Severe feeding disorder and malnutrition in 2 children with autism

Leanna, a 10-year-old girl with autism, was hospitalized for severe malnutrition and 20 pound weight loss secondary to reduced intake over 4 months. Her food choices became increasingly restrictive to the point where she only ate certain types and brands of foods. She gradually stopped drinking and developed severe constipation and encopresis. A new behavior of collecting saliva in her mouth and spitting onto napkins also emerged. Vital signs and electrolytes were normal on admission. A nasogastric tube was placed because she refused to eat. A behavior modification plan was implemented that awarded points for completing specific tasks related to feeding, which could later be redeemed for specific rewards, such as computer time. Although her ideal body weight increased from 68% to 75% (due to continuous nasogastric tube feeds), her refusal to eat persisted. Upon further data gathering, the staff learned that she moved and changed schools 5 months ago. She was cared for by either a family friend or paid caregiver while her mother worked. Although she could conduct basic self-care activities without assistance and write and draw at a third-grade level, she functioned cognitively at a 4-year-old level. The behavior plan was modified, breaking the tasks into shorter components with immediate and tangible rewards. She soon began eating small portions of food and spitting less frequently. Toileting was later incorporated into this plan. She was referred to a behavioral therapist in the community to work with her at home and school. Weekly visits with her pediatrician and appointments with a child psychiatrist and dietician were made. Orlando, a 3-year-old boy with autism, was evaluated in the emergency room for lethargy and generalized edema for 6 weeks. The history revealed a restrictive diet of commercial pureed fruit and coconut juice for 2 years. He only ate a particular brand and with specific containers; the limited food intake occurred only with his favorite blanket. He refused to eat other types of food. Outpatient treatments were unsuccessful. On physical examination, he was irritable with an erythematous, scaly rash throughout his body. His hair was thin, coarse, and blonde. He had nonpitting edema in his arms, legs, and periorbital region. The laboratory evaluation was significant for anemia, hypoalbuminemia, and hypoproteinemia. He was admitted to the pediatric service where nutritional formula feedings were initiated through a nasogastric tube. Weight gain was adequate, and the hemoglobin, serum albumen, and protein became normal. The rash improved with zinc supplementation. He was transferred to an inpatient feeding disorders unit where a team of occupational therapists implemented a behavioral modification program to overcome his severe food aversion.