Redefining feeding and eating disorders: What is avoidant/restrictive food intake disorder?

A 10-year-old boy presented to the emergency department with an eight-week history of food refusal. The parents reported that he had been preoccupied and “afraid to eat” any solid foods following a choking episode while eating steak 18 months previously. He became progressively more restricted in the type of foods that he considered to be ‘safe’. His paediatrician sent him to the emergency department along with a copy of his growth charts, which showed a steady decline in weight and faltering growth in height. Before the choking episode, his physical growth and development were normal. His weight and height had always followed the 50th percentile. Over the past 18 months, he had fallen off his curve and his current weight was 23 kg (third percentile) and height 89 cm (between the 15th and 50th percentiles). Despite his parents’ best attempt to feed him soft and pureed food, he failed to gain any weight. He had a medical history of generalized anxiety disorder and, as a result, was homeschooled until grade 3. The child denied intentional weight loss, a fear of weight gain, or concerns about his body weight or shape. However, he did express a desire to “grow taller and not be so skinny”. The child’s restricted intake had made it difficult for him to spend time with friends. On physical examination, he appeared cachectic, with dry mucous membranes. Cardiovascular examination revealed a resting heart rate of 44 beats/min, delayed capillary refill, and mottled hands and feet. LEARNING POINTS Avoidant/restrictive food intake disorder (A5),D) is a new diagnostic category in the section on Feeding and Eating Disorders in the Diagnostic and Statistical Manual, 5th Edition.(1) ARFID takes the place of and extends Feeding Disorder of Infancy or Early Childhood in the Diagnostic and Statistical Manual, 4th Edition. The aim of this revision was to improve the clinical utility by adding more detail to the diagnostic criteria and widening the criteria to be applicable across the lifespan. Clinical features of ARFID include an eating or feeding disturbance that is manifested by persistent failure to meet appropriate nutritional and/or energy needs leading to one or more of the following:(1) ○ Significant weight loss (ie, crossing percentiles on the growth chart for weight and/or height or failure to achieve expected weight gain over time); ○ Significant nutritional deficiency (which warrants additional clinical attention); ○ Dependence on enteral feeding or oral nutritional supplements; ○ Marked interference with psychosocial functioning. ARFID is not: ○ The result of not having enough available food or the result of an associated culturally sanctioned practice; ○ Associated with any abnormalities in the way in which one perceives his/her own body weight or shape; ○ Attributable to a concurrent medical condition or not better explained by another mental disorder. In cases in which the eating disturbance occurs in the context of another condition or disorder, the severity of the eating disturbance exceeds that routinely associated with the condition or disorder and warrants additional clinical attention. In a recent Canadian Paediatric Surveillance Program (CPSP) one-time survey,(2) paediatricians and paediatric subspecialists retrospectively reported having seen 339 cases of ARFID over the past year (unpublished data). Because this is a new diagnosis, many clinicians are unfamiliar with this new diagnostic category and the specific diagnostic criteria that define this disorder. ○ The CPSP one-time survey revealed that two-thirds (418 of 657 [63%]) of paediatricians and paediatric subspecialists were unfamiliar with ARFID (unpublished data). ○ Of the paediatricians and paediatric subspecialists who suspected a diagnosis of ARFID (239 of 657 [36%]), 30% inappropriately applied the exclusion criteria, resulting in a misdiagnosis (unpublished data). The presence of other psychological disorders, such as anxiety disorder, obsessive-compulsive disorder, attention deficit disorder or autism spectrum disorder, may be a risk factor for ARFID. When a child or adolescent presents with one of these illnesses and an eating problem, a diagnosis of ARFID should be given only when the feeding disturbance itself is causing significant clinical impairment that requires intervention beyond that usually required for the other condition. Little is known about effective treatments for children and adolescents with ARFID. Moving forward, it will be important for researchers to embark on studies that set out to inform how such patients are best treated. Currently, treatment is informed by the area most responsible for contributing to the avoidance or restriction of the food intake.(3) In most cases, treatment will include psychological interventions, nutritional involvement and medical monitoring.(3) Experience to date suggests that patients with ARFID often present with complex histories and require the expertise of clinicians (and multidisciplinary teams, when available) with experience in complex feeding and eating disorders.

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