Having mealtime battles with your toddler or older child is no fun. In fact, it can be downright scary. What about when picky eating seems like it is more than “picky eating”? Maybe you’ve heard about picky eating gone too far and are asking, “What is ARFID?”

To address these concerns, let’s first distinguish between ‘picky eating’ and Avoidant Restrictive Food Intake Disorder (ARFID), and explain why understanding these differences is important.

What is Picky Eating?

A “picky eating” phase is normal in young children, especially between the ages of 2 and 4. Unfortunately, there isn’t a widely accepted definition of picky eating. One definition that covers a lot of what I see in my practice with picky eating is “unwillingness to eat familiar foods or to try new foods, as well as strong food preferences.”¹

What this looks like is your child rejecting foods they used to eat or refusing to try new foods even though you’ve put the food on the table, or their plate, multiple times. They may have a list of foods they will eat, and all others are no-nos.

Picky eating can lead to eating a limited variety of foods. You’re concerned that your child isn’t meeting their nutritional needs. If there is a lack of variety in foods, however, and the child continues to meet growth markers and stay on the trajectory of the height-weight charts as they get older, they may be OK.

However, there are a few things picky eating does not lead to:

• Weight loss
• The inability to meet nutritional needs in maintaining their growth pattern
• Difficulty eating out or attending social gatherings due to fear that acceptable food won’t be available.²

You may find that some or all of the things that picky eating isn’t (listed above) are happening. What then?

What is Avoidant Restrictive Food Intake Disorder (ARFID)?

Let’s define ARFID so you can better understand what you may be facing.

ARFID is a newly designated eating disorder. The formal definition of ARFID is an “eating or feeding disturbance that manifests by ongoing failure to meet appropriate nutritional and/or energy needs associated with one or more of the following:

• Significant weight loss (or failure to achieve expected weight gain or faltering growth in children)
• Significant nutritional deficiency
• Dependence on enteral feeding or oral nutritional supplements
• Marked interference with psychosocial functioning.”3

Unlike picky eating, ARFID causes the trajectory on the height-weight chart to plummet. Basically, the child may be following a consistent growth pattern, then fall off the curve.

ARFID, and the reasons it develops, are not well understood. “[P]sychological, genetic, and triggering events (such as choking) can lead to the condition. Some kids with ARFID have gastroesophageal reflux disease (GERD) or other medical conditions that can lead to feeding problems.⁴

Some of the ways ARFID presents include:

• Having a lack of interest in food and eating
• Getting full quickly
• Having issues with food smells, tastes, textures, and temperature
• Fear of choking, becoming sick, or even a fear of dying from eating^{5, 6}

ARFID may result in an intense fear or anxiety about food and eating. The fear can be so extreme that there is a fear of dying if a food is eaten. Fear derived from ARFID may cause the mouth, throat, and digestive tract to constrict and stop a variety of foods from being eaten.⁶

Someone with ARFID may not eat due to fear or anxiety, even though they feel hungry.

ARFID is different from anorexia nervosa and bulimia nervosa because it is not driven by the desire to change the body’s shape or size, or a fear of weight gain.

You might now be curious about the risk factors for ARFID.

What are Risk Factors for Developing ARFID?

Since ARFID is not well understood, the full picture of risk factors remains unclear. However, research has found certain conditions and experiences that are associated with a higher likelihood of developing ARFID:

• Autism spectrum disorders, ADHD, and intellectual disabilities
• Ongoing or severe picky eating,
• Having a co-occurring anxiety or mood disorder7, 8

Now that you understand more about ARFID, you may wonder how it is diagnosed.

How is ARFID Diagnosed?

Diagnosing ARFID involves a medical doctor assessing for malnutrition, a mental health professional using DSM-5 criteria and age-appropriate tools, and a registered dietitian reviewing eating patterns, if needed.

The medical doctor assesses malnutrition through exams and tests, such as blood tests. The mental health professional uses DSM-5 criteria and age-appropriate screening. The dietitian reviews eating patterns and restrictions.

Diagnosis involves collaboration among the doctor, therapist, dietitian, family, and patient to decide if ARFID treatment is needed.

A registered dietitian will evaluate eating patterns, allowed and restricted foods.

Together, the doctor, mental health professional, dietitian, family, and individual can determine whether to proceed with treatment for ARFID.

What are Treatment Options for ARFID?

The good news is that treatment for ARFID can be effective. The approach depends on underlying causes, such as anxiety or sensory issues, and typically involves a medical doctor, mental health professional, and registered dietitian. Treatment is individualized to address the specific factors that led to ARFID.

In my practice, we follow a multidisciplinary approach to treating ARFID. We require our patients to work with an ARFID-trained therapist and to have a medical provider on board for medical management. This allows us to focus on our role as registered dietitians to address food exposures and meet nutritional needs, accelerating growth, and improving health.

Takeaways

Picky eating is normal in kids, particularly in those between 2 and 4 years old. However, if the child’s normal growth pattern stops or signs of nutritional deficiency appear, ARFID may be developing. If you’re not sure about what is happening with your child, you can set up an appointment.

References

1. Picky/fussy eating in children: Review of definitions, assessment, prevalence, and dietary intakes https://pubmed.ncbi.nlm.nih.gov/26232139/
2. https://www.waldeneatingdisorders.com/blog/6-differences-between-picky-eating-and-avoidant-restrictive-food-intake-disorder-arfid/
3. https://www.nationaleatingdisorders.org/learn/by-eating-disorder/arfid
4. https://kidshealth.org/en/parents/arfid.html
5. https://centerfordiscovery.com/conditions/arfid/
6. https://www.nationaleatingdisorders.org/blog/what-exactly-arfid
7. https://www.nationaleatingdisorders.org/learn/by-eating-disorder/arfid
8. https://www.nationaleatingdisorders.org/blog/more-picky-eating%E2%80%947-things-know-about-arfid