Avoidant-Restrictive Food Intake Disorder

Aka: Avoidant-Restrictive Food Intake Disorder, ARFID, Selective Eating Disorder, Feeding Disorder of Infancy and Childhood

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II. Epidemiology

  1. Prevalence: 3-5% of school age children
  2. ARFID accounts for 14% of Eating Disorder referrals
  3. Mean age at diagnosis: 11 to 14 years
  4. Often associated with Family History of restrictive eating

III. Background

  1. ARFID is a refactoring of the diagnosis - Feeding Disorder of Infancy and Childhood
    1. Feeding Disorder had been previously limited to onset prior to age 6 years
    2. Required significant failure to gain weight or significant weight loss over at least 1 month

IV. Diagnosis: DSM-5

  1. Background: Screening Tools
    1. Nine Item ARFID Screen
      1. https://peds.arizona.edu/sites/default/files/intake_forms-child_v12.2018.pdf
  2. Avoidance of Food Intake
    1. Lack of interest
    2. Food sensory characteristics
    3. Concerns regarding eating consequences
  3. Inadequate nutrition
    1. Signficant weight loss
    2. Inadequate weight gain during growth period
    3. Nutritional deficiency
    4. Decreased psychosocial functioning
    5. Supplemental feeding requirements (enteral feeding, Nutritional Supplements)
  4. No disturbance in body weight or shape Perception
    1. Contrast with Anorexia Nervosa and Bulimia Nervosa
  5. Not due to other condition
    1. Not due to decreased food availability
    2. Not due to cultural practice (e.g. religious Fasting)
    3. Not due to other mental health condition or medical condition

V. Types: Presentations

  1. Sensory Sensitivity
    1. Aversion to specific food textures or shapes
    2. Nutritional Supplements are used
  2. Low appetite
    1. Early satiety
    2. Lack of interest or enjoyment with eating
    3. Often skips meals or forgets to eat
    4. Greater association with Attention Deficit Disorder
  3. Fear
    1. Trauma History
    2. Specific food avoidance
    3. Shorter duration and greater weight loss (higher risk for hospitalization)

VI. Associated Conditions

  1. Major Depression
  2. Anxiety Disorder
  3. Autism Spectrum Disorder
  4. Cognitive Disorders
  5. Gastrointestinal Symptoms

VII. Differential Diagnosis

  1. See Failure to Thrive Causes
  2. Cancer
  3. Gastrointestinal Disorders (e.g. Inflammatory Bowel Disease, Celiac Sprue)
  4. Food Allergy or intolerance
  5. Endocrine conditions (e.g. Hypothyroidism, Type 1 Diabetes Mellitus, Addison's Disease)
  6. Infectious disease (e.g. HIV Infection, Tuberculosis)
  7. Other Eating Disorders (e.g. Anorexia Nervosa)
  8. Mechanical Swallowing Disorders (e.g. Tonsillar Hypertrophy, Achalasia)

VIII. Evaluation

  1. Diagnostics may include labs, ekg, endoscopy
  2. Obtain a careful history and physical
    1. Diet history
    2. Gastrointestinal symptoms
    3. Growth chart review
    4. Vital Signs
    5. Malnutrition related findings

IX. Management

  1. Weight Restoration
    1. Critical in children who have fallen below the growth curve
    2. Focus on preferred foods that are calorie dense
    3. Eating should be by plan (not based on pain, appetite)
    4. Increase calories by 500 kcals/day every 3 to 7 days (goal weight gain 1 kg/week)
  2. Psychosocial Treatment
    1. General Strategies
      1. Behavioral strategies
        1. Multidisciplinary approach for age >=7 years
      2. Family Based Approach
        1. Indicated in age 6 to 12 years with parents managing the disorder
      3. Cognitive Behavioral Therapy
        1. Indicated in age >=10 years with parents managing the disorder in age <16 years and underweight
    2. Sensory Sensitivity
      1. Patient selects foods they wish to learn about (representing items from all food groups)
        1. Describe with neutral words
        2. What does it look like (e.g. red)?
        3. What does it feel like (e.g. rough)?
        4. What does it smell like (e.g. bitter)?
        5. What does it taste like (e.g. salty)?
        6. What is the texture like (e.g. chewy)?
      2. Repeat exposures to very small portions
      3. Gradually increase exposures into meals and snacks
    3. Lack of Food Interest
      1. Self monitor, increasing the awareness of hunger and fullness
      2. Practice in clinic sessions with high preference foods
      3. Exposures to desensitize to early fullness
        1. Drink several glasses of water rapidly to counter early fullness Sensation
        2. Push the Abdomen out to decrease the sensitivity to bloating
        3. Spin in a chair to decrease the sensitivity to Nausea
  3. Strategies for parents
    1. Validate the child's struggle with eating
    2. Set reasonable and clear expectations (start small)
    3. Provide positive encouragement to help the child succeed
      1. Be calm, engaged and compassionate
      2. Disengage from negative or inapproptiate behaviors
      3. Reward and praise positive behavior
  4. Medications to assist with weight gain
    1. Mirtazapine
    2. Olanzapine
    3. Selective Serotonin Reuptake Inhibitors
    4. D-Cycloserine
  5. Additional Symptom Management
    1. Cyproheptadine (Antihistamine that increases appetite)
    2. Antiemetics (e.g. Ondansetron)
    3. Bowel regimens to improve Pediatric Constipation
    4. Probiotics
    5. Chronic Pain Management

X. Course

  1. Untreated restrictive eating begets greater restrictive eating
    1. Cycles to worsening ARFID and may lead to other Eating Disorders (e.g. Anorexia Nervosa)

XI. References

  1. (2014) DSM5, APA
  2. Sim (2024) Mayo Clinic Pediatric Days, lecture attended 1/14/2024
  3. Klein (2021) Am Fam Physician 103(1): 22-32 [PubMed]

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