Feeding disorders of infants, toddlers, and preschoolers must be taken seriously. Treatment is best done in the context of the whole family, with assessment and treatment by a multidisciplinary team. The presentation of eating problems in early childhood or eating disorders in adolescence is a strong indicator of risk for eating disorders in young adulthood.
Practitioners who treat adults of reproductive age with a history of eating disorders, or those who see young children with feeding disorders should be aware of the risks involved. Mothers of children with feeding problems had a markedly increased rate of both current and past eating disorders themselves. It is crucial for pediatricians and for physicians in general to be aware of the child at risk and to interact effectively with child mental health caregivers. Primary care physicians should be alert not only to those children who “fall off the growth curve” but also to children of adults with eating disorders or children whose parents show persistent difficulty feeding them. In collaboration with professional colleagues, physicians can interact effectively to prevent feeding disorders in early life. This should have a primary preventive effect on the incidence of eating disorders of young adulthood.
Current classification of eating disorders is failing to classify most clinical presentations; ignores continuities between child, adolescent and adult manifestations; and requires frequent changes of diagnosis to accommodate the natural course of these disorders. The classification is divorced from clinical practice, and investigators of clinical trials have felt compelled to introduce unsystematic modifications. Classification of feeding and eating disorders in ICD-11 requires substantial changes to remediate the shortcomings.
Diagnostic Criteria of Feeding Disorder
Two sets of diagnostic criteria are commonly used for infants and children with feeding disorders. The Feeding Disorder of Infancy or Early Childhood system from the DSM-IV-R contains the following criteria:
- Criterion A. Persistent failure to eat adequately, as reflected in significant failure to gain weight or significant weight loss over at least 1 month.
- Criterion B. The disturbance is not due to gastrointestinal or other general medical condition (e.g., esophageal reflux).
- Criterion C. The disturbance is not better accounted for by another mental disorder (e.g., rumination disorder) or by lack of available food.
- Criterion D. The onset must be before age 6.
Chatoor’s Diagnostic Classification of Feeding Disorders, hich has been edited and included in DC: 0-3R, states:
- The diagnosis of feeding behavior disorder, the symptoms of which may become evident at different stages of infancy and early childhood, should be considered when an infant or young child has difficulty establishing regular feeding patterns—that is, when the child does not regulate his or her feeding in accordance with physiological feelings of hunger or fullness. If these difficulties occur in the absence of hunger or interpersonal precipitants such as separation, negativism, or trauma, the clinician should consider a primary feeding disorder.
The six subcategories of feeding behavior disorder are summarized in DC: 0-3R as follows:
- Feeding disorder of state regulation. The infant has difficulty reaching and maintaining a calm state during feeding (e.g., the infant is too sleepy, too agitated, or too distressed to feed). This disorder starts in the newborn period.
- Feeding disorder of caregiver-infant reciprocity. The infant or young child does not display developmentally appropriate signs of social reciprocity (e.g., visual engagement, smiling, or babbling) with the primary caregiver during feeding.
- Infantile anorexia. The infant or young child refuses to eat adequate amounts of food for at least 1 month. The onset of the food refusal occurs before the child is 3 years old. The infant or young child does not communicate hunger and lacks interest in food, but shows strong interest in exploration or interaction with caregiver, or both.
- Sensory food aversions. The child consistently refuses to eat foods with specific tastes, textures, or smells. The onset of the food refusal occurs during the introduction of a novel type of food (e.g., the child may drink one type of milk but refuse another, may eat carrots but refuse green beans, may drink milk but refuse baby food). This child eats without difficulty when offered preferred foods, and the food refusal causes specific nutritional deficiencies or a delay of oral-motor development.
- Feeding disorder associated with concurrent medical condition. The infant or young child readily initiates feeding, but shows distress over the course of feeding and refuses to continue feeding. The child has a concurrent medical condition that the clinician judges to be the cause of the distress.
- Feeding disorder associated with insults to the gastrointestinal tract. Food refusal follows a major aversive event or repeated noxious insults to the oropharynx or gastrointestinal tract (e.g., choking, severe vomiting, reflux, insertion of nasogastric or endotracheal tubes, suctioning). This infant or young child consistently refuses food in one of the following forms: bottle, solids, or both. Reminders of the traumatic event(s) cause distress, and are manifested by anticipatory distress.
Recommendations for The classification of feeding and eating disorders in the ICD-11:
- Merge feeding and eating disorders into a single grouping, with diagnostic categories available for all age groups.
- Broaden the category of anorexia nervosa (AN) by dropping the requirement for amenorrhea, extending the weight requirement to include any significant underweight, and extending the cognitive criterion to include developmentally and culturally relevant conditions and behavioral equivalents of fear of fatness, preoccupations with body weight and shape or food and eating.
- Introduce a means of qualifying severity “with a dangerously low body weight” to distinguish most severe cases that carry the riskiest prognosis within the broad category of AN.
- Broaden the category of bulimia nervosa (BN) to include subjective binge eating.
- Include the category of binge eating disorder (BED), defined by either subjective or objective binge eating in the absence of regular compensatory behaviors.
- Create a category of Combined Eating Disorder to classify subjects who concurrently or sequentially fulfill the criteria for both AN and BN.
- Introduce a category of Avoidant/Restrictive Food Intake Disorder (ARFID) to classify restricted food intake that is not accompanied by body weight- and shape-related psychopathology.
- Introduce a uniform minimal duration criterion of 4 weeks.
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