Pica and Avoidant/Restrictive Food Intake Disorder

• The lecture covers Pica, Rumination Disorder, and Avoidant/Restrictive Food Intake Disorder.
• Students will learn diagnostic criteria, clinical features, etiological factors, epidemiology, differential diagnosis, course of illness, and prognosis for these disorders.
• Treatment strategies for these disorders will also be covered.
• The student should be able to compare the evidence for neurobiological, genetic, psychological, and environmental etiologies of Pica, Rumination Disorder, and Avoidant/Restrictive Food Intake Disorder.
• The student should be able to state the epidemiologic features of these disorders.
• The student should be able to diagnose these Feeding and Eating disorders based on DSM 5 diagnostic criteria.
• The student should be able to formulate treatment of these disorders and predict prognosis.

Pica

• Pica involves persistent eating of nonnutritive substances.
• Approximately 1.1% of adults experience recurrent PICA behaviors.
• 5% of youth aged 7 to 14 years experience recurrent PICA behaviors.
• Pica is most common in adolescents and adults with intellectual disabilities.
• Pica is often present in patients neglected or abused and populations with food scarcity.
• Diagnostic criteria for Pica include persistent eating of nonnutritive, nonfood substances over a period of at least 1 month.
• The eating of nonnutritive, nonfood substances must be inappropriate to the developmental level of the individual.
• The behavior must not be part of a culturally supported or socially normative practice.
• If the eating behavior occurs in the context of another mental disorder or medical condition, it must be sufficiently severe to warrant additional clinical attention.
• Differential diagnoses for Pica include autistic disorder, Kleine-Levin syndrome, psychosocial dwarfism, and feral children.
• Key steps in managing Pica in children include evaluating the living situation for neglect or maltreatment and eliminating exposure to toxic substances.
• It's important to evaluate iron and zinc serum levels and administer supplements if levels are low, along with evaluating hemoglobin.
• Pica may be caused by pregnancy, nutritional deficiencies, low socioeconomic status, stress, learned behavior or underlining mental health disorders.
• Frequently ingested non-nutritive substances can include animal feces, dirt, clay, small objects, starch, hair/stones or paint.
• Complications of Pica can include parasite infections, anemia, zinc deficiency, intestinal obstruction, iron deficiency, GI obstruction, lead poisoning, malnutrition, starvation, choking, exposure to infectious diseases or life-threatening toxicities.
• For lead poisoning due to Pica, chelation treatment is provided where lead poisoning can cause behavior or attention problems, failure at school, slowed body growth.
• Behavioral interventions for children with Pica include increasing parental attention, stimulation, and nurturance.
• Aversion treatment is also a behavioral interventions for children with Pica.
• Behavioral interventions for adults with Pica include understanding and reassurance.
• Counseling the patient about complications is a helpful intervention.
• Other interventions include initiating a harm reduction strategy.
• Pica usually self-resolves in children with normal intelligence.
• In adults, Pica can continue for years.
• In pregnant women, symptoms are usually limited to pregnancy.

Rumination Disorder

• Rumination Disorder involves repeatedly regurgitating undigested or partially digested food from the stomach.
• A study in Sri Lanka reported a prevalence of 5.1% among children aged 10 to 16 years, evenly distributed between boys and girls.
• Diagnostic criteria include repeated regurgitation of food over at least 1 month.
• Key traits of rumination disorders are where regurgitated food may be re-chewed, re-swallowed, or spit out.
• Repeated regurgitation is not attributable to an associated gastrointestinal or other medical condition and the eating disturbance does not occur exclusively during anorexia nervosa, bulimia nervosa, or avoidant/restrictive food intake disorder.
• If symptoms occur in the context of another mental disorder, they are sufficiently severe to warrant additional clinical attention.
• Recommended evaluations include endoscopy and/or CT to exclude obstruction.
• Also high-resolution esophageal manometry (HRIM) with impedance testing.
• Also electromyography (EMG) of the abdominothoracic muscles
• Clinical features include strained of arched back where it usually occurs after 3 months of age and it seems to be enjoyed by the child
• Rumination Disorder is observed in children who receive inadequate emotional interaction or have developmental delays.
• Complications include progressive malnutrition, metabolic changes/dehydration, dental erosion, failure to thrive, and lowered resistance to disease.
• Evaluations include a test for endocrine function, serum electrolytes where management includes rewarding nonrurdinating behavior with parental attention or administering lemon drops in mouth
• For older individuals, diaphragmatic breathing should be initiated with signs of incoming regurgitations.
• In a 2018 study, 20% of adolescents with rumination syndrome experienced a cessation of symptoms for at least six months.

Avoidant/Restrictive Food Intake Disorder

• Avoidant/Restrictive Food Intake Disorder involves persistent failure to eat.
• Diagnostic criteria include an eating or feeding disturbance associated with lack of interest in eating or food, avoidance based on sensory characteristics, or concern about aversive consequences.
• The disturbance is not better explained by lack of available food or culturally sanctioned practice, and does not occur exclusively during anorexia or bulimia nervosa.
• Key signs of Avoidant/Restrictive Food Intake Disorder: No evidence of a disturbance in the way in which one's body weight or shape is experienced
• Epidemiology: Usually develops in infancy/childhood the prevalence in the general child population is 0.35% to 3.2% and globally in adult populations from 0.3% to 3.1%.
• In a person with ARFID may have atypical activation patterns in the insula causing sensitivity to textures, tastes, or food smells.
• Those with ARFID may exhibit food refusal, selectivity and eating too little or avoid eating where this can causing Impaired physical development/relationship with social difficulties with and caregiver stress
• ARFID is co-morbid with generalized anxiety disorder in 60% of cases.
• The management of ARFID includes medical health where it is important to provide adequate nutrition/monitor progress addressing any fears or discomforts with eating by identifying enjoyable foods.
• Proposed feeding models are designed for every 3-4 hours which Praise for child self-feeding efforts with reduced distraction during feedings from temperamental traits.
• Hospitalization is recommend with BMI levels lower than <75% or patients with signs such as Dehydration (or )Hypothermia where treatment in these scenarios is where one is excessively malnourished by giving Nasogastric tube for supplemental feedings
• Medications such as Mirtazapine, cyproheptadine, selective serotonin reuptake inhibitors (SSRIs), or atypical antipsychotics can be administered.
• Most infants recover, in chronic cases can lead to severe nutritional deficits and psychosocial impairments and closely mirrors that of what you see with anorexia.