Pica and other Feeding Disorders

• This presentation covers Pica, Rumination Disorder, and Avoidant/Restrictive Food Intake Disorder which are all feeding and eating disorders.
• The general objective is to use diagnostic criteria, clinical features, etiological factors, epidemiology, differential diagnosis, course of illness, and prognosis to diagnose and initiate treatment in patients with the aforementioned disorders as they apply to general medical practice.

Pica

• Pica involves persistent eating of non-nutritive 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 who are neglected or abused, and in populations with food scarcity.
• Diagnosis requires persistent eating of non-nutritive, nonfood substances for at least 1 month.
• The eating of non-nutritive, nonfood substances must be inappropriate to the developmental level of the individual
• The eating behavior cannot 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, Schizophrenia, Psychosocial dwarfism, and feral children.
• Pica behaviors may be triggered by Kleine-Levin syndrome (causing hypersomnia and hyperphagia).
• Steps in managing Pica in children include evaluating their living situation for neglect or maltreatment, and eliminating exposure to toxic substances.
• Iron and zinc serum levels should be evaluated, and administration considered if levels are low, along with hemoglobin evaluation.
• Causes of Pica are unknown, but associated factors include pregnancy, nutritional deficiencies, low socioeconomic status, stress, learned behavior, and underlying mental health disorders.
• Frequently ingested non-nutritive substances can lead to complications like parasite infections (from animal feces and dirt) or lead poisoning (from paint).
• Other substances ingested may lead to anemia (from clay), intestinal obstruction (from small objects), or GI obstruction (from hair/stones).
• Additional complications of Pica include death if left untreated, malnutrition/starvation, choking, life-threatening toxicities, and exposure to infectious diseases.
• Treatment is chelation if lead poisoning has occurred in a child.
• Behavioral interventions in children include increasing parental attention/stimulation/nurturance, positive reinforcement/modeling/behavioral shaping, and aversion treatment.
• Behavioral interventions for adults include understanding/reassurance, identifying consumed substances, and harm reduction strategies like treating the underlying cause of the craving.
• Substituting a healthier alternative that will satisfy the craving
• Pica usually self-resolves in children with normal intelligence.
• In adults it can continue for years, and in pregnant women, symptoms are usually limited to pregnancy.

Rumination Disorder

• Rumination Disorder is a condition in which someone repeatedly regurgitates undigested or partially digested food from the stomach.
• A Sri-Lankan population-based study with more than 2000 children aged 10 to 16 found a 5.1% prevalence evenly distributed between boys and girls.
• Diagnosis requires repeated regurgitation of food for at least 1 month, with the food possibly being re-chewed, re-swallowed, or spit out.
• The repeated regurgitation must not be attributable to an associated gastrointestinal or other medical condition.
• The eating disturbance must not occur exclusively during the course of anorexia nervosa, bulimia nervosa, binge-eating disorder, or avoidant/restrictive food intake disorder.
• The symptoms must be sufficiently severe to warrant additional clinical attention if they occur in the context of another mental disorder.
• Recommended evaluations for suspected rumination syndrome include endoscopy/CT to exclude mechanical obstruction.
• Also recommended is high-resolution esophageal manometry (HRIM) with impedance testing; postprandial intragastric pressure is usually above 25 to 30 mmHg in patients with rumination syndrome.
• An electromyography (EMG) of the abdominothoracic muscles shows a characteristic spiking of activity during episodes of rumination.
• Rumination Disorder usually occurs after 3 months of life.
• This can result in a characteristic position; Straining and arching of the back, with the head held back.
• Observed in children who receive inadequate emotional interaction and developmental delays.
• Clinical features for Rumination Disorder include progressive malnutrition, metabolic changes/dehydration, dental erosion, failure to thrive, and lowered resistance to disease.
• The management/treatment of Rumination disorder includes evaluating GI disorders, testing endocrine function and serum electrolytes, rewarding nonruminating behavior with parental attention, and using lemon drops in mouth as aversive therapy
• J-tube if the child is severely malnourished.
• For older individuals, diaphragmatic breathing and cognitive behavioral therapy for rumination can be utilized, as well as Baclofen.
• A 2018 study evaluating 47 adolescents with rumination syndrome over 12 months reported continued improvement in rumination symptoms over time, with a cessation of rumination symptoms for at least six months in 20% of the patients.

Avoidant /Restrictive Food Intake Disorder (ARFID)

• ARFID is characterized by persistent failure to eat.
• Diagnostic criteria involve an eating or feeling disturbance (e.g., lack of interest in eating, avoidance based on sensory characteristics, or concern about aversive consequences).
• Additional signs include significant weight loss, significant nutritional deficiency, dependence on enteral feeding or oral nutritional supplements, and marked interference with psychosocial functioning.
• The disturbance must not be better explained by lack of available food/culturally sanctioned practice.
• The eating disturbance must not occur exclusively during anorexia nervosa or bulimia nervosa, and there is no evidence of a disturbance in body weight or shape experience.
• ARFID is not attributable to a concurrent medical condition or not better explained by another mental disorder.
• ARFID usually develops in infancy/childhood but may be present in adolescent and adult life.
• ARFID prevalence in the general child population ranges from 0.35% to 3.2% and globally in adult populations from 0.3% to 3.1%
• Individuals with ARFID may have atypical activation patterns in the insula when exposed to food stimuli, leading to aversive responses to certain textures, tastes, or food smells.
• Impaired physical development, relationship and social difficulties, caregiver stress, and problems in family functioning may be clinical presentations of ARFID.
• Common behaviors of ARFID include food refusal, food selectivity,eating too little, avoid eating, and delayed self feeding, and less affectionate touch and reject to the mother's touch.
• There is a comorbidity with generalized anxiety disorder of 60% with ARFID.
• Management steps for ARFID include attaining medical stability, determining the appropriate level of care, providing adequate nutrition to restore weight, and enhancing nutritional health.
• It also involves addressing any fears/discomforts related to eating (exposure therapy) and promoting the enjoyment of eating by identifying enjoyable foods/developing a positive relationship with food.
• In practice, this includes educating the parents regarding temperamental traits, exploring parent anxiety, feeding the child every 3 to 4 hours with only water between meals, praising the child for self-feeding efforts, and reduce distraction during feedings
• The American Psychiatric Association recommends hospitalization if specific clinical factors are present such as; BMI, dehydration, psychiatric comorbidity, etc.
• If excessively malnourished, the use of Nasogastric tube may be used for supplemental feedings.
• Pharmacotherapy is not the primary approach for treating ARFID but may be applicable in certain cases using Mirtazapine, cyproheptadine, selective serotonin reuptake inhibitors (SSRIs), or atypical antipsychotics (eg, olanzapine)
• Olanzapine has also been used off-label to help reduce anxiety, cognitive rigidity, and food-related beliefs that can contribute to ARFID symptoms.
• Most infants that is being treated for ARFID, recover quickly but may continue to have some eating problems.
• Chronic cases can lead to severe nutritional deficits and psychosocial impairments.
• The medical complications arising from ARFID closely mirror those of anorexia nervosa.