Escitalopram in the Treatment of a 3-Year-Old Child with Posttraumatic Feeding Disorder

To the Editor:

Posttraumatic feeding disorder (PTFD) is defined as food refusal by an infant after a traumatic insult to the oropharynx or gastrointestinal tract. The content of the rejected food can be changed depending on the nature of the traumatic event(s). Although some patients refuse to eat all solids, but accept drinks, others will refuse to drink, but accept solids. A child may refuse eating or drinking all types of food in more severe cases. If untreated, this condition can adversely affect the physical and emotional development of the child (Chatoor and Ganiban 2003). Although some behavioral techniques and pharmacological agents have been used for this condition, there is no standardized treatment suggested in the literature.

Here, we report on a toddler with food refusal who started eating after escitalopram treatment.

A 3-year-old boy was referred to our clinic for a psychiatric evaluation with a complaint of refusing to eat solid food, resulting in weight loss. His parents reported he had swallowed a coin and experienced a choking episode 1 month earlier. The coin had been seen in a radiological examination performed at the emergency department, and it had passed through the gastrointestinal tract within a day without any medical problem. He began to refuse eating some types of solid foods, such as meats, after this experience. However, he then suddenly began to refuse eating all solid foods by saying that his throat hurt. He was then only able to drink water and fruit juice during the week before our evaluation. No medical problem could be found explaining the patient's complaints in either his physical examination or the invasive and noninvasive screenings (i.e., X-ray, laryngoscopy, and upper gastrointestinal endoscopy) performed in the emergency and pediatric clinics. His parents stated that he had been displaying severe anxiety symptoms and crying when any solid food was presented to him during this period.

The patient was drowsy and anxious with limited eye contact and did not respond to the clinician's contact attempts during his psychiatric evaluation. His parents reported that he had lost ∼1.5 kg within 1 week before his admission to our clinic. At the first visit, we planned to start escitalopram and behavioral treatment together because the food refusal could have resulted in serious health problems. We started the medication (escitalopram 3 mg/day); however, we decided to start the behavioral intervention at the next visit due to time limitations. At the second visit 10 days after the first admission, his parents reported that he had begun eating all solid foods on the 6th day of treatment and had been more cheerful and active, even when compared with before the experience of swallowing a coin. We interpreted this situation as behavioral activation related to the treatment; thus, we decreased the escitalopram dose to 2 mg/day. At the third visit, 1 week after the second visit, his parents reported no complaints regarding eating, and the patient had tolerated the drug well.

The treatment for PTFD is not well known; however, because these children are fearful, distressful, and anxious due to the reminders of a traumatic event, the treatment mostly aims to reduce their anxiety and fear (Chatoor and Ganiban 2003). In the literature, there are few reports on the treatment of PTFD with medical treatment. These reports include fluoxetine (Celik et al. 2007), paroxetine, sertraline (Banerjee et al. 2005), mirtazapine (Tanıdır and Herguner 2015), and lorazepam (Kardas et al. 2014). To our knowledge, this is the first report indicating the effectiveness of escitalopram in PTFD in a toddler. The effectiveness and long-term effects of selective serotonin reuptake inhibitors (SSRIs) in preschool children are not well known. Therefore, behavioral treatments are mostly recommended as the first-line treatment for psychiatric conditions, such as anxiety disorders, in preschool children. Pharmacological treatments are considered if the symptoms cause severe distress or significant impairment in the child's daily life (Gleason et al. 2007). In addition, some researchers have suggested that SSRIs can be effective in the treatment of anxiety disorders in preschool children; however, preschoolers are more vulnerable to the adverse effects of SSRIs, especially behavioral disinhibition (Coşkun et al. 2012).

In this report, we presented a patient whose food refusal responded to escitalopram. The patient's behavioral activation symptoms, which had been observed at 10 days after the beginning of the medication, supported the notion that the food refusal had been resolved due to the anxiety diminishing effect of the medication. Further studies are needed to determine the efficacy and safety of escitalopram in preschool children with eating disorders.