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Chapter: Essentials of Psychiatry: Childhood Disorders: Feeding and Other Disorders of Infancy or Early Childhood

Post Traumatic Feeding Disorder

Food refusal follows a traumatic event or repeated traumatic insults to the oropharynx or gastrointestinal tract (e.g., chok-ing, severe vomiting, reflux, insertion of nasogastric or en-dotracheal tubes, suctioning) that trigger intense distress in the infant.

Post Traumatic Feeding Disorder


Diagnostic Criteria


1.  Food refusal follows a traumatic event or repeated traumatic insults to the oropharynx or gastrointestinal tract (e.g., chok-ing, severe vomiting, reflux, insertion of nasogastric or en-dotracheal tubes, suctioning) that trigger intense distress in the infant.


·           B. Consistent refusal to eat manifests in one of the following ways:


·           Refuses to drink from the bottle, but may accept food of-fered by spoon (although consistently refuses to drink from the bottle when awake, may drink from the bottle when sleepy or asleep).


·           Refuses solid food, but may accept the bottle.


·           Refuses all oral feedings.


2.        Reminders of the traumatic event(s) cause distress as mani-fested by one or more of the following:


·           Shows anticipatory distress when positioned for feeding.


·           Shows intense resistance when approached with bottle or food.


·           Shows intense resistance to swallow food placed in the in-fant’s mouth.


3.        The food refusal poses an acute or long-term threat to the child’s nutrition.




Although no studies on the prevalence of this disorder are avail-able, it appears that the occurrence of this feeding disorder has been increasing because of the growing number of infants with complex medical problems who survive.




Although it is difficult to say what the inner experience of a young infant might be, the affective and behavioral expressions of in-fants provide a window to their inner life. In a study of infants diagnosed with post traumatic feeding disorder, also including a control group of healthy eaters and a group of anorectic infants matched by age, sex, race and socioeconomic background, con-flict in mother–infant interactions during feeding was present in both feeding-disordered groups. However, only those subjects with a post traumatic feeding disorder demonstrated intense pre-oral and intraoral feeding resistance. They appeared distressed, cried and pushed the food away in anticipation of being fed, and kept solid food in their cheeks or spat it out if the mothers were able to place any food in their mouths. The mothers usually re-ported that these defensive behaviors started abruptly after the infant experienced severe vomiting, gagging, or choking or un-derwent invasive manipulation of the oropharynx (e.g., insertion of feeding and endotracheal tubes or vigorous suctioning).


Diagnosis and Differential Diagnosis


This feeding disorder is characterized by the infant’s consistent refusal either to drink from the bottle or to eat any solid foods, and in most severe cases, by the infant’s refusal to eat at all. De-pending on the mode of feeding that the infants appear to associ-ate with the traumatic event(s), some refuse to eat solids, but will continue to drink from the bottle, whereas others may refuse to drink from the bottle, but are willing to eat solids. Some infants may put baby food in their mouths, but then spit out any food that has any little lumps in it. Most infants get stuck in these food patterns and may lose weight or lack certain nutrients because of their limited diet.


Reminders of the traumatic event(s) (e.g., the bottle, the bib, or the high chair) may cause intense distress for some infants, whereby they become fearful when they are positioned for feed-ings and/or presented with feeding utensils and food. They resist being fed by crying, arching and refusing to open their mouths. If food is placed in their mouths, they intensely resist swallowing. They may gag or vomit, let the food drop out, actively spit the food out, or store the food in their cheeks and spit it out later. The fear of eating seems to override any awareness of hunger. There-fore, infants who refuse all foods, including liquids and solids, require acute intervention due to dehydration and starvation.


In addition to a thorough history about the onset of the infant’s food refusal and the medical and developmental history, the observation of the infant and mother during feeding is critical for understanding this feeding disorder and differentiating it from infantile anorexia and from sensory food aversions. It is helpful to ask the mother to bring a variety of foods, including those that the infant refuses and those that he or she accepts. Infants with a post traumatic feeding disorder characteristically appear en-gaged and comfortable with their mothers as long as the feared food is out of sight. Some infants begin to show distress when they are placed in the high chair and they struggle to get away. In less severe cases, the infant might allow the food to go into the mouth but then spit it out and show distress only when urged to swallow. This anticipatory fear of food differentiates infants with a post traumatic feeding disorder from anorectic infants, whose food refusal appears random and related to issues of control in the relationship with the mothers. Toddlers with sensory aversions to certain types of food might also show distress when urged to eat these foods. However, their mothers do not remember a traumatic event that seemed to trigger the food refusal behaviors.


Course and Natural History


Most infants seem to get locked into their food refusal patterns. The more anxiously the parents react to the infant’s food refusal, the more anxious the infants appear to become, with the parent and the infant feeding off each other’s anxiety. Individual case studies indicate that some of these infants depend for years on gastrostomy feedings to survive. Others may live on milk and puréed food until school age, when the social embarrassment of their eating behavior urges the parents to seek help.




Because of the complexity of many of these cases, a multidisci-plinary team (consisting of a pediatrician or gastroenterologist, a psychiatrist or psychologist, a social worker, an occupational therapist or hearing and speech specialist, a nutritionist and a specially trained nurse to serve as team coordinators) is best equipped to meet all the needs of these infants and their parents.


Before any psychiatric treatment can be successfully initi-ated, the medical and nutritional needs of the infant need to be addressed. In severe cases of total food refusal, it is important to act quickly to maintain the infant’s hydration. The medical and psychiatric team members must work together to assess whether temporary nasogastric tube feedings are indicated or whether plans for a gastrostomy should be made. Unfortunately, the re-peated insertion of nasogastric feeding tubes can intensify a post traumatic feeding disorder, and an infant in a labile medical con-dition can take months if not years to recover.


The psychiatric treatment of this feeding disorder involves a desensitization of the infant to overcome the anticipatory anxi-ety about eating and return to internal regulation of eating in re-sponse to hunger and satiety. It is most important to help the par-ents understand the dynamics of a post traumatic feeding disorder so that they can recognize the infant’s anticipatory anxiety and become active participants in the treatment. After identification of triggers of anticipatory anxiety (e.g., the sight of the high chair, the bottle, or certain types of food), a desensitization by gradual exposure can be initiated or a more rapid desensitization through more intensive behavioral techniques can be implemented.


With both techniques, it is important to have a professional assess the infant’s oral motor coordination because many infants who refuse to eat for extended periods fall behind in their oral motor development due to lack of practice. The rapid introduc-tion of table food to a child who has delayed oral motor skills may lead to choking, thereby creating a setback to the desensitization process.


During the desensitization process, the infant has to be re-inforced for swallowing the food. This behavioral manipulation of the infant’s eating frequently leads to external regulation of eating in response to the reinforcers. Once the infant has become comfortable with eating, it is important to phase out these exter-nal reinforcers to allow the infant to regain internal regulation of eating in response to hunger and fullness. This can be a difficult transition because many infants gain control over their parent’s emotions by eating or not eating. The techniques described under infantile anorexia – the implementation of the feeding guidelines contained in step 3 – can be helpful in making this transition.


As summarized in Figure 29.1, each of these five feeding disorders presents with specific symptom patterns and charac-teristic mother–infant interactions, which help to diagnose and differentiate the various feeding disorders. The correct diagno-sis is critical because a treatment that is helpful for one feed-ing disorder may be ineffective or even worsen another feeding disorder. For example, infants with infantile anorexia become more aware of their hunger cues and feed better if fed only every4 hours without being offered food or liquids in between meals. However, an infant with post traumatic feeding disorder who is afraid of eating will not accept food regardless of how long he or she has been kept without feeding. On the other hand, behav-ioral techniques that help extinguish fear-based food refusal in a post traumatic feeding disorder further distract an infant with infantile anorexia and further interfere with the awareness of hunger.


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