PAEDIATRIC
AVOIDANT/RESTRICTIVE FOOD INTAKE DISORDER Priya Tew Freelance Dietitian Priya runs Dietitian UK, a freelance dietetic service that specialises in eating disorder support. She works with NHS services, The Priory Hospital group and private clinics. Priya also provides Skype support to clients nationwide.
Avoidant/restrictive food intake disorder (ARFID) is a fairly new type of eating disorder, but one which is now the second most common eating disorder in children 12 years and younger. It is sometimes called picky eating and was formally categorised in 2013. The definition for ARFID in The Diagnostic and Statistical Manual of Mental Disorders (DSM–5) includes an eating or feeding disturbance (e.g. a lack of interest in eating/food, avoidance of foods due to sensory concerns and/ or aversion to foods), with a persistent failure to meet appropriate nutritional or energy needs.1 One or more of the following should be associated with ARFID: weight loss (or failure to gain weight in children), significant nutritional deficiency, the need for enteral feeding or ONS and an effect on psychosocial functioning (see Table 1). The issues should not be due to an unavailability of food, food poverty or any cultural eating practices and it should not be better described by any other medical condition.
SIGNS AND SYMPTOMS
There may be no outward obvious signs that someone is suffering from ARFID. Most sufferers want to make changes to their eating habits but do not know how to move forward with it. More obvious physical symptoms include retching and vomiting around foods, anxiety with eating, loss of appetite, abdominal pain and socially avoiding being around food. There are usually safe and excluded foods. These foods may be categorised by certain brands, food groups, smells, colours and textures. Some people may only like to eat very hot/cold foods, may have to eat foods without any sauces, or eat foods presented in a certain way. There is fear around eating certain foods that can be overwhelming
Table 1: DSM-5 diagnosis of avoidant/restrictive food intake disorder1,2 A 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) as manifested by persistent failure to meet appropriate nutritional and/or energy needs associated with one (or more) of the following: 1. Significant weight loss (or failure to achieve expected weight gain, or faltering growth in children). 2. Significant nutritional deficiency. 3. Dependence on enteral feeding or oral nutritional supplements. 4. Marked interference with psychosocial functioning. B The disturbance is not better explained by lack of available food or by associated culturally sanctioned practice. C The eating disturbance does not occur exclusively during the course of anorexia nervosa or bulimia nervosa, and there is no evidence of a disturbance in the way in which one's body weight or shape is experienced. D The eating disturbance is not attributable to a concurrent medical condition or not better explained by another mental disorder. When 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. www.NHDmag.com July 2017 - Issue 126
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PAEDIATRIC
Children
are taught relaxation
techniques with an aim to reduce the anxiety around
foods. One technique is to and disturbing to watch. Often this can be perceived as the patient being difficult or acting out behaviourally, but there is usually an underlying reason for the fear. Unlike anorexia and bulimia, there are no fears around weight gain, less comorbidity and fewer eating disorder behaviours, such as hiding food and manipulating their weight. However, the same anxiety around food is present. The research suggests that ARFID is more likely to affect males and is more likely to present before the age of 12.3 Some of these patients can then be at risk of anorexia nervosa, so highlighting these groups could be a way to prevent the eating disorder progressing. A study by Fisher et al found the main reasons for ARFID were picky eating from childhood, anxiety, fear of vomiting or choking, food allergies and gastrointestinal symptoms.1 People with ARFID are also more likely to have another medical condition alongside. A review of adolescents with eating disorders compared those with Anorexia nervosa, bulimia and ARFID.3 Adolescents with ARFID had a lower bone mineral density (BMD), especially in their 42
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create a storyline around the foods.
lumbar spine, but they have similar rates of depression. Triggers for the development of the selective eating were bullying, weightbased teasing and trauma around food, such a choking or vomiting after eating something. Having ARFID will have an impact on a person socially, making it harder, or not possible, to eat out; eating at work or school can be difficult and may lead to them missing lessons due to the time it takes to complete a meal.5 Subcategories of ARFID include the following: 1. Sensory-based avoidance, where the person refuses foods based on smell, tastes, texture, colour and presentation. 2. Lack of interest in food and not being able to tolerate being near it. 3. Negative experiences with the food, leading to anxiety and fear around it.
RISK OF OTHER CONDITIONS
Eighty percent of children with a developmental disability also have ARFID. Children with ARFID often show signs of obsessive compulsive disorder or autism, but may not meet a full clinical diagnosis. For example, they may struggle with making change and will like strict routine. A study by Schreck et al6 found that children with some degree of autism spectrum disorder (ASD) had significantly more issues with food, being more selective in their food choices and eating a narrower range of foods. TREATMENT
Over time, the symptoms of ARFID should lessen and to some extent children can grow out of it. There may not be a need to treat a low severity case. When the fears around certain foods become overwhelming and lead to the patient not being able to properly nourish themselves, then intervention is needed. Obviously nutritional deficiencies will need correcting and may impact on a child’s growth, but also ARFID may develop into a more severe eating disorder such as anorexia nervosa. Early treatment can help prevent this. For some cases, treatment will involve outpatients’ appointments, dietetic support and therapy and oral nutritional supplementation and, for some, it can require hospitalisation. Although the calories required for weight restoration are the same in anorexia nervosa and ARFID patients, more patients with ARFID are enterally fed and longer hospitalisations tend to be needed.4 Support is helpful if the child is nutritionally deficient, if weight is a concern, or symptoms become a problem socially, or if the symptoms continue into adulthood. Cognitive behavioural therapy is the main form of treatment. This focuses less on
the food and more on changing behaviours. Talking about why food is needed and what the different food groups provide is a good educational point and can give the person motivational reasons to eat. Replacing the scripts of fear with positive scripts can reduce the anxiety. Other anxiety management techniques including breathing, journaling and relaxation can also enable people to start to increase the range of foods that they eat. Simple mealtime management techniques, such as distraction with conversation, having a calm environment, putting a candle on the table to focus on, may all be helpful. Specifically for children, there is a fourstage treatment programme that is used, based on systematic desensitisation. Stage 1: Record. Children keep a log of eating behaviours and their feelings. Stage 2: Rewards. Children write a list of foods they would like to try. This can be variations on current foods, prepared in a different way, or a different brand. Rewards are given when they try something new. Stage 3: Relaxation. Children are taught relaxation techniques with an aim to reduce the anxiety around foods. One technique is to create a storyline around the foods, using their favourite people and/or places so that they can imagine themselves enjoying the foods as a prelude to eating them. Stage 4: Review. It is key to also keep track of how a child is progressing and feed this back to the family and child, as it can sometimes be hard to see how much change has been made.
ARFID is a fairly new diagnosis and is an eating disorder subcategory. More research is needed to look at optimal approaches to refeeding and why the disease is triggered. However, a lot of the treatments used in anorexia nervosa will be able to be adapted and transferred through for this patient group.
References 1 Fisher MM et al (2014). Characteristics of avoidant/restrictive food intake disorder in children and adolescents: A ‘new disorder’ in DSM-5. J Adolesc Health; Vol 55 (1): 49-52 2 Diagnostic and Statistical Manual of Mental Disorders (DSM-5). www.psychiatry.org/psychiatrists/practice/dsm 3 Norris ML et al (2014). Exploring avoidant/restrictive food intake disorder in eating disordered patients: a descriptive study. Int J Eat Disord; 45 (5): 495-9 4 Strandjord SE et al (2015). Avoidant/restrictive food intake disorder: illness and hospital course in patients hospitalised for nutritional insufficiency. J Adolesc Health; 57 (6): 673-8 5 What is ARFID? The Centre for Eating Disorders Blog. http://eatingdisorder.org/blog/2013/08/what-is-arfid/ 6 Schreck KA, Williams K, Smith AF (2004). A comparison of eating behaviours between children with and without autism. J Autism Dev Disord. 2004. Aug; 34 (4): 433-8
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