31.9c Avoidant/Restrictive Food Intake Disorder
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Pathology and Laboratory
Examination
No specific laboratory examination is pathognomonic of rumi-
nation disorder; however, rumination disorder is not uncom-
monly associated with gastrointestinal abnormalities. Clinicians
are recommended to evaluate other physical causes of vomiting,
such as pyloric stenosis and hiatal hernia, before making the
diagnosis of rumination disorder. Rumination disorder can lead
to states of malnutrition and dehydration. In very severe cases,
laboratory measures of endocrinological function, serum elec-
trolytes, and a hematological workup may determine the need
for medical intervention.
Differential Diagnosis
To make the diagnosis of rumination disorder, clinicians must
rule out primary gastrointestinal congenital anomalies, infec-
tions, and other medical illnesses that could account for fre-
quent regurgitation. Pyloric stenosis is usually associated with
projectile vomiting and is generally evident before 3 months of
age, when rumination has its onset. Rumination has been asso-
ciated with both autism spectrum disorder and intellectual dis-
ability in which stereotypic behaviors and eating disturbances
are not uncommon. Rumination behavior may occur comorbidly
in youth with severe anxiety disorders as well. Rumination dis-
order may also occur in patients with other eating disorders,
such as anorexia nervosa and bulimia nervosa.
Course and Prognosis
Rumination disorder is believed to have a high rate of spontane-
ous remission. Indeed, many cases of rumination disorder may
develop and remit without ever being diagnosed. Limited data
are available about the prognosis of rumination disorder in ado-
lescents and adults. Behavioral interventions using habit-reversal
techniques may significantly lead to improved prognosis.
Treatment
The treatment of rumination disorder is often a combination of
education and behavioral techniques. Sometimes, an evaluation
of the mother–child relationship reveals deficits that can be
influenced by offering guidance to the mother. Behavioral inter-
ventions, such as habit-reversal are aimed at reinforcing an alter-
nate behavior that becomes more compelling than the behaviors
leading to regurgitation. Aversive behavioral interventions, such
as squirting lemon juice into the infant’s mouth whenever rumi-
nation occurs, have been used in the past to diminish rumina-
tion behavior. Although aversive behavioral interventions have
been reported anecdotally to be effective in some cases, current
recommendations support the use of habit-reversal techniques.
When features of child maltreatment of neglect may have
contributed to rumination behaviors in an infant, treatments
include improvement of the child’s psychosocial environment,
increased tender loving care from the mother or caretakers,
and psychotherapy for the mother or both parents. Anatomi-
cal abnormalities, such as hiatal hernia, are not uncommon,
and must be evaluated, in some cases leading to surgical repair.
In severe cases in which malnutrition and weight loss have
occurred, placement of a jejunal tube may need to be inserted
before other treatments can be utilized.
Medication is not a standard part of the treatment of rumina-
tion. Case reports, however, cite a variety of medications that
have been tried, including metoclopramide (Reglan), cimeti-
dine (Tagamet), and even antipsychotics such as haloperidol
(Haldol) have been cited to be helpful according to anecdotal
reports. The treatment of adolescents with rumination disorder
is often complex and includes a multidisciplinary approach
consisting of individual psychotherapy, nutritional intervention,
and pharmacologic treatment for the frequent comorbid anxiety
and depressive symptoms.
31.9c Avoidant/Restrictive Food
Intake Disorder
Avoidant/restrictive food intake disorder, formerly known as
feeding disorder of infancy or early childhood, is characterized
by a lack of interest in food, or its avoidance based on the sen-
sory features of the food or the perceived consequences of eat-
ing. This newly included DSM-5 disorder adds more detail about
the nature of the eating problems, and has also been expanded
to include adolescents and adults. The disorder is manifested by
a persistent failure to meet nutritional or energy needs as evi-
denced by one or more of the following: significant weight loss
or failure to achieve expected weight, nutritional deficiency,
dependence on enteral feedings or nutritional supplements, or
marked interference with psychosocial functioning. It may take
the form of outright food refusal, food selectivity, eating too
little, food avoidance, and delayed self-feeding. The diagnosis
should not be made in the context of anorexia nervosa or bulimia
nervosa, or if caused by a medical condition, by another mental
disorder, or by a true lack of available food.
Infants and children with the disorder may be withdrawn, irri-
table, apathetic, or anxious. Because of the avoidant behavior dur-
ing feeding, touching and holding between mothers and infants
are diminished during the entire feeding process compared with
other children. Some reports suggest that food avoidance or
and his ruminatory activity decreased accordingly. After 1 week in
the hospital, small feedings were started; however, Luca again suc-
cessfully was able to bring up his food by his rumination activity,
and the oral feedings had to be temporarily stopped. At this point,
Luca’s mother decided to stop working and take Luca home to con-
tinue an intensive behavioral “distracting” intervention in order to
interrupt his rumination during meals. Luca’s mother started small
feedings while playing with him during and after feedings, and was
able to interest him in other activities, so that he would not rumi-
nate. After 4 weeks of slow increments in his feedings, Luca was
able to take all his feedings by mouth without ruminating, and the
nasojejunal tube could be removed. Luca and his mother contin-
ued to use simulating and distracting activities during and just after
meals, which over time became more interesting to Luca than his
previous ruminating behavior.
