal body weight for that age, and is present for at least 1-month duration. It may be caused by a wide variety of disorders, organic and/or non-organic in nature.

 

DSM-IV Diagnostic Criteria    – Feeding Disorder in Infancy or Early Childhood

1. Feeding disturbance as manifested by persistent failure to eat adequately with significant failure to gain weight or significant loss of weight over at least 1 month.
2. The disturbance is not due to an associated gastrointestinal or other general medical condition (e.g., esophageal reflux).
3. The disturbance is not better accounted for by another developmental disorder (e.g., Rumination Disorder) or by lack of available food.
4. The onset is before the age of 6 years.

 

The broad scope of the DSM-IV diagnostic criteria does not differentiate between different types of infant/toddler feeding disorders. Three sub classifications of developmental feeding disorders have been described (Chatoor, Schaefer, Dickson, and Egan, 1984): 1) Feeding Disorder of Homeostasis, 2) Feeding Disorder of Attachment, and 3) Infantile Anorexia (Feeding Disorder of Separation).

 

A Feeding Scale for Research and Clinical Practice to Assess Mother-Infant Interactions in the First Three Years of Life

(Article by Chatoor, Getson, Menvielle, Brasseaux, O’Donnell, Rivera, and Mrazek; 1997)

The aim of the study was to develop and validate a practical tool that can code the observations of mother-infant interactions during feeding. The study included infants who were failing to thrive and who also met the clinical diagnostic criteria for a developmental feeding disorder. The following criteria were specified in the paper for each of the disorders.

1. Feeding Disorder of Homeostasis

-Characterized by difficulties in establishing regular, calm feedings and by inadequate food intake of the infant. The regulation of feeding is closely tied to the mother-infant relationship. Characteristics of the infant and parent contribute to the disorder.

1. Infant
   1. Onset of feeding problem between birth and 3 months of age
   2. Irregular feeding pattern and poor intake
   3. Infant shows poor regulation of state during feeding

-Infant show irritability, easy fatigability, and/or excessive sleepiness.

4. Failure to thrive
5. Parent

– Parental anxiety, depression, psychopathology and/or psychosocial stressors lead to inability of the mother to read the infant’s cues and to facilitate calm, successful feedings.

1. Differential Diagnosis

Associated organic problems of the infant may contribute to but do not fully explain the feeding problems. These may include:

1.prematurity;

2.cardiac or pulmonary disease

3. Functional or structural abnormalities of the oropharynx or

gastrointestinal tract (cleft palate, gastroesophageal reflux, esophageal

atresia, etc)”

 

2. 2. Feeding Disorder of Attachment

– Characterized by lack of engagement between the mother and infant.

1. Infant
   1. Onset of growth failure between 2 and 8 months
   2. Infant shows lack of age-appropriate social responsivity
      • – Lack of visual engagement and avoidance of eye contact, but may be hypervigilant when people are at a distance
      • – Lack of social smiling
      • – Lack of vocal reciprocity
      • – Lack of age appropriate anticipatory reaching when picked up
      • – Lack of molding and cuddling when held
   3. Infant development shows
      • – Delay in motor milestones
      • – Delayed cognitive development,
      • – Poor muscle tone (hyperextension when picked up, surrender position when held)
      • – Failure to thrive
   4. Parent characteristics

The parent is frequently described as having acute or chronic depression, and/or personality disorder, drug or alcohol abuse, and/or psychosocial stress. There is a lack of affectionate care and lack of regular feedings or the infant. Often bottles are propped for the infants to feed by themselves or feedings are forgotten.

1. Differential Diagnosis

Needs to be differentiated from organic conditions, which lead to the lack of weight gain”

3. Infantile Anorexia

– This is defined as a feeding disorder of separation and is characterized by food refusal by the infant with intense conflict in the mother-infant relationship over issues of autonomy, dependency, and control. Occurs after the infant has learned to regulate himself and has established an attachment to the primary caregiver

1. Infant
   1. Onset of food refusal occurs during the infants transition to self-feeding, between 6 months and 3 years
   2. Food refusal by the infant, which varies from meal to meal and among different caregivers, and results in inadequate food intake in general.
   3. Inadequate weight gain has resulted in failure to thrive
      • – Weight is below the 5^th percentile for age, or weight has deviated across two major percentiles over a 2 – 6 month period
      • – Weight for height has fallen below the 90% of ideal weight for height.
   4. Development of the infant appears normal except for:
      • – Delay in motor development in severe cases secondary to malnutrition.
      • – Delay in expressive speech in some infants who appear to refuse to talk as they refuse to eat.
   5. Parent
      1. The parent perceives the infant as
         • – Having a poor appetite
         • – Being curious and demanding of attention
         • – Being difficult and stubborn during feedings, rejecting the parental efforts to get the infant to eat
      2. High parental anxiety about the infants poor food intake expressed by at least two of the following behaviors
         • – Coaxing the infant to eat more
         • – Distraction the infant with toys or games to induce the infant to eat
         • – Feeding the infant around the clock including at night
         • – Trying different types of food if the infant does not eat
         • – Force feeding the infant
      3. Differential Diagnosis

Food refusal of the infant is not due to a traumatic event such as choking, gagging, insertion of feeding or endotracheal tubes, vomiting or pain secondary to gastroesophageal reflux, or any other medical illness.”

 

The Feeding Scale was developed as a “global rating scale standardized for the observation of mother-infant/ toddler interactions during a 20 minute feeding session”

Forty-six mother and infant behaviors are rated in order to yield 5 subscale scores:

1. Dyadic Reciprocity
2. Dyadic conflict
3. Talk and Distraction
4. Struggle for Control
5. Maternal Non-Contingency

 

The Feeding Scale was found to differentiate infants and children in the 3 types of developmental feeding disorders. ‘In general it was found that mother-infant pairs with Feeding Disorder of Homeostasis demonstrated poor dyadic reciprocity. Feeding Disorder of Attachment was associated with poor dyadic reciprocity, as well increased maternal non-contingency. In toddlers with Infantile Anorexia there was high levels of dyadic conflict, struggle for control, as well as poor dyadic reciprocity and maternal non-contingency.’

It was concluded that The Feeding Scale accurately identified 80% of the infants with feeding disorders. It was able to differentiate infants with one of the types of developmental feeding disorders from each other as well as from healthy well–feeding infants.

 

Mother-Infant Interactions in Infantile Anorexia Nervosa

(Chatoor, Egan, Getson, Menvielle, O’Donnell; 1987)

The study examined interaction patterns between mothers and infants during feeding and play. It was found that mothers of infants with infantile anorexia tended to lack the flexibility to pace their behavior according to the infant’s cues. They were found to try to impose their will on the infant. “Feeding became a chore instead of an enjoyable experience.”

Mothers of the of the non-anorexic infants tended to wait more for the infant to initiate interactions and allowed greater participation of the infant in the feeding process. In addition the mothers in the control group were generally more cheerful and at ease in their interaction with their child were as the mothers of the children with infantile anorexia often appeared to be sad, distressed, or angry during their interactions with their child.

It is felt that the infant with infantile anorexia has difficulties in the development of separation and autonomy. “ These conflicts affect eating behaviors and interfere with the development of somatopyshcological differentiation. It is thought that by the mother missing or repeatedly overriding the infant’s cues the infant becomes confused as to the differences between physical sensation and emotional needs. Food intake becomes regulated by the infants emotional instead of physiological needs.”

 

Diagnosing Infantile Anorexia: The Observation of Mother-Infant Interactions

(Chatoor, Hirsch, Ganiban, Persinger, Hamburger; 1998)

The study was conducted to first delineate the diagnostic criteria for infantile anorexia, then determine interrater agreement of child psychiatrists making the diagnosis or infantile anorexia. The feeding scale was used as a diagnostic tool and comparisons were made between children having infantile anorexia, those classified as “ picky eaters”, and those classified as “ healthy eaters.” The study was able to differentiate between interactional patterns of infants with Infantile Anorexics and those who were classified as “ healthy eaters”. The study found considerable overlap in symptoms of food refusal, parental concern about infants intake, mother- infant conflict, talk and distraction during feeding between the group of children classified as “picky eaters” and those with infantile anorexia. The children with infantile anorexia tended to show more severe symptoms than the children classified as “picky eaters”. “Picky eaters” did not have acute or chronic malnutrition that is seen in the children suffering from infantile anorexia. The study was not able to accurately identify which of the infants who exhibited refusal to eat behaviors were at a significant risk for the development of malnutrition. It was suggested that future research should try to establish a method for increased “diagnostic precision” for the identification of Infantile Anorexia. This is important since it was been found that “maladaptive interactional patterns between the infant and the caregiver tend to become increasing solidified over time and appear to maintain this disorder.” It is important to have a way for the early recognition and differentiation of infantile anorexia from other feeding disorders in order to develop and utilize specific and appropriate interventions.

Maternal Characteristics and Toddler Temperament in Infantile Anorexia

( Chantoor, Ganiban, Hirsch, Borman-Spurrell, Mrazek; 2000)

The study was done to assess the extent that maternal characteristics and perceptions of their toddler temperament were associated with infantile anorexia. Results indicated that toddlers with infantile anorexia were perceived by their mothers to have a “ more difficult” temperament than toddlers who did not have a feeding disorder. They found the infants to have more irregular feeding and sleeping patterns, be more negative in mood, more demanding of attention, and more willful.

The mother’s perceptions of there own early attachment relationships were also examined. It was found that ‘ insecure attachment representations were more prevalent in mothers of toddlers with Infantile Anorexia than in mothers of infants who were healthy eaters. This is thought to contribute to some of the difficulty that these mothers have understanding their toddlers behaviors and knowing when to initiate or stop feeding as well as difficulty setting limits. Mothers of toddlers with Infantile Anorexia reported neither more disordered eating attitudes nor more marital dissatisfaction than other control groups.

 

References 

Chatoor, I., Egan, J., Getson, P., Menvielle, E., O’Donnell, R., (1987).

Mother-infant interactions in infantile anorexia nervosa. Journal of American Academy of Child and Adolescent Psychiatry, 27(5): 535-540.

Chatoor, I., Getson, P., Menvielle, E., Brasseaux, C., O’Donnell, R., Rivera, Y., and

Mrazek, D. (1997). A feeding scale for research and clinical practice to assess mother-infant interactions in the first three years of life. Infant Mental Health Journal, 18(1): 76-91.

Chatoor, I., Ganiban, J., Hirsch, R., Borman-Spurrell, E., Mrazek, D. (2000).

Maternal characteristics and toddler temperament in infantile anorexia. Journal of American Academy of Child and Adolescent Psychiatry, 39(6): 743-751.

Chatoor, I., Hirsch, R., Ganiban, J., Persinger, M., Hamburger, E. (1998).

Diagnosing infantile anorexia: The observation of mother-infant interactions. Journal of American Academy of Child and Adolescent Psychiatry, 37(9): 959-967. 

Chatoor, I., Schaefer, S., Dickson, L., Eagan, J. (1984). Non-organic failure-to-thrive:

A developmental perspective. Pediatric Annals, 13:829-843.

Diagnostic Criteria from DSM-IV. (1994). American Psychiatric Association,

Washington, DC