Infantile Anorexia

Infantile Anorexia

Diagnostic Criteria

·           Refusal to eat adequate amounts of food for at least 1 month.

·           Onset of the food refusal under 3 years of age, most com-monly during the transition to spoon- and self-feeding.

·           Does not communicate hunger signals, lacks interest in food, but shows strong interest in exploration and/or interaction with caregiver.

·           Shows significant growth deficiency.

·           The food refusal did not follow a traumatic event.

·           The food refusal is not due to an underlying medical illness.

Epidemiology

A study from Sweden reported that 1 to 2% of infants younger than 1 year of age had severe feeding problems associated with refusal to eat or vomiting, resulting in poor weight gain. At 4 years, 71% of those with food refusal were reported by their par-ents as still having feeding problems (Dahl and Sundelin, 1992). The disorder seems to be equally as common among boys and girls of all racial backgrounds and appears most commonly in the middle and upper middle class.

Etiology

Chatoor and colleagues (2000) tested a transactional model for the understanding of infantile anorexia by which certain charac-teristics of the infant combine with certain vulnerabilities in the mother to bring out negative responses and conflict in their inter-actions. They also found that infants with infantile anorexia were rated higher by their mothers on temperament difficulty, irregu-larity of feeding and sleeping patterns, negativity, dependence and unstoppable behaviors than were healthy eaters. The moth-ers of children with infantile anorexia were found to demonstrate more attachment insecurity to their own parents. The mothers’ attachment insecurity frequently stemmed from extremes of pa- rental discipline in the form of parental over control or emotional unavailability while they were growing up. The infants’ tempera-ment characteristics, their mothers’ insecure attachment to their own parents, and the mothers’ drive to be thin themselves corre-lated significantly with mother–infant conflict during feeding.

It is helpful to look at infantile anorexia from a develop-mental perspective. Between 9 and 18 months of age, the general developmental task of separation and individuation takes on spe-cial significance in the feeding relationship. Issues of autonomy versus dependency must be worked out in the dyad, particularly during the transition to self-feeding. If the mother is able to read the infant’s signals correctly and responds contingently, the in-fant will learn to differentiate physiological feelings of hunger and fullness from emotional experiences such as anger, frustra-tion, or the wish for attention. In this case, the infant’s food in-take will be internally regulated through physiological cues of hunger and satiety. On the other hand, if the mother is insecure in how to interpret the infant’s cues and responds in a noncontin-gent way, the infant will learn to associate feeding with negative or positive emotional experiences. Consequently, infants who are irregular and whose cues are difficult to read, and mothers who are insecure in how to interpret their infants’ cues and respond in an inconsistent and noncontingent way, will develop conflict during feeding, and the infant will fail to develop internal regula-tion of eating.

Diagnosis

Infants with this feeding disorder are usually referred for a psychiatric evaluation due to food refusal and growth failure. The infants’ food refusal usually becomes of concern between 6 months and 3 years, most commonly between 9 and 18 months of age, during the transition to spoon- and self-feeding. However, some parents report that even during the first few months of life, these infants were easily distracted by external stimuli and be-came disinterested in feeding. Then, the mothers were able to compensate for the infants’ poor feeding by feeding them more frequently. However, by the end of the first year when infants are transitioned to spoon- and self-feeding, these infants take only a few bites and want to get out of the high chair to play. Most par-ents report that these infants hardly show any signals of hunger and seem more interested in exploring and playing than eating. Usually, the parents become increasingly worried about their in-fants’ poor food intake and try to increase their infants’ eating by coaxing, distracting, offering different food, feeding during play, feeding at night, threatening and even force-feeding their infants. However, most parents report that these methods worked only temporarily, if at all, and that their infants continued to eat poorly in spite of all their efforts.

The diagnostic evaluation of this feeding disorder should include the infant’s feeding, developmental and health history, and the observation of mother and infant during feeding. In addi-tion to the infant’s history, the mother’s perception of her infant’s temperament, her family situation, her childhood background, and her own eating habits and attitude toward limit setting need to be explored.

Course and Natural History

Initially, infants with this feeding disorder fail to gain adequate weight. After several weeks or months of poor food intake, their linear growth slows down and they develop chronic malnutrition. In most cases their heads continue to grow at a normal rate. As the children grow older, their bodies appear small and thin, but their head size and brain development appear to progress at a normal rate.

Treatment

The psychotherapeutic intervention is based on the developmen-tal psychopathological model of infantile anorexia as outlined in the section on etiology. The major goal of the intervention is to “facilitate internal regulation of eating” by the infant. The inter-vention consists of three components:

·           Assess and then explain the infant’s special temperamental characteristics and developmental conflicts to the mother to help her understand the lack of expected hunger cues and the infant’s struggle for control during the feeding situation.

·           Explore the mother’s upbringing and the effect it has had on the parenting of her infant to help the mother understand her conflicts and difficulties in regard to limit setting.

·           Explain the concept of internal versus external regulation of eating. Help the mother to develop mealtime routines that fa-cilitate the infant’s awareness of hunger, leading to internal regulation of eating, improved food intake and growth. In ad-dition, coach the parents to set limits to the infant’s behaviors that interfere with eating. These feeding guidelines include:

a)        Schedule meals and snacks at regular 3- to 4-hour intervals and do not allow the infant to snack or drink from the bottle or breast in between.

b)       Limit meal duration to 30 minutes.

c)        Praise the infant for self-feeding but stay emotionally neu-tral whether the infant eats little or a lot.

d)       Do not use distracting toys or television during feedings.

e)        Eliminate desserts or sweets as a reward at the end of the meal; rather integrate them into regular meals and snacks.

f)         Put the infant in “time-out” for inappropriate behaviors during feeding (e.g., throwing the spoon or food, climbing out of the high chair).

These three steps in the treatment are best accomplished in three sessions lasting 2 to 3 hours each and grouped close together within a 2- to 3-week period. The intensity of this brief intervention facilitates a close therapeutic alliance between the therapist and the mother and gives the mother the opportunity to experience the support she needs to make major changes in her interactions with her infant.

Giving the mother the choice as to who in the family (or anyone else) should be included in the therapeutic process, and at what point, is part of putting the mother in control. Because many of these mothers have felt helpless as children and ineffective as parents, the empowerment of the mother is critical to the success of the treatment