Eating Disorders: Infantile Anorexia

Eating disorders in mid-childhood are diverse and can be carried over from feeding difficulties during infancy or early childhood, or may signal fears of fatness and early struggles to control one’s weight. In addition, some children develop fears of choking and dying after they have experienced a traumatic event or witnessed someone else choking, and they avoid any foods that they fear would get stuck in their throat. In order to help affected children to overcome their fears, it is important to understand the factors that are troubling to them: is it the fear of being “fat,” the fear of eating new foods, or the fear of choking? In addition, the family needs to provide an environment in which these children can learn to regulate eating in accord with hunger and fullness and deal with their emotions more effectively.

Eating disorders in mid-childhood are diverse and can be carried over from feeding difficulties during infancy or early childhood, or may signal fears of fatness and early struggles to control one’s weight. In addition, some children develop fears of choking and dying after they have experienced a traumatic event or witnessed someone else choking, and they avoid any foods that they fear would get stuck in their throat. In order to help affected children to overcome their fears, it is important to understand the factors that are troubling to them: is it the fear of being “fat,” the fear of eating new foods, or the fear of choking? In addition, the family needs to provide an environment in which these children can learn to regulate eating in accord with hunger and fullness and deal with their emotions more effectively.

Infantile Anorexia

Chatoor and Egan first described this feeding disorder as a separation disorder because it usually becomes apparent in the first 3 years of life during the developmental phase of separation and individuation. Later, it was renamed “infantile anorexia” to emphasize the onset of this disorder during infancy and the lack of appetite that accompanies it.10 Infantile anorexia usually presents during the first 3 years of life with food refusal and growth deficiency. When these infants are transitioned to spoon and self-feeding at 9–18 months of age, the parents frequently report that they take only a few bites of food and then refuse to eat any more. The children do not open their mouths for feeding, they throw food and feeding utensils, and they frequently try to climb out of the high chair or leave the table to play. Many parents report that these children hardly show any signals of hunger. The parents usually become worried about the infants’ poor food intake, and they try to increase the infants’ eating by coaxing, distracting, bribing, offering different foods, offering food constantly, threatening, and by force feeding when they become desperate. As time goes on, the children’s feeding becomes increasingly dependent on the interactions with their parents, who end up feeling frustrated and helpless because the harder they try, the less the children seem to eat.

Chatoor and colleagues explored the mother-toddler interactional patterns associated with infantile anorexia and found that toddlers with infantile anorexia and their mothers demonstrated less dyadic reciprocity, more conflict, engaged in more struggle for control, and engaged in more talk and distractions during feeding than did healthy eaters and their mothers. In addition, mothers whose toddlers exhibited infantile anorexia rated them as more emotionally intense, negative, irregular in feeding and sleeping patterns, dependent, unstoppable, and difficult than did mothers with healthy eaters. Physiological measures of heart rate showed that toddlers with infantile anorexia experience a higher level of arousal and have more difficulty shifting into a calmer, less-aroused state than healthy eaters. This physiological pattern may explain the difficulty anorexic toddlers experience in settling down in order to eat or to sleep.

In summary, these studies indicate that toddlers with infantile anorexia demonstrate a special temperament constellation that is characterized by intense interest in play and interaction with their caretakers, higher physiological arousal, and difficulty in calming themselves in order to eat or sleep. As these children get older, they verbalize their disinterest in eating by stating that they do not feel hungry, that they are bored with eating, that they do not want to stop their activities in order to eat, and that they want to get up from the table and play.

Initially, children with infantile anorexia fail to gain weight at a normal rate for their age. Then they slow down in their linear growth and may end up as small and thin children. Children 3–4 years of age with infantile anorexia may look like 2-year-olds, and 10-year-olds may have the bone age and the appearance of children 6–7 years of age. However, in most cases, their heads grow at a normal rate for age, and their intellectual development is usually average and may even be superior despite their growth failure.

This eating disorder seems to occur with the same frequency in boys as in girls. However, as the children get older, boys seem to suffer emotionally because they are subjected to teasing by their peers, and they are often excluded from team sports because of their small size. Girls seem to be less bothered by their small size, and some girls seem to be quite confused about their body and experience body image distortions, complaining of a big stomach or big thighs, not unlike adolescents with anorexia nervosa. However, there are no longitudinal studies of infantile anorexia, and the relationship between infantile anorexia and anorexia nervosa is not known at this time.

The diagnostic criteria for infantile anorexia, sensory food aversions, and posttraumatic feeding disorder in infants and young children were recently revised with the help of a national task force in order to follow the pattern of the DSM-IV. The diagnostic criteria for these feeding disorders are modified where necessary to characterize the symptoms in elementary-school–age children

Treatment

The first step of the intervention is a thorough evaluation of the affected children’s eating history, developmental history, medical history, psychiatric history, and the family’s history of eating habits, medical disorders, and psychiatric disorders. It is important to grasp the children’s understanding of their eating and growth problems, especially their awareness of hunger and fullness; whether they are bothered by their poor growth; or whether they purposefully restrict food intake out of fear of becoming fat.

Should affected children confirm that they do not feel hungry most of the time and prefer to play or talk to their friends instead of eating, but are worried about their small size, they can be told that the therapist will help them to recognize hunger, eat more, and grow better. The intervention consists of helping the parents schedule regular meals and snacks, spaced at least 3–4 hours apart, without any snacking or drinking (except water) in between. Anorexic children should be given small portions and encouraged to ask for second and third helpings until they feel satiated. The parents are to abstain from praise for eating more or coaxing or threatening for eating less than expected. Affected children must learn to read their inner hunger and fullness signals and should be encouraged to speak about hunger and fullness instead of complaining about not having any time to eat or wanting to do something else other than sitting at the table. Although the intervention is rather simple, many families need help in dealing with the children’s behavior around mealtime.

References

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