In this month’s article, I would like to provide information about a topic regarding feeding that has come up more often. It is a difficult issue that many parents face and have concerns about but isn’t really talked about. As a pediatric feeding specialist, I get tons of questions every day regarding children and their eating. Is this normal for my baby? When should I start solids? What is normal picky eating, and what is not? But recently, parents have been asking me the same question: “Is my child too old to be helped with feeding therapy?”

And the answer is no! Many older children can be helped with the right feeding therapy. It is not always easy, but older children can benefit from food exposures or treatment and can change the way they eat. In fact, there is now a diagnosis newer to the world of pediatric feeding difficulties many parents have not even heard of, one that often impacts the lives of older children. It is called Avoidant Restrictive Food Intake Disorder, or ARFID for short. 

ARFID is characterized by a persistent disturbance in eating, leading to weight loss or growth disturbances, nutrient deficiencies, dependence on supplements, and impaired psychosocial functioning. This unwillingness to eat is not the result of the child wanting to change their body or lose weight. ARFID is a relatively new diagnosis for picky eaters with food phobia. The fear of food, or anxiety around food, is the hallmark of this diagnosis.

Here are some common signs of ARFID:

• Food refusal
• Poor or delayed eating or feeding skills
• Underweight or slowed growth
• Anxiety, especially around new food or when trying foods
• Texture sensitivities
• A very limited list of preferred foods
• Eating foods of similar characteristics
• Preferences for particular ways foods are prepared
• Avoidance of entire food groups (like no veggies or meats)
• Eliminates foods with the result of these foods never getting back into their diets
• Nutrient deficiencies (iron, vitamin A, and vitamin C most common)
• Becomes emotional or demonstrates stress around unfamiliar foods
• Food limitations impacting social engagements negatively
• Simply unwilling to try new foods
• Parents deciding to seek help in late elementary years or early middle school

Kids with ARFID may or may not have underlying reasons for their food refusals. They also often have some of the following comorbidities: 

• Early negative associations with food (choking, gagging, vomiting)
• Poor or delayed eating/feeding skills
• Often being low on the growth chart; may have been labeled as failure to thrive at one point
• Anxiety
• Texture sensitivities
• A diagnosis of an anxiety disorder, ADD, ADHD, or autism spectrum disorder

So, how does this impact my family?

Having a picky eater in the house is stressful! Add in a busy life, years of refusals, some quick negotiations, parents’ worries about their child not growing well, advice from relatives, and it is easy to see how quickly unhealthy patterns arise. Short order cooks evolve over time. Items that were preferences are gradually set in stone. A limited diet becomes smaller and smaller. Sometimes force or pressure is used, making the situation worse. Bribery becomes accepted. Unhealthy diets go from bad to worse. Nutritional gaps grow bigger until help is needed.

Luckily, there is treatment for ARFID! Treatment is not quick, but you should see improvement between sessions if you are putting in work at home. Be aware that treatment for ARFID can be long, and it takes the effort of the entire family for things to progress. 

Things you can look forward to with treatment:

1. It can improve nutritional status and growth.
2. It can help overcome a fear of food.
3. It can improve family relations and decrease stress at mealtimes.
4. It can help with diet expansion.

Things you should be aware of when beginning treatment:

1. Progress may be slow.
2. Family follow through is key – it may be challenging to put in the effort to see real results. This therapy is not simply about your child. Parental involvement is essential.
3. Healthcare professionals who are not trained in feeding or nutrition may cause more harm to a child with ARFID. Choose your providers carefully.
4. Things may get worse before they get better. This is a process. You may need to break through some barriers before you see real results.
5. Goals should be realistic and explained prior to starting therapy.

Kelly is a feeding specialist and founder of pickyeatersonline.com, treating children with feeding disorders such as ARFID in Lake Nona. If you would like to ask her any questions regarding feeding concerns for children at any age, email her at kelly@pickyeatersonline.com, and she will be answering your questions in upcoming articles!