Archives de Pédiatrie 26 (2019) 437–441

Available online at

ScienceDirect
www.sciencedirect.com

Review article

Nutritional risks of ARFID (avoidant restrictive food intake disorders)

and related behavior
F. Feillet a,*, A. Bocquet b, A. Briend c, J.-P. Chouraqui d, D. Darmaun e, M.-L. Frelut f,
J.-P. Girardet g, D. Guimber h, R. Hankard i, A. Lapillonne j, N. Peretti k, J.-C. Rozé e,
U. Simeoni d, D. Turck h, C. Dupont j, Comité de nutrition de la Société française
de pédiatrie (CNSFP)l
a
Université de Lorraine, 54000 Nancy, France
b
Université de Franche-Comté, 25000 Besançon, France
c
Institut de recherche pour le développement, 13002 Marseille, France
d
Université de Lausanne, 1011 Lausanne, Switzerland
e
Universite Nantes-Atlantique, 44300 Nantes, France
f
Université Paris-Sud, 75005 Paris, France
g
Université Paris 6 Pierre et Marie Curien, 75005 Paris, France
h
Université de Lille, 59000 Lille, France
i
Université de Tours, 37000 Tours, France
j
Université Paris Descartes, 75006 Paris, France
k
Université de Lyon, 69000 Lyon, France
l
Société française de pédiatrie, hôpital Necker Carré Necker, 149, rue de Sèvres, 75015 Paris, France

A R T I C L E I N F O A B S T R A C T

Article history: Avoidant/restrictive food intake disorder (ARFID) has recently been added to the DSM V (Diagnostic and
Received 1st February 2019 Statistical Manual of Mental Disorders, 5th edition) as a new class of eating disorders (EDs). ARFID is
Received in revised form 16 April 2019 characterized by a lack of interest in eating or avoiding specific types of foods because of their sensory
Accepted 2 August 2019
characteristics. This avoidance results in decreased nutritional intake, eventually causing nutritional
Available online 26 September 2019
deficiencies. In severe cases, ARFID can lead to dependence on oral nutritional supplements, which
interferes with psychosocial functioning. The prevalence of ARFID can be as high as 3% in the general
Keywords:
population, and it is often associated with gastrointestinal symptoms and mainly appears in children
ARFID
Nutrition
with anxiety disorders. Given the high prevalence of ARFID, a rapid and systematic nutrition survey
Deficiency should be conducted during every pediatric consultation. Its treatment should also be adapted
depending on the severity of the nutritional problem and may involve hospitalization with
multidisciplinary care (pediatrician, nutritional therapist, dietitian, psychologists, and speech
therapists).
C 2019 French Society of Pediatrics. Published by Elsevier Masson SAS. All rights reserved.

1. Introduction latest version of the Diagnostic and Statistical Manual of Mental

Disorders (DSM-5) in 2013, which now include pica, rumination
Nutritional assessment is part of the routine examination in disorder, and avoidant/restrictive food intake disorder (ARFID) [2].
pediatric practice and has become more important than ever as Similar restrictive feeding behavior has been described earlier
children and adolescents increasingly adopt restrictive feeding in children with autism spectrum disorders (ASD) [3], but its onset
behaviors that entail risks of severe nutritional deficiencies in children and adolescents without ASD seems new. The aim of
[1]. Such behavior changes underlie the reason for the latest this paper is to draw attention to ARFID and the nutritional risks
modification on the classification of eating disorders (EDs) in the induced by this new type of eating disorder.

2. What is ARFID?
* Corresponding author at: Service de médecine infantile, centre de référence des
maladies métaboliques de Nancy, CHU Brabois-Enfants, 54110 Vandoeuvre-lès-
Nancy, France. ARFID, a new diagnostic category in the latest edition of the
E-mail address: [email protected] (F. Feillet). DSM, includes previously specific types of diagnosis such as

https://doi.org/10.1016/j.arcped.2019.08.005
0929-693X/ C 2019 French Society of Pediatrics. Published by Elsevier Masson SAS. All rights reserved.
438 F. Feillet et al. / Archives de Pédiatrie 26 (2019) 437–441

Feeding Disorder of Infancy and Early Childhood and Eating such as color, smell, texture, temperature, or taste. Such behavior
Disorders [2]. It is defined as an eating or feeding disturbance (e.g., has been described as ‘‘restrictive eating,’’ ‘‘selective eating,’’
apparent lack of interest in eating or food avoidance based on the ‘‘choosy eating,’’ ‘‘perseverant eating,’’ ‘‘chronic food refusal,’’ and
sensory characteristics of food; concern about aversive conse- ‘‘food neophobia’’ and may lead to refusals to eat certain foods or
quences of eating) manifested by persistent failure to meet even intolerances to the smell of certain foods being eaten by
appropriate nutritional and/or energy needs associated with one others. Individuals with enhanced sensory food sensitivity
(or more) of the following criteria: associated with ASD may show similar behavior. Food avoidance
or restriction may also result from conditioned negative responses
 significant weight loss (or failure to achieve expected weight associated with aversive experiences, such as repeated vomiting,
gain or faltering growth in children); suffocation or an episode of choking during a traumatic
 significant nutritional deficiency; investigative procedure [12].
 dependence on oral nutritional supplements or enteral feeding
or pronounced interference with psychosocial functioning.
5. Associated symptoms

To qualify for ARFID, the disorder must meet several exclusion

5.1. Nutrition and gastroenterology
criteria:
Associated gastrointestinal symptoms are frequent during
 food avoidance must not be due to lack of available food or
ARFID. In a retrospective study, 33 out of 2231 children referred
adherence to culturally or religiously sanctioned precepts;
to 19 gastroenterology clinics were diagnosed with ARFID and
 it does not occur exclusively during the course of anorexia
presented one or more nutritional or gastroenterologic symptoms.
nervosa or bulimia nervosa, and there is no evidence of a
Seventeen of 33 (52%) of them suffered from poor weight gain/
disturbance in the way in which one’s body weight or shape is
growth, ten (30%) low weight/underweight, ten (30%) poor
experienced [2];
appetite, nine (27%) abdominal pain, five (15%) weight loss, five
 it is not attributable to a concurrent medical condition or not
(15%) reflux, three (9%) nausea, three (9%) diarrhea/loose stools,
better explained by another mental disorder. When the eating
and three (9%) food allergies [9].
disturbance occurs in the context of another condition or
disorder, the severity of the eating disturbance exceeds that
5.2. Psychiatric context
routinely associated with the condition or disorder and warrants
additional clinical attention;
Feeding disorders are common features in many psychiatric
 ARFID does not refer to developmentally normal behaviors (e.g.,
patients, especially those with anxiety disorders [5,8], ASD [6], and
picky eating in toddlers, reduced intake in adults).
attention deficit hyperactivity [6]. Other psychiatric symptoms
associated with ARFID such as obsessive-compulsive or somato-
ARFID is now a specific diagnosis in the classification of EDs and
form disorders, emetophobia (fear of vomiting), food neophobia
from a nutritional standpoint, it is important to screen for
(fear of new foods), or choking phobia (fear and avoidance of
restrictive feeding behavior in every child, mainly those with a
swallowing food, fluids, or pills) have been reported [13]. In a
concomitant disease, particularly autism or other psychiatric
retrospective study of 34 pediatric ARFID patients, almost 50% of
diseases [4].
these children had generalized anxiety disorders [8]. The treatment
of these associated disorders can negatively influence the efficacy of
3. Epidemiology of ARFID their nutritional management, because a common side effect of the
stimulant medication (methylphenidate prescribed for hyperactiv-
Epidemiology studies are scarce for ARFID. Its prevalence ity/attention deficit disorder) is decreased appetite [14].
ranged from 5% to 14% in tertiary care units of children and
adolescent ED programs; it sometimes even reached 22.5% in
6. Nutritional risks of ARFID
pediatric day treatment programs [5–8]. In a pediatric gastroen-
terology clinical sample of 2250 children, Eddy et al. identified
As examples, we report here two teenagers with nutritional
33 cases of confirmed ARFID (1.5%) and 54 cases (2.4%) of possible
deficiency related to abnormal feeding behavior. The first case was a
ARFID with patients carrying one or more ARFID symptoms [9]. In a
14-year-old boy who never ate any fruit or drank any fruit juice. He
school-based survey in Switzerland, 3.2% of 1444 children aged 8–
showed mild microcytic anemia (95 g/L [Nl: 130–160 g/L], MCV:
13 years self-reported clinical characteristics consistent with
74 fl [Nl: 80–100 fl]) related not to inadequate iron status (which
ARFID [10]. The high prevalence of ARFID may further be confirmed
was normal), but to profound vitamin C deficiency (3 mmol/L [Nl:
in the general population by epidemiologic studies, rendering the
30–60 mmol/L]). The second case was a 12-year-old girl who would
screening of ARFID relevant for every child or adolescent seen in
only eat ‘‘white colored foods,’’ i.e., milk, bread, rice and pasta. She
clinics. In the few studies looking at patient populations drawn
suffered from pronounced vitamin deficiencies: plasma folates:
from ED clinical samples, ARFID patients were consistently
2 nmol/L [Nl: 6–36 nmol/L], plasma cobalamin: 95 pmol/L [N: 156–
younger than those with other EDs, more likely to be male
674 pmol/L], and plasma homocysteine: 45 mmol/L [Nl < 10 mmol/
(compared to adolescents with anorexia nervosa), with a high rate
L]. Both teenagers, referred by their worrying parents for their
of comorbid psychiatric and/or medical symptoms [5–8].
restrictive feeding patterns, were diagnosed as ARFID despite the
absence of clinical symptoms.
4. Determinants of ARFID The diagnosis of significant nutritional deficiencies in ARFID
children is based on dietary history, clinical and biological
Parental pressure to eat, higher disgust sensitivity, and aversive assessments (e.g., assessment of dietary intake, physical examina-
food experiences were associated with general picky eating (PE) tion, and laboratory testing), and the presence of clinical
behavior [11], which may pave the way to ARFID. In some consequences on physical health. The severity of these conse-
individuals, food avoidance or restriction may arise from extreme quences is greater than that resulting from anorexia nervosa
sensitivity to the appearance or sensory characteristics of food, (e.g., hypothermia, bradycardia, and anemia) [15,16]. Specific
 F. Feillet et al. / Archives de Pédiatrie 26 (2019) 437–441 439

nutritional deficiencies must be screened according to each dietary consuming dairy products (as a source of protein and calcium),
pattern. The restrictive behavior can induce specific deficiencies meat, fish or eggs (vitamin B12, iron, zinc, and selenium),
related to the nature of the excluded foods. In severe cases, vegetables (group B vitamins), fruit (vitamin C), oil or butter (fat
particularly in infants, the consequent malnutrition can even be soluble vitamins), or starchy foods (energy) are adequate and not
life-threatening. overly time-consuming for the pediatrician in charge. These
The nutritional consequences of ARFID remain poorly de- nutritional deficiencies can be diagnosed by biological analysis,
scribed. Most papers reported weight loss [7,17–19]. Only one which must be adapted to each nutritional deficiency. These
paper describes a patient (17 years old) presented with macrocytic analyses are summarized in Table 1. This, together with growth
anemia. The dietary assessment history revealed that he only ate measurement, should identify potential overall or specific
boiled rice, fried potato chips, chicken nuggets, potato crisps, and malnutrition. The ensuing treatment must then be adapted to
sometimes chocolate. This patient presented with a subacute the severity and the specifics of the nutritional problems (Fig. 1).
combined degeneration of the spinal cord related to multiple Hospitalization with multidisciplinary management (pediatrician,
vitamin deficiencies (A, E, K, D, B12, and folates) [20]. The second nutritional therapist, dietician, psychologists, and speech and
case reported here at the beginning of this article was a similar, occupational therapists) is required for severe malnutrition, which
although less severe case. is defined by low nutritional indices (BMI below the 3rd centile for
age and sex, weight for height Z-score below 2 SD for sex) and
7. Autism spectrum disorder and ARFID symptoms growth faltering at least for weight and associated with height
in case of chronic malnutrition associated with clinical signs of
Selective feeding behavior is a well-known feature of ASD malnutrition [28]. Hospitalization is also required when outpatient
[21,3]. Specific ARFID symptoms in ASD were reported in 2017 management fails to normalize the nutritional status. In severe
[4]. A meta-analysis showed that children with ASD suffered more cases, the use of a complete balanced dietary supplement shall
from feeding problems than their peers as a result of their more be attempted first prior to nasogastric feeding to help restore a
frequent food selectivity [22]. Additionally, mealtime behavioral proper nutritional status.
problems, food refusal, and preference for specific textures or Psychological follow-up remains the mainstay treatment for
smells [23,24] are described. Approximately 80% of young children sick children requiring a multidisciplinary approach. It should
with ASD had EDs because of their picky eater behaviors, with 95% include a systematic desensitization, a structured nutritional plan
of them resisting tasting new foods [25]. A study compared 40 ASD with gradual exposure-based therapy, and management of anxiety
children to 40 healthy controls and found that ASD but not normal via techniques such as relaxation techniques [12]. Problematic
children had statistically significant moderate nutritional conse- foods should progressively be incorporated into the patient’s
quences of their abnormal feeding behavior (i.e., vitamin B12, folate eating pattern. In severe cases of ARFID, drugs such as olanzapine
deficiencies) [26]. Other observations such as lower protein, [29] or mirtazapine [30] have been proposed.
calcium, and phosphorus intakes, as well as lower bone mineral
density (BMD) z-scores at the lumbar spine, femoral neck, total hip, 9. Progression
and whole body were recently made by Neumeyer et al., who
compared 25 ASD children with ARFID to 24 normally developed ARFID has recently been recognized as a new category of ED and
children. The same study also showed that the lower protein, data on its long-term outcome are scarce. One study suggests that
calcium, and phosphorus intakes in ASD children with ARFID were this disorder has a favorable outcome if medical care is adequate
associated with lower BMD [27]. [31]. Others report that the percentage of patients achieving
remission is similar across ARFID and AN, but ARFID patients relied
8. Diagnosis and management on more enteral nutrition and required longer hospitalizations
than AN patients [17]. Failure-to-thrive ARFID patients will have
The high prevalence of primary or secondary ARFID (in case of to depend on enteral feeding or oral nutritional supplements to
ASD) justifies the necessity of taking a quick dietary survey for maintain adequate intake. Some patients will need gastrostomy
children during their visits to the pediatric clinic. Questions to the tube feeding or complete dietary supplements in the absence of
parents such as whether the child is regularly drinking milk or any underlying organ dysfunction. Certain treatment interventions

Table 1
Nutritional consequences of avoided foods.

Avoided food Nutrient deficiency Primary parameter Functional consequence

Starchy foods Carbohydrates Weight and height Hypotrophy

Milk, dairy products Calcium PTH, alkaline phosphatases, Hypocalciuriaa Rickets
Meat, fish, eggs Total protein Plasma protein, albumin, prealbumin Edema
Cobalamin Plasma cobalamin Hyperhomocysteinemia
Iron Plasma ferritin Microcytic anemia
Zinc Plasma zinc Oxidative stress
Selenium Plasma selenium Oxidative stress
Vegetables Folates Plasma folates Hyperhomocysteinemia
Fruits Vitamin C Plasma vitamin C Microcytic anaemia, scurvy
Low fat intake Vitamin E Vitamin E/lipidsb Oxidative stress
Vitamin A Plasma vitamin Ac Hemeralopia

The main functional consequences are cited.

a
Hypocalcemia is a late consequence of low calcium intake and is not the primary biological parameter to assess calcium intake.
b
Plasma vitamin E depends on the plasma lipids levels.
c
Vitamin A deficiency can be avoided by intake of high beta-carotene -containing foods (i.e., yam, pumpkin, carrots, etc.).
440 F. Feillet et al. / Archives de Pédiatrie 26 (2019) 437–441

Fig. 1. Management of restrictive feeding behavior in children.

may lead to patients’ inability to participate in normal social food selectivity: An Electronic Medical Record Review. J Acad Nutr Diet
2018;118:1943–50.
activities such as eating with others or to sustain relationships [2]. [4] Lucarelli J, Pappas D, Welchons L, et al. Autism Spectrum Disorder and
Avoidant/Restrictive Food Intake Disorder. J Dev Behav Pediatr 2017;38:79–
80.
10. Prevention
[5] Fisher MM, Rosen DS, Ornstein RM, et al. Characteristics of avoidant/restrictive
food intake disorder in children and adolescents: a ‘‘new disorder’’ in DSM-5.
The literature shows that parental pressure on their children’s J Adolesc Health 2014;55:49–52.
food intake negatively impacts the latter’s eating behavior which, [6] Nicely TA, Lane-Loney S, Masciulli E, et al. Prevalence and characteristics of
avoidant/restrictive food intake disorder in a cohort of young patients in day
in turn, correlates with their incidence of picky eating and a below- treatment for eating disorders. J Eat Disord 2014;2:21.
average body weight. It can contribute both to the dissociation of [7] Ornstein RM, Essayli JH, Nicely TA, et al. Treatment of avoidant/restrictive food
eating and hunger/satiety cues, and to abnormal eating habits for intake disorder in a cohort of young patients in a partial hospitalization
program for eating disorders. Int J Eat Disord 2017;50:1067–74.
extrinsic reasons such as emotion [12,32]. Parents also need to [8] Norris ML, Robinson A, Obeid N, et al. Exploring avoidant/restrictive food
be aware that the pressure they generate is often more related intake disorder in eating disordered patients: A Descriptive Study. Int J Eat
to their own anxiety than to the nutritional risk for their children Disord 2014;47 [495-v9].
[9] Eddy KT, Thomas JJ, Hastings E, et al. Prevalence of DSM-5 avoidant/restrictive
[12]. Counseling parents on the deleterious effects of feeding food intake disorder in a pediatric gastroenterology healthcare network. Int
pressure and the verifications of their children’s consumption of J Eat Disord 2015;48:464–70.
balanced diets should be part of routine pediatric clinical practice. [10] Kurz S, van Dyck Z, Dremmel D, et al. Early-onset restrictive eating distur-
bances in primary school boys and girls. Eur Child Adolesc Psychiatry
2015;24:779–85.
11. Conclusion [11] Ellis JM, Galloway AT, Webb RM, et al. Recollections of pressure to eat during
childhood, but not picky eating, predict young adult eating behavior. Appetite
2016;97:58–63.
Eating disorders are commonly encountered in pediatric [12] Zimmerman J, Fisher M. Avoidant/Restrictive Food Intake Disorder (ARFID).
practice. Restrictive feedings have been observed in ASD for many Curr Probl Pediatr Adolesc Health Care 2017;47:95–103.
years. A short dietary screening should be systematically [13] Herpertz-Dahlmann B. Treatment of eating disorders in child and adolescent
psychiatry. Curr Opin Psychiatry 2017;30:438–45.
performed as part of the pediatric follow-up to prevent both the [14] Osland ST, Steeves TD, Pringsheim T. Pharmacological treatment for attention
nutritional and psychologic consequences of this newly defined deficit hyperactivity disorder (ADHD) in children with comorbid tic disorders.
disorder. A regular approach in outpatient clinical practice can be Cochrane Database Syst Rev 2018;6:CD007990.
[15] Takeshima M, Ishikawa H, Kitadate A, et al. Anorexia nervosa-associated
sufficient in mild cases, but multidisciplinary management is pancytopenia mimicking idiopathic aplastic anemia: a case report. BMC
required in severe cases. Psychiatry 2018;18:150.
[16] Lowe B, Zipfel S, Buchholz C, et al. Long-term outcome of anorexia nervosa in a
prospective 21-year follow-up study. Psychol Med 2001;31:881–90.
Disclosure of interest [17] Strandjord SE, Sieke EH, Richmond M, et al. Avoidant/restrictive food intake
disorder: illness and hospital course in patients hospitalized for nutritional
The authors declare that they have no competing interest. insufficiency. J Adolesc Health 2015;57:673–8.
[18] Cooney M, Lieberman M, Guimond T, et al. Clinical and psychological features
of children and adolescents diagnosed with avoidant/restrictive food intake
References disorder in a pediatric tertiary care eating disorder program: a descriptive
study. J Eat Disord 2018;6:7.
[1] Kohn JB. What Is ARFID? J Acad Nutr Diet 2016;116:1872. [19] Pennell A, Couturier J, Grant C, et al. Severe avoidant/restrictive food intake
[2] American Psychiatric Association. Diagnostic and Statistical Manual of Mental disorder and coexisting stimulant treated attention deficit hyperactivity
Disorders, Fifth Edition, Arlington, VA: American Psychiatric Association; disorder. Int J Eat Disord 2016;49:1036–9.
2013. p. 334–8. [20] Chandran JJ, Anderson G, Kennedy A, et al. Subacute combined degeneration of
[3] Sharp WG, Postorino V, McCracken CE, et al. Dietary intake, nutrient status, the spinal cord in an adolescent male with avoidant/restrictive food intake
and growth parameters in children with autism spectrum disorder and severe disorder: A clinical case report. Int J Eat Disord 2015;48:1176–9.
 F. Feillet et al. / Archives de Pédiatrie 26 (2019) 437–441 441

[21] Kerwin ME. Empirically supported treatments in pediatric psychology: severe [27] Neumeyer AM, Cano Sokoloff N, McDonnell EI, et al. Nutrition and Bone Density
feeding problems. J Pediatr Psychol 1999;24:193–214 [discussion 5-6]. in Boys with Autism Spectrum Disorder. J Acad Nutr Diet 2018;118:865–77.
[22] Sharp WG, Berry RC, McCracken C, et al. Feeding problems and nutrient intake [28] Hankard R, Colomb V, Piloquet H, et al. Dépister la denutrition de l’enfant en
in children with autism spectrum disorders: a meta-analysis and comprehen- pratique courante. Arch Pediatr 2012;19:1110–7.
sive review of the literature. J Autism Dev Disord 2013;43:2159–73. [29] Brewerton TD, D’Agostino M. Adjunctive use of olanzapine in the treatment of
[23] Bandini LG, Anderson SE, Curtin C, et al. Food selectivity in children with avoidant restrictive food intake disorder in children and adolescents in an
autism spectrum disorders and typically developing children. J Pediatr eating disorders program. J Child Adolesc Psychopharmacol 2017;27:920–2.
2010;157:259–64. [30] Gray E, Chen T, Menzel J, et al. Mirtazapine and weight gain in avoidant and
[24] Evans EW, Must A, Anderson SE, et al. Dietary patterns and body mass index in restrictive food intake disorder. J Am Acad Child Adolesc Psychiatry 2018;57:
children with autism and typically developing children. Res Autism Spectr 288–9.
Disord 2012;6:399–405. [31] Forman SF, McKenzie N, Hehn R, et al. Predictors of outcome at 1 year in
[25] Lockner DW, Crowe TK, Skipper BJ. Dietary intake and parents’ perception adolescents with DSM-5 restrictive eating disorders: report of the national
of mealtime behaviors in preschool-age children with autism spectrum eating disorders quality improvement collaborative. J Adolesc Health
disorder and in typically developing children. J Am Diet Assoc 2008;108: 2014;55:750–6.
1360–3. [32] O’Connor G, Nicholls D, Hudson L, et al. Refeeding Low Weight Hospitalized
[26] Cosar A, Ipcioglu OM. Re. Low folate and vitamin B12 nourishment is common Adolescents With Anorexia Nervosa: A Multicenter Randomized Controlled
in Omani children with newly diagnosed autism. Nutrition 2013;29:1170. Trial. Nutr Clin Pract 2016;31:681–9.