Understanding and Managing ARFID: A Guide for Pediatricians

Avoidant/Restrictive Food Intake Disorder (ARFID) is a condition characterized by problematic eating behaviors that result in significant health concerns.  ARFID can be hard to distinguish from the typical picky eating behaviors seen in childhood.  The key distinction? ARFID results in medical complications.  

According to the DSM-5, ARFID is characterized by avoidant or restrictive eating that leads to one of the following: failure to gain weight, nutritional deficiencies, and/or psychological disturbances lasting at least one month. Importantly, ARFID is not attributed to another medical condition (for example, constipation), mental health disorder or lack of available food; it does not involve body image distortion, distinguishing it from other eating disorders.

Recognizing ARFID in Clinical Practice

Each patient with ARFID may present differently and will likely not meet every criteria in the DSM-5 definition; therefore, a careful evaluation of the degree of malnutrition is essential in guiding management. Here are key elements to include in your history-taking and assessment:

• Feeding history: Identify patterns of avoidant or restrictive eating that may have started in infancy or early childhood.
• Bowel habits: Regularly assess for gastrointestinal concerns.
• Body perception: Ask straightforward, non-judgemental questions such as, “How do you feel about your body?” to differentiate ARFID from disorders involving body image issues, such as anorexia nervosa.

Populations at Risk

Certain populations are more prone to develop food-avoidant restrictive disorders:

• Extreme picky eaters
  • Picky eating can turn into ARFID eating, but picky eating alone without medical complications does not meet ARFID criteria.
• Patients with anxiety disorders
  • The anxiety may manifest as nausea and GI upset, leading to eliminating foods (not because of body image).
• Individuals with sensory sensitivities or autism spectrum disorder.
• Past or perceived trauma related to food (for example, past episodes of choking on food).
• Pre-teens and teens represent the most common age group for presentation.

Physical Examination

A comprehensive physical exam is critical, with attention to:

• Growth curves: Evaluate for failure to thrive or plateauing growth.
• Skin and hair: Assess for capillary refill, rashes, or irregular hair growth.
• Neurologic function: Check for deficits that may suggest nutritional deficiencies.
• Parotid glands: Inspect for swelling, which could indicate compensatory behaviors.
• Blood pressure: Measure orthostatic blood pressures to evaluate for dehydration or cardiovascular effects of malnutrition.

Laboratory Workup

The following lab tests are typically recommended to assess the nutritional and metabolic status of patients:

• Basic metabolic panel (Chem 10) and levels of magnesium, phosphorus, and calcium
• CBC with differential, ESR, iron panel, Vitamin D, Vitamin B12
• Thyroid function tests: TSH, T4, total T3 (can have low T3 in patients with malnutrition)
• Hormone levels: LH, FSH, and estrogen for females; testosterone for males

Treatment and Management

Management of ARFID requires an individualized approach, beginning with an emphasis on refeeding and nutritional rehabilitation.  Emphasize the malnutrition component in discussions with patients and families, as delays in treatment can worsen complications.

Key Considerations:

• Setting of care: Decide between inpatient versus outpatient treatment based on vitals and physical exam findings.
• Interdisciplinary care: Collaborate with ARFID specialists, nutritionists, and therapists. Familiarize yourself with local resources and interdisciplinary teams.
• Motivation strategies: Positive reinforcement and rewards are generally more effective than punitive measures.
• Dietary monitoring: Encourage families to document food intake with 24-hour recalls or photos for accurate assessment.

Prognosis and Follow-Up

With early intervention, the prognosis for ARFID is excellent. Follow-up schedules should be tailored to the patient’s clinical status, with frequent monitoring initially and adjustments as they stabilize.

Promoting Healthy Eating Behaviors

Preventive strategies can help reduce the risk of ARFID and support recovery:

• Avoid labeling foods as “good” or “bad.”
• Introduce a variety of foods and promote adventurous eating.
• Model moderation and a balanced approach to food.
• De-emphasize weight as a focal point of health.

By recognizing the signs of ARFID early, understanding its implications, and providing timely, evidence-based care, pediatricians can play a vital role in supporting children and adolescents to achieve healthy eating behaviors and overall well-being.