Review articleNutritional risks of ARFID (avoidant restrictive food intake disorders) and related behavior
Introduction
Nutritional assessment is part of the routine examination in pediatric practice and has become more important than ever as children and adolescents increasingly adopt restrictive feeding behaviors that entail risks of severe nutritional deficiencies [1]. Such behavior changes underlie the reason for the latest modification on the classification of eating disorders (EDs) in the latest version of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5) in 2013, which now include pica, rumination disorder, and avoidant/restrictive food intake disorder (ARFID) [2].
Similar restrictive feeding behavior has been described earlier in children with autism spectrum disorders (ASD) [3], but its onset in children and adolescents without ASD seems new. The aim of this paper is to draw attention to ARFID and the nutritional risks induced by this new type of eating disorder.
Section snippets
What is ARFID?
ARFID, a new diagnostic category in the latest edition of the DSM, includes previously specific types of diagnosis such as Feeding Disorder of Infancy and Early Childhood and Eating Disorders [2]. It is defined as an eating or feeding disturbance (e.g., apparent lack of interest in eating or food avoidance based on the sensory characteristics of food; concern about aversive consequences of eating) manifested by persistent failure to meet appropriate nutritional and/or energy needs associated
Epidemiology of ARFID
Epidemiology studies are scarce for ARFID. Its prevalence ranged from 5% to 14% in tertiary care units of children and adolescent ED programs; it sometimes even reached 22.5% in pediatric day treatment programs [5], [6], [7], [8]. In a pediatric gastroenterology clinical sample of 2250 children, Eddy et al. identified 33 cases of confirmed ARFID (1.5%) and 54 cases (2.4%) of possible ARFID with patients carrying one or more ARFID symptoms [9]. In a school-based survey in Switzerland, 3.2% of
Determinants of ARFID
Parental pressure to eat, higher disgust sensitivity, and aversive food experiences were associated with general picky eating (PE) behavior [11], which may pave the way to ARFID. In some individuals, food avoidance or restriction may arise from extreme sensitivity to the appearance or sensory characteristics of food, such as color, smell, texture, temperature, or taste. Such behavior has been described as “restrictive eating,” “selective eating,” “choosy eating,” “perseverant eating,” “chronic
Nutrition and gastroenterology
Associated gastrointestinal symptoms are frequent during ARFID. In a retrospective study, 33 out of 2231 children referred to 19 gastroenterology clinics were diagnosed with ARFID and presented one or more nutritional or gastroenterologic symptoms. Seventeen of 33 (52%) of them suffered from poor weight gain/growth, ten (30%) low weight/underweight, ten (30%) poor appetite, nine (27%) abdominal pain, five (15%) weight loss, five (15%) reflux, three (9%) nausea, three (9%) diarrhea/loose stools,
Nutritional risks of ARFID
As examples, we report here two teenagers with nutritional deficiency related to abnormal feeding behavior. The first case was a 14-year-old boy who never ate any fruit or drank any fruit juice. He showed mild microcytic anemia (95 g/L [Nl: 130–160 g/L], MCV: 74 fl [Nl: 80–100 fl]) related not to inadequate iron status (which was normal), but to profound vitamin C deficiency (3 μmol/L [Nl: 30–60 μmol/L]). The second case was a 12-year-old girl who would only eat “white colored foods,” i.e., milk,
Autism spectrum disorder and ARFID symptoms
Selective feeding behavior is a well-known feature of ASD [21], [3]. Specific ARFID symptoms in ASD were reported in 2017 [4]. A meta-analysis showed that children with ASD suffered more from feeding problems than their peers as a result of their more frequent food selectivity [22]. Additionally, mealtime behavioral problems, food refusal, and preference for specific textures or smells [23], [24] are described. Approximately 80% of young children with ASD had EDs because of their picky eater
Diagnosis and management
The high prevalence of primary or secondary ARFID (in case of ASD) justifies the necessity of taking a quick dietary survey for children during their visits to the pediatric clinic. Questions to the parents such as whether the child is regularly drinking milk or consuming dairy products (as a source of protein and calcium), meat, fish or eggs (vitamin B12, iron, zinc, and selenium), vegetables (group B vitamins), fruit (vitamin C), oil or butter (fat soluble vitamins), or starchy foods (energy)
Progression
ARFID has recently been recognized as a new category of ED and data on its long-term outcome are scarce. One study suggests that this disorder has a favorable outcome if medical care is adequate [31]. Others report that the percentage of patients achieving remission is similar across ARFID and AN, but ARFID patients relied on more enteral nutrition and required longer hospitalizations than AN patients [17]. Failure-to-thrive ARFID patients will have to depend on enteral feeding or oral
Prevention
The literature shows that parental pressure on their children's food intake negatively impacts the latter's eating behavior which, in turn, correlates with their incidence of picky eating and a below-average body weight. It can contribute both to the dissociation of eating and hunger/satiety cues, and to abnormal eating habits for extrinsic reasons such as emotion [12], [32]. Parents also need to be aware that the pressure they generate is often more related to their own anxiety than to the
Conclusion
Eating disorders are commonly encountered in pediatric practice. Restrictive feedings have been observed in ASD for many years. A short dietary screening should be systematically performed as part of the pediatric follow-up to prevent both the nutritional and psychologic consequences of this newly defined disorder. A regular approach in outpatient clinical practice can be sufficient in mild cases, but multidisciplinary management is required in severe cases.
Disclosure of interest
The authors declare that they have no competing interest.
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Avoidant restrictive food intake disorder (ARFID) in children and adolescents
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