Is this child a picky eater, or do they have ARFID?

Sarah and her Mum have come in to see you because of Sarah’s recurrent tummy aches. As part of the history, you ask about appetite and diet.

As Mum tells you what Sarah – who is 6 - eats on a typical day, you realise that she has a very limited diet. In fact, she eats the same 8 things every day. Mum says she’s always been a “picky eater”, but she hoped this would improve when she got older and started school. Mum has tried giving a range of options but Sarah quickly becomes distressed, and sometimes will gag or vomit which is upsetting for everyone.

You strongly suspect Sarah’s diet isn’t going to meet the needs of a healthy, growing child. What should you advise?

UNICEF estimate 1 in 3 children in the UK have overweight or obesity when they leave primary school, with The Food Foundation estimated that 4 million children in UK households are affected by food insecurity. Ensuring children have access to a healthy diet is essential for their current and future health and has long been a stated priority of the NHS and government. For some families, these challenges are compounded by a child who cannot tolerate more than a small number of types of food.

This is one of the many consultations that pop up regularly in general practice, that falls somewhere in the spectrum of “normal childhood behaviour” at one end, and pathology at the other. Honestly, how much of your training talked about what advice to give in this situation? We can all talk about a balanced diet, fruit and vegetables, fibre and fluid intake, but the reality of making any child actually eat that is a different cup of tea!

Our understanding has moved on from labelling all children like Sarah as “picky eaters”. Instead, we need to think “does this child have ARFID?”

Avoidant Restrictive Food Intake Disorder (ARFID) is a formal diagnosis of a recognised eating disorder and should be made by an appropriate MDT. Almost all of these children will have contact with general practice and the wider primary care team months or years before they get such an MDT assessment, if indeed they ever do. The BJGP has published an excellent summary of ARFID, and what we can do in primary care to support these children and their families. 

The potential 8 signs they suggest looking out for include:

• A diet limited to usually <10 preferred/ ”safe” foods
• Lack of interest in eating or missing meals completely
• Avoidance of whole food groups or sensory specific foods e.g. crunchy foods
• Disgust response to foods e.g. retching, gagging
• Negative impact on physical health status (including nutritional deficiencies that may only be evident on investigation)

The article discusses the spectrum that exists between normal childhood “picky eating”, and the severe, clinically diagnosable ARFID which has a significant detrimental impact on quality of life of affected children and families. Common associations include autism spectrum disorder (usually related to sensory specificity, although not all autistic individuals have ARFID); chronic history of food avoidance, often worsening over time; acute onset of food avoidance secondary to a phobia e.g. a vomiting/choking/contamination episode. 

ARFID is not anorexia nervosa, as the avoidance of food is not driven by concerns about weight or body shape. It is easy to imagine that in a child where the condition has gone unrecognised, who then reaches their teenage years and is visibly underweight, they may be incorrectly labelled as having anorexia and the resultant management will not address the underlying condition of ARFID. The role of primary care is to be aware of this as a condition and make an initial assessment:

• Take a history of both the presenting difficulties and any early feeding difficulties
• Look for underlying or compounding physical symptoms that might impact appetite or cause food aversion. Do these need medical investigations first?
• Make a physical assessment checked against the MEED guidelines on management of emergencies in eating disorders. If the child is showing signs of malnutrition or growth disturbance, intervention may be urgent. 
• Be mindful of co-existing autism spectrum disorders, or that they may be undiagnosed.
• Use an assessment tool to support your consultation, such as from the Maudsley Centre who have a range of publications and resources on ARFID. 

While each child will require a unique management plan, exclusion of other underlying medical conditions is a key step. The summary recommends that referral to an appropriate dietician for further assessment and to develop a full nutritional assessment and link into the relevant local MDT pathway is likely to be the most appropriate first step. 

For Sarah and her Mum, we need to explore more about the background and share our thoughts about a possible ARFID diagnosis. We need to make an effort so that Sarah’s parents in particular feel supported. The BJGP article highlights that for many families their experience of healthcare is of being judged, criticised or blamed. We should be hopeful too and tell Sarah and her Mum that ARFID is considered to be a treatable disorder with the right help and support. 

Like me, you might be looking back and thinking of all those consultations where you wish you’d know this before and may have not given the right advice to a parent or family. The article includes some links to additional CPD resources and support for both professionals and parents. Hopefully Sarah and her family will be the first to benefit from this incredibly helpful guidance.