Pica and Other Feeding Disorders

Feeding and Eating Disorders

• Focus on Pica, Rumination Disorder, and Avoidant/Restrictive Food Intake Disorder.
• Students need to understand diagnostic criteria, clinical features, etiological factors, epidemiology, differential diagnosis, illness course, and prognosis.
• Students will diagnose and initiate treatment for these disorders in general medical practice.
• Compare evidence for neurobiological, genetic, psychological, and environmental etiologies.
• State the epidemiologic features of these disorders.
• Diagnose these Feeding and Eating disorders based on DSM 5 diagnostic criteria.
• Formulate treatment of these disorders and predict prognosis.
• Eating disorders include: Diabulimia, Orthorexia, OSFED, Binge Eating Disorder, Bulimia Nervosa, Anorexia Nervosa

Pica

• Characterized by persistently eating non-nutritive substances.
• Approximately 1.1% of adults experience recurrent PICA behaviors.
• 5% of youth aged 7 to 14 years experience recurrent PICA behaviors.
• Most common eating disorder in adolescents and adults with intellectual disabilities.
• Associated with 25-60% of pregnant women, iron and zinc and other essential nutrients deficiency.
• Often present with patients neglected or abused and populations with food scarcity.
• The persistent eating of non-nutritive, nonfood substances must occur for at least 1 month.
• The eating must be inappropriate for the individual's developmental level (typically not younger than 24 months developmentally).
• The eating behavior is not part of a culturally supported or socially normative practice.
• The eating behavior must be sufficiently severe to warrant additional clinical attention if it occurs within the context of another mental disorder or medical condition, including pregnancy.
• Differential diagnosis may include: Autistic disorder, Kleine-Levin syndrome, Psychosocial dwarfism, Schizophrenia, Feral Children
• To manage pica in children, evaluate the living situation for neglect or maltreatment and eliminate exposure to toxic substances.
• Additional Steps in Management in Children = Evaluate iron and zinc serum levels
• Causes are unknown but linked to pregnancy, nutritional deficiencies, low socioeconomic status, stress, learned behavior, familial psychopathology, cultural factors, and underlining mental health disorders.
• Frequently ingested non-nutritive substances can lead to complications like parasite infections, anemia, intestinal obstruction, iron deficiency, lead poisoning and GI obstruction
• Pica can lead to death if untreated as well as other complications, like malnutrition, choking, life-threatening toxicities and exposure to infections
• Other management recommendations for lead poisoning include assessing for behavior/attention problems, kidney damage, and reduced IQ
• Treat lead poisoning with chelation therapy.
• Behavioral interventions involve increasing parental attention and nurturing, positive reinforcement, and aversion treatment.
• Behavioral interventions for adults include understanding/reassurance, identifying consumed substances, counseling on complications, and harm reduction strategies.
• Initiating a harming reduction strategy = treating the underlying cause of the craving, decreasing exposure to the item craved, or substituting a healthier alternative
• Pica usually self-resolves in children with normal intelligence, but can continue for years in adults, and symptoms in pregnant women are usually limited to the pregnancy.

Rumination Disorder

• 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, a prevalence of 5.1% evenly distributed between boys and girls were affected.
• Repeated regurgitation of food that occurs over a period of at least 1 month.
• Regurgitated food can be re-chewed, re-swallowed, or spit out.
• The repeated regurgitation is not attributable to an associated gastrointestinal or other medical condition.
• The eating disturbance does not occur exclusively during anorexia/bulimia nervosa, binge eating disorder, or avoidant/restrictive food intake disorder.
• Patients evaluation include Endoscopy and/or CT scans to exclude mechanical obstruction and High-resolution esophageal manometry (HRIM) with impedance testing
• Postprandial intragastric pressure is usually above 25 to 30 mmHg in patients with rumination syndrome
• Electromyography (EMG) of the abdominothoracic muscles will show a characteristic spiking of activity
• Clinical features include: typically occurs after three months of life, straining and arching of the back with the head held back, seems to be enjoyed by child, may sooth self
• Complications include : progressive malnutrition, metabolic changes, dental erosion, lowered resistance to diseases, failure to thrive
• Management includes: Evaluate for GI disorders, Test endocrine function, serum electrolytes, Reward nonruminating behaviour with parental attention, use lemon drops and a J Tube if required
• Management for older individuals: Diaphragmatic breathing exercises with detection of regurgitations(EMG/HRIM), cognitive behavioural therapy, Baclofen
• A 2018 study with 47 adolescents with rumination syndrome indicated that after 12 months reports were showing improvements and a cessation of ruminations 20% of the time.

Avoidant/Restrictive Food Intake Disorder (ARFID)

• Characterized by persistent failure to eat.
• Involves apparent lack of interest, avoidance based on sensory characteristics, or concern about aversive consequences of eating.
• Results in significant weight loss, nutritional deficiency, dependence on enteral feeding, or psychosocial interference.
• The eating disturbance is not better explained by lack of available food or by an associated culturally sanctioned practice.
• The eating disturbance does not occur exclusively during the course of anorexia nervosa or bulimia nervosa.
• The eating disturbance is not attributable to a concurrent medical condition or not better explained by another mental disorder.
• ARFID commonly develops in infancy/childhood but can appear in adolescence/adult life.
• ARFID prevalence ranges from 0.35% to 3.2% in children and 0.3% to 3.1% in adults.
• Individuals with ARFID exposed to food stimuli may have atypical activation patterns, leading to aversive responses.
• Behaviors include: food refusal, food selectivity, eating too little, avoid eating, and delayed self-feeding.
• Individuals with ARFID may also show less affectionate touch and reject a moms touch
• Consequences involve impaired physical development, relationship and social difficulties, caregiver stress, and family problems.
• Comorbidity with generalized anxiety is observed in 60% of those with ARFID.
• Management steps include: medical stabilization, appropriate care level, adequate nutrition, enhancing nutritional health, addressing fears, and promoting enjoyment of eating.
• Chatoor model emphasizes parental education, exploration of parental anxiety, structured feeding, praising self-feeding, and reducing distractions during feedings.
• Hospitalization is recommended if BMI or BP are dangerously low
• In excessively malnourished, use a Nasogastric tube for supplemental feedings.
• Pharmacotherapy is not the primary approach for treating ARFID but may be applicable in certain cases with drugs like mirtazapine to reduce anxiety.
• Most infants recover quickly, but some issues with eating could remain whilst chronic cases can lead to psychosocial and nutritional imparements.
• The medical complications arising from ARFID closely mirror those of anorexia nervosa.