Feeding disorder of infancy or early childhood
Feeding disorder of infancy or early childhood is characterized by the failure of an infant or child under six years of age to eat enough food to gain weight and grow normally over a period of one month or more. The disorder can also be characterized by the loss of a significant amount of weight over one month. Feeding disorder is similar to failure to thrive, except that no medical or physiological condition can explain the low food intake or lack of growth.
Infants and children with a feeding disorder fail to grow adequately, or even lose weight with no underlying medical explanation. They do not eat enough energy or nutrients to support growth and may be irritable or apathetic. Factors that contribute to development of a feeding disorder include lack of nurturing, failure to read the child's hunger and satiety cues accurately, poverty, or parental mental illness. Successful treatment involves dietary, behavioral, social, and psychological intervention by a multidisciplinary team of health professionals.
Causes and symptoms
Feeding disorder of infancy or early childhood can occur with inappropriate parent-child interactions, such as failure to read the child's hunger cues or forcing food when the child is not hungry. Lack of nurturing and/or parental aggression, anger, or apathy can make eating a negative experience for the child, increasing the risk of feeding disorders.
Feeding disorders are more common in infants and children who are born prematurely, had a low birth weight, or who are developmentally delayed. Many medical (or physiological) causes can contribute to eating difficulties, eating aversions, or failure to thrive, including:
- diseases of the central nervous system
- metabolic diseases
- sensory defects
- anatomical abnormalities, such as cleft palate
- muscular disorders, such as cerebral palsy
- heart disease
- gastrointestinal diseases, such as Crohn's disease
To meet criteria for a true feeding disorder of infancy or childhood, these medical conditions must be ruled out.
Because the child or infant with a feeding disorder is not consuming enough energy, vitamins, or minerals to support normal growth, symptoms resemble those seen in malnourished or starving children. The infant or child may be irritable, difficult to console, apathetic, withdrawn, and unresponsive.
Delays in development, as well as growth, can occur. In general, the younger the child, the greater the risk of developmental delays associated with the feeding disorder.
Laboratory abnormalities may also be associated with the disorder. Blood tests may reveal a low level of protein or hemoglobin in the blood. Hemoglobin is an iron-containing substance in blood that carries oxygen to body cells.
Although minor feeding problems are common in infancy and childhood, true feeding disorder of infancy or early childhood is estimated to occur in 1% to 3% of infants and children. Children separated from their families or living in conditions of poverty or stress are at greater risk. Mental illness in a parent, or child abuse or neglect , may also increase the risk of the child developing a feeding disorder.
Between 25% and 35% of normal children experience minor feeding problems. In infants born prematurely, 40% to 70% experience some type of feeding problem. For a child to be diagnosed with feeding disorder of infancy or early childhood, the disorder must be severe enough to affect growth for a significant period of time. Generally, growth failure is considered to be below the fifth percentile of weight and height.
Feeding disorder of infancy or early childhood is diagnosed if all four of the following criteria are present:
- Failure to eat adequately over one month or more, with resultant weight loss or failure to gain weight.
- Inadequate eating and lack of growth not explained by any general medical or physiological condition, such as gastrointestinal problems, nervous system abnormalities, or anatomical deformations.
- The feeding disorder cannot be better explained by lack of food or by another mental disorder, such as rumination disorder.
- The inadequate eating and weight loss or failure to gain weight occurs before the age of six years. If feeding behavior or weight gain improves when another person feeds and cares for the child, the existence of a true feeding disorder, rather than some underlying medical condition, is more likely.
Successful treatment of feeding disorders requires a multidisciplinary team approach to assess the child's needs and to provide recommendations and education to improve feeding skills, behavior, and nutrient intake. The multidisciplinary team for treatment of feeding disorders in childhood usually includes physicians specializing in problems of the gastrointestinal tract or of the ear, nose, and throat; a dietitian, a psychologist , a speech pathologist, and an occupational therapist. Support from social workers and physicians in related areas of medicine is also helpful.
An initial evaluation should focus on feeding history, including detailed information on type and timing of food intake, feeding position, meal duration, energy and nutrient intake, and behavioral and parental factors that influence the feeding experience. Actual observation of a feeding session can give valuable insight into the cause of the feeding disorder and appropriate treatments. A medical examination should also be conducted to rule out any potential medical problems or physical causes of the feeding disorder.
After a thorough history is taken and assessment completed, dietary and behavioral therapy is started. The goal of diet therapy is to gradually increase energy and nutrient intake as tolerated by the child to allow for catch up growth. Depending on the diet history, energy and nutrient content of the diet may be kept lower initially to avoid vomiting and diarrhea. As the infant or child is able to tolerate more food, energy and nutrient intake is gradually increased over a period of one to two weeks, or more. Eventually, the diet should provide about 50% more than normal nutritional needs of infants or children of similar age and size.
Behavioral therapy can help the parent and child overcome conditioned feeding problems and food aversions. Parents must be educated to recognize their child's hunger and satiety cues accurately and to promote a pleasant, positive feeding environment. Changing the texture of foods, the pace and timing of feedings, the position of the body, and even feeding utensils can help the child overcome aversions to eating. If poverty, abuse, or parental mental illness contribute to the feeding disorder, these issues must also be addressed.
If left untreated, infants and children with feeding disorders can have permanent physical, mental, and behavioral damage. However, most children with feeding disorders show significant improvements after treatment, particularly if the child and parent receive intensive nutritional, psychological, and social intervention.
Providing balanced, age-appropriate foods at regular intervals—for example, three meals and two or three snacks daily for toddlers—can help to establish healthy eating patterns. If a child is allowed to fill up on soft drinks, juice, chips, or other snacks prior to meals, appetite for other, more nutritious foods will decrease.
Positive infant and childhood feeding experiences require the child to communicate hunger and satiety effectively and the parent or caregiver to interpret these signals accurately. This set of events requires a nurturing environment and an attentive, caring adult. Efforts should be made to establish feeding as a positive, pleasant experience. Further, forcing a child to eat or punishing a child for not eating should be avoided.
American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders. 4th edition, text revised. Washington, DC: American Psychiatric Association, 2000.
Queen, Patricia M., M.M.Sc., R.D. and Carol E. Lang, M.S., R.D. Handbook of Pediatric Nutrition. Gaithersburg, Maryland: Aspen Publishers, Inc., 1993.
Colin D. Rudolph and Dana Thompson Link. "Feeding Disorders in Infants and Children." Pediatric Clinics of North America 49 (2002): 97-112.
Nancy Gustafson, M.S., R.D., F.A.D.A., E.L.S.