child AVOIDANT RESTRICTIVE FOOD INTAKE DISORDER

Evaluation and Treatment of Avoidant/Restrictive Food Intake Disorder (ARFID) in Adolescents

Kathryn S. Brigham, MD1,2, Laurie D. Manzo, RD1,3, Kamryn T. Eddy, Ph.D#3,4, and Jennifer J. Thomas, Ph.D#3,4

1Division of Adolescent and Young Adult Medicine, Massachusetts General Hospital

2Department of Pediatrics, Harvard Medical School

3Eating Disorders Clinical and Research Program, Massachusetts General Hospital

4Department of Psychiatry, Harvard Medical School

# These authors contributed equally to this work.

Abstract

Purpose of review: Avoidant/restrictive food intake disorder (ARFID) was added to the psychiatric nomenclature in 2013. However, youth with ARFID often present first to medical—

rather than psychiatric—settings, making its evaluation and treatment relevant to pediatricians.

Recent findings: ARFID is defined by limited volume or variety of food intake motivated by sensory sensitivity, fear of aversive consequences, or lack of interest in food or eating, and

associated with medical, nutritional, and/or psychosocial impairment. It appears to be as common

as anorexia nervosa and bulimia nervosa and can occur in individuals of all ages. ARFID is

heterogeneous in presentation and may require both medical and psychological management.

Summary: Pediatricians should be aware of the diagnostic criteria for ARFID and the possibility that these patients may require medical intervention and referral for psychological treatment. The

neurobiology underlying ARFID is unknown, and novel treatments are currently being tested.

Keywords

Avoidant/restrictive food intake disorder; ARFID; eating disorder; nutrition deficiencies; cognitive-behavioral therapy; CBT-AR

Introduction

The Diagnostic and Statistical Manual of Mental Disorders 5th Edition (DSM-5) introduced avoidant/restrictive food intake disorder (ARFID)(1) as a reformulation of DSM-IV feeding

disorder of infancy and early childhood (2). According to DSM-5 criteria, to be diagnosed with ARFID, an individual must have problematic eating habits, which may be due to an

inability to tolerate certain sensory properties of food (e.g., texture, taste, appearance); a fear

Corresponding author:Kathryn S. Brigham, MD, Division of Adolescent and Young Adult Medicine, Massachusetts General Hospital. 55 Fruit St- Yawkey 6D, Boston, MA 02114, [email protected].

HHS Public Access Author manuscript Curr Pediatr Rep. Author manuscript; available in PMC 2019 June 01.

Published in final edited form as: Curr Pediatr Rep. 2018 June ; 6(2): 107–113. doi:10.1007/s40124-018-0162-y.

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of potential adverse consequences of eating (e.g., choking, vomiting); and/or an overall lack

of interest in food or eating. These alterations must be significant enough to cause either

weight loss or failure to gain appropriate weight in growing children; nutritional

deficiencies; dependence on nutritional supplements (e.g., energy-dense drinks or tube-

feeding); or psychosocial dysfunction. However, these behaviors cannot be due to food

insecurity or culturally accepted practices; are not motivated by fear of weight gain or

weight/shape overvaluation as in anorexia nervosa (AN) or bulimia nervosa (BN); and are

not better explained by another medical or psychological disorder. If there is another medical

or psychiatric disorder present, food avoidance or restriction must be more extreme than

what would typically be expected for the co-occurring condition. ARFID can be diagnosed

in individuals of all ages. This new diagnosis provides a framework to categorize, evaluate,

and treat individuals who are nutritionally deficient but did not meet criteria for previously

defined eating or feeding disorders.

What is known about ARFID?

Clinical presentation.

ARFID is a heterogeneous psychiatric disorder in which individuals present with avoidance of certain foods or categories of food resulting in a diet that is limited in variety, and/or

restriction of overall intake resulting in a diet that is limited in volume. One of the most common rationales for avoidance and restriction in ARFID is a heightened sensitivity to the

sensory properties of food (e.g., taste, texture, appearance, smell). Individuals with sensory

sensitivity may experience vegetables or fruits as intensely bitter, for example, and therefore

avoid these foods and be fearful of or disgusted by the prospect of trying novel foods. In

turn, these individuals frequently rely on highly processed energy-dense foods and may have

significant deficiencies in vitamins and minerals. For individuals with sensory sensitivity,

food avoidance is often longstanding, having developed in early childhood.

Individuals with ARFID may also exhibit food avoidance or restriction due to a fear of

aversive consequences, such as a fear of choking, vomiting, or gastrointestinal pain. Often

these individuals have experienced a food-related trauma and subsequently begin avoiding

the index food to guard against another negative experience. While the avoidance reduces

anxiety momentarily, it reinforces anxiety over time by preventing the opportunity for new

corrective learning to occur. In our clinical experience, these individuals often have an

anxious predisposition and their food avoidance generalizes beyond the index food to similar

foods, then to entire food groups, and in some of the most severe cases, to avoidance of all

solid foods. When fear of aversive consequences is primary, the onset is often acute.

A lack of interest in food or eating is also common in individuals with ARFID and can be

maintained by a diet that is limited in volume. Individuals with lack of interest describe

eating as a chore and present with low homeostatic and hedonic appetites. Due to their low-

volume intake, they often present to treatment with low weight or a failure to thrive, and

their lack of interest is often longstanding.

In ARFID, an individual can present with one, two, or even three of these rationales for food

avoidance or restriction, resulting in a heterogeneous diagnostic category. Rather than

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existing as diagnostic subtypes, our clinical impression is that these rationales for restriction

represent dimensions on which any given patient can be high or low (3).

Epidemiology.

In pediatric, adolescent medicine, and eating disorder clinics, preliminary studies suggest

that, compared to patients with AN or BN, cohorts of patients with ARFID tend to be

younger (4,5), include a greater proportion of males (4,6), experience a longer duration of

illness before treatment presentation (4), and are more likely to be diagnosed with a co-

occurring medical condition (5). One retrospective case control study showed that patients

with ARFID were more likely to have an anxiety disorder but less likely to have a mood

disorder than patients with AN or BN (4). Since ARFID is a relatively new diagnosis, there

have only been two population-based prevalence studies. An Australian interview-based

study of males and females ages 15 and older reported a 3-month point prevalence of

ARFID of 0.3% in 2013 and in 2014 (7). A study of schoolchildren ages 8–13 in

Switzerland reported a point prevalence of 3.2% measured via self-report questionnaire (8).

These emerging data suggest that ARFID may be as common as AN and BN. Further,

studies from North America have shown that 5–12% of patients presenting for eating

disorder care at outpatient clinics (9–11) and 22.5–24.6% of patients presenting to an

outpatient day program for younger adolescents with eating disorders (12,13) meet DSM-5 criteria for ARFID.

Contributing factors.

Because ARFID is so new, its etiology is unknown. Similar to other eating and feeding

disorders, it is probable that both biological and environmental factors—and their interplay

—contribute to pathogenesis. We hypothesize that there may be biological bases that

underlie sensory sensitivity, trait anxiety, and both homeostatic and hedonic appetites, which

may increase vulnerability to ARFID (3). Environmental factors such as family meal milieu,

availability of fruits and vegetables in the local environment, and exposure to models of

healthy eating and/or diverse foods may also play a role.

Evaluation

Medical evaluation.

In the initial medical evaluation, the pediatrician should obtain a careful history of the

patient’s eating habits. Patients with ARFID can have a variety of altered eating habits,

which can include apathy, dislike, or fear of specific foods, or of eating in general. Some

patients may present with a lifelong history of picky eating and avoidance of particular

textures, colors, tastes, or smells and unwillingness to eat news foods; others may have had a

more recent change in eating habits secondary to gastrointestinal discomfort or an acute

episode of choking or vomiting experienced as traumatic (4,5). It is crucial to query the

patient’s attitudes towards weight and body image, in order to rule out AN, BN, or a related

eating disorder.

Patients may report symptoms attributable to acute malnutrition, including fatigue,

dizziness, and syncope and/or more long-standing malnutrition, such as abdominal pain,

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constipation, cold intolerance, amenorrhea, dry skin, and hair loss (14). On exam, signs of

malnutrition can include cachexia, hypothermia, bradycardia, orthostatic tachycardia and

hypotension, scaphoid abdomen, lanugo, and pallor (14). The wide variety of presentations

of ARFID can lead to a wide variety of sequelae, from specific micronutrient deficiencies

(see Table 1) to more global malnutrition, weight loss, and/or failure to appropriately gain

weight and height as the patient progresses through childhood and adolescence. Pre-

menarchal females may experience primary amenorrhea while post-menarchal females may

experience secondary amenorrhea due to weight loss and chronic malnutrition. It is

important to consider other etiologies of these presenting signs and symptoms, including

malignancies, chronic gastrointestinal disorders (e.g. celiac disease, inflammatory bowel

disease), endocrine disorders (e.g. hyperthyroidism, Addison’s disease, type 1 diabetes),

infectious diseases (e.g. tuberculosis or human immunodeficiency virus), or conditions that

hinder chewing or swallowing of boluses of food (e.g. tonsillar hypertrophy, oromotor

dysfunction, achalasia) (15).

Most patients should have screening blood work including complete metabolic panel,

magnesium, phosphorus, complete blood count with differential, thyroid stimulating

hormone, erythrocyte sedimentation rate, and c-reactive protein, as well as a urinalysis. It is

worth considering screening for celiac disease with a total immunoglobulin A (IgA) and

tissue transglutaminase IgA, as there is a high rate of co-occurrence of celiac disease and

AN (16). Patients with bradycardia or hemodynamic instability should have an

electrocardiogram. A human chorionic gonadotropin (HCG) should be checked in post-

menarchal females who present with amenorrhea; bone density can be assessed using dual-

energy X-ray absorptiometry (DXA) in patients who have menstruated fewer than 6 times in

the past year (17). While blood tests are useful for determining micronutrient deficiencies,

diet history as well as family reports of intake are often just as or more important to identify

potential deficiencies (18).

Part of the initial evaluation should include determination of a target weight for patients who

are underweight. Target weight and body mass index (BMI) is typically determined for

patients with restrictive eating disorders by looking at the patient’s BMI growth charts and

trying to return the patient to his or her pre-illness trajectory (19). Target weights can be

more difficult to determine in patients presenting with lifelong malnutrition due to ARFID,

as these patients may have been chronically underweight. In these situations, the pediatrician

should set a target weight that is high enough to enable the patient to progress through

puberty appropriately and gain the height at the expected rate for age, sex, and genetic

potential; this is assessed by looking closely at the patient’s growth charts throughout

treatment. For those under the age of 20, the goal weight will increase with time, given

increases in height and expected increases in BMI. Often, the physician will need to make

the case for the importance of frank weight gain in ARFID, rather than weight restoration

(as in other eating disorders such as AN), with the patient and parents.

Psychological evaluation.

A clinical interview with a mental health clinician is critical to confer diagnosis. Ideally, the

psychological evaluation would include both the patient and his or her caregivers (e.g.,

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parents). Clinical assessment comprises review of ARFID diagnostic criteria, recall of a

typical day of eating, assessment of foods regularly accepted across the five basic food

groups (fruits, vegetables, protein, dairy, and grains) vs. those that are avoided,

determination of the impact of the patient’s eating on health or psychosocial functioning,

and evaluation of the degree of caregiver accommodation currently in place. As the

diagnosis is new, formal diagnostic assessment tools are still under development. The Pica

ARFID and Rumination Disorder Interview (PARDI) (20) is a comprehensive structured

clinical interview designed to confer diagnosis and to measure global severity and severity

across rationales for restriction. In addition, patient responses to brief self-report screening

tools, such as the Eating Disorders in Youth Questionnaire (EDY-Q) (21) or the Nine-Item

ARFID Screen (NIAS) (22), may provide clues to appropriate follow-up questions at the

clinical interview.

Ascertaining the ARFID diagnosis requires differential diagnosis from the other eating and

feeding disorders, as well as from other psychiatric diagnoses. While ARFID is

characterized by restricted intake, which can overlap with AN, in ARFID the restriction is

not due to fear of fatness or efforts to control weight or body shape. ARFID is also

differentiated from garden variety picky eating, which often develops in preschoolers but

ultimately remits without treatment. By contrast, ARFID is more persistent, severe, and

associated with medical and psychosocial sequelae. Rather than improving with age, the

selective eating associated with ARFID typically escalates, becoming more entrenched

during childhood and adolescence if left untreated.

Psychiatric comorbidities including anxiety and mood disorders, obsessive-compulsive

disorder, autism spectrum disorder, and attention deficit hyperactivity disorder are

commonly seen in individuals with ARFID. When food avoidance or restriction is primary

and associated with significant medical, nutritional, and/or psychosocial compromise it

generally requires clinical attention outside of what would be warranted in treating these

comorbid conditions alone, which can guide in determining the threshold for an ARFID

diagnosis when comorbidity is present.

Treatment

Medical.

Treatment can range from an outpatient multidisciplinary team treatment to inpatient

medical hospitalization (14). Because ARFID is such a new diagnosis, there is little evidence

supporting treatment strategies and consensus guidelines have not yet been developed (5).

Depending on the needs of the patient, an outpatient medical team should comprise, at

minimum, a medical provider and mental health clinician, and potentially other specialty

providers as needed, such as a dietitian, pediatric gastroenterologist, occupational therapist,

and/or speech pathologist. Until there is further evidence to guide practitioners, it seems

reasonable that treatment goals for ARFID be similar to goals for other restrictive eating

disorders, including weight restoration and resumption of menses in amenorrhoeic females

(19).

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Some patients with ARFID can become medically compromised and require medical

hospitalization for monitoring and nutritional rehabilitation. The Society for Adolescent

Health and Medicine has published guidelines for when an individual with a restrictive

eating disorder should be medically hospitalized (19). In our experience, many patients with

ARFID have been underweight for such an extended period that they have developed a level

of homeostasis so they do not present with the same degree of bradycardia and hypotension

as is seen in patients with AN who are actively losing weight. In such cases, the physician

can use the patient’s weight as a guide to determine the need for hospitalization: A medical

admission may still be necessary if the patient’s current BMI is less than 75% of the median

BMI for sex and age. If a patient with ARFID is medically hospitalized, he or she may

benefit from being placed on a structured refeeding protocol to promote weight gain and

monitor for the electrolyte shifts that can be a harbinger of refeeding syndrome. However,

given that patients with ARFID may have difficulty with both variety and volume, it may be

necessary to rely on preferred foods to facilitate the initial increase in volume that will be

necessary to support weight gain. One retrospective chart review of patients medically

hospitalized showed that patients with ARFID experienced electrolyte shifts similar to

patients with AN; compared to patients with AN, patients with ARFID had a longer length

of stay, thought to be due to increased reliance on enteral feeding and lower starting calorie

goals early in the admission (23).

Some of these patients require oral nutritional supplements, nasogastric tube feedings, or

gastrostomy tube feedings to maintain adequate nutrition (1). One study of patients

medically hospitalized for eating disorders showed that patients with ARFID are more likely

to rely on enteral nutrition than patients with AN (23). The patient’s current intake,

motivation for treatment, and diet limitations should be considered when deciding whether

to use supplements or food alone. In our experience, patients with ARFID are more likely

than those with other eating disorders (e.g., AN) to present for initial evaluation relying on

long-term enteral feedings in an ambulatory setting, whereas patients with other eating

disorders generally receive short-term enteral feedings in the inpatient setting. We

hypothesize that the greater reliance on tube feeding in the ARFID group is due to many of

these patients presenting to medical providers (e.g., pediatric gastroenterologists) rather than

mental health clinicians, prior to the advent of ARFID as a psychiatric diagnosis. Tube

feeding can be a life-saving treatment strategy in the setting of acute malnutrition, but, in

most cases, should be considered a temporary measure to support the ultimate treatment goal

of obtaining adequate nutrition through oral intake. Once patients have gained to a healthy

weight and can take in at least some nutrition by mouth, weaning off tube feeds is typically

done under close supervision in an inpatient (24) or day treatment (25) setting.

For patients who are not medically compromised, the physician should consider whether

outpatient psychotherapy is sufficient or whether referral to day treatment or intensive

outpatient treatment eating disorder program is warranted. For example, day treatment can

serve as a valuable source of structure and support to both improve weight and increase

variety in eating habits. It is worth considering a higher level of care with an eating disorder

program in patients who either have been unable to make progress with an outpatient team

or are losing weight and may end up medically hospitalized if changes are not made

relatively rapidly. In some patients, it can be difficult to ascertain in a single evaluation

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whether the patient has ARFID or AN, and the close observation of an eating disorder

program can provide diagnostic clarification. One study demonstrated that patients with

ARFID could be successfully treated at eating disorder day treatment programs,

demonstrating weight gain, decreased food restriction, and decreased anxiety symptoms

(13).

There are limited studies that look at the prevalence of nutritional deficiencies in eating

disorders and specifically in ARFID. The types and severity of deficiencies this population

can vary greatly. Since decreased intake and elimination or avoidance of food groups often

occur over an extended period of time, conservation and adaptation mechanisms of

metabolism can result in laboratory values appearing normal despite prolonged inadequate

intake (18). Supplementation or repletion of specific vitamins and minerals should be

considered if labs or symptoms are clinically significant or if diet remains limited. A prompt

repletion is required to avoid the negative effects that deficiencies of B12, zinc, iron, vitamin

C and folate may have on appetite, taste, mood and energy levels, which may in turn affect a

patient’s ability to fully participate in treatment. Most nutrients require initial high doses that

would be difficult to achieve with food alone and may require prolonged courses of

supplementation to reverse the deficiency effectively. Patients should be encouraged to

include foods high in the deficient nutrients regardless of supplementation because

continued intake of these nutrients is necessary to maintain repletion and health.

Some low-weight individuals with the lack of interest presentation of ARFID may benefit

from off-label use of cyproheptadine, a medication with antihistaminergic and

antiserotingeric properties; a study in children ages 7 months to 6 years with a variety of

feeding difficulties showed that patients receiving cyproheptadine had greater improvements

in weight gain and positive changes in mealtime and feeding behaviors as compared to those

not taking cyproheptadine (26). In our experience, some but not all patients benefit from

cyproheptadine promoting increased appetite and gastric accommodation. It is important to

be aware that patients can develop tachyphylaxis to cyproheptadine, so if the efficacy wanes

with time, it may be worth having the patient take a one week medication holiday on a

monthly basis.

Psychological treatment.

Psychological treatments for ARFID are emerging. At Massachusetts General Hospital, our

Eating Disorders Clinical and Research Program team has developed a cognitive-behavioral

therapy for ARFID (CBT-AR) to treat individuals ages 10 and older with all presentations of

ARFID who are medically stable and not reliant on enteral feeding (27). This structured

time-limited outpatient intervention can be delivered in an individual or family-supported

format depending on the patient’s age, and lasts between 20 to 30 sessions depending on the

degree of nutritional compromise. The treatment operates using the principle of volume before variety to support nutritional rehabilitation (i.e., weight restoration, correction of deficiencies). Specifically, patients who are underweight are encouraged to eat larger

volumes of preferred food in the early stages of treatment, before increasing dietary variety

in later stages. The key intervention is structured in-session exposure to systematically

address the maintaining mechanisms most relevant for the patient, including sensory

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sensitivity, fear of aversive consequences, and lack of interest in food and eating. CBT-AR is

currently being tested in an open trial at Massachusetts General Hospital, so efficacy data are

not yet available. However, preliminary results are promising in terms of weight gain,

resolution of nutrition deficiencies, and modest expansion of dietary variety, as illustrated in

a published case report utilizing the approach (15).

Psychiatric medications.

There is currently no psychotropic medication for treatment of ARFID approved by the U.S.

Food and Drug Administration. However, case reports and small case series have described

the use of mirtazapine (15) or lorazepam (28) to decrease anxiety related to eating; and

olanzapine (29) to reduce cognitive rigidity in beliefs about food and to promote weight

gain. Future randomized placebo-controlled trials are needed to evaluate the efficacy of these

medications for the resolution of ARFID symptoms.

Conclusions

ARFID is a relatively new psychiatric diagnosis, which captures a clinically significant and

prevalent restrictive eating problem that occurs in individuals of all ages and across genders.

Emerging data suggest that ARFID is as common as the classical eating disorders and can be

associated with important medical and psychological consequences. Moreover, data from

pediatric and adolescent medicine clinics nationwide highlight the prevalence of this

problem in medical settings, underscoring the need for pediatricians to be familiar with the

evaluation and clinical management of this diagnosis.

References

(1). American Psychiatric Association, American Psychiatric Association DSM-5 Task Force. Diagnostic and statistical manual of mental disorders : DSM-5. 5th ed. ed. Arlington, VA; 2013.

(2). American Psychiatric Association, American Psychiatric Association Task Force on DSM. Diagnostic and statistical manual of mental disorders : DSM-IV. 4th ed. ed. Washington, DC; 1994.

(3). Thomas JJ, Lawson EA, Micali N, Misra M, Deckersbach T, Eddy KT. Avoidant/Restrictive Food Intake Disorder: a Three-Dimensional Model of Neurobiology with Implications for Etiology and Treatment. Curr Psychiatry Rep 2017 8;19(8):54–017–0795–5. [PubMed: 28714048]

(4). Fisher MM, Rosen DS, Ornstein RM, Mammel KA, Katzman DK, Rome ES, et al. Characteristics of avoidant/restrictive food intake disorder in children and adolescents: a “new disorder” in DSM-5. J Adolesc Health 2014 7;55(1):49–52. [PubMed: 24506978]

(5). Norris ML, Spettigue WJ, Katzman DK. Update on eating disorders: current perspectives on avoidant/restrictive food intake disorder in children and youth. Neuropsychiatr Dis Treat 2016 1 19;12:213–218. [PubMed: 26855577]

(6). Eddy KT, Thomas JJ, Hastings E, Edkins K, Lamont E, Nevins CM, et al. Prevalence of DSM-5 avoidant/restrictive food intake disorder in a pediatric gastroenterology healthcare network. Int J Eat Disord 2015 7;48(5):464–470. [PubMed: 25142784]

(7). Hay P, Mitchison D, Collado AEL, Gonzalez-Chica DA, Stocks N, Touyz S. Burden and health- related quality of life of eating disorders, including Avoidant/Restrictive Food Intake Disorder (ARFID), in the Australian population. J Eat Disord 2017 7 3;5:21-017-0149-z. eCollection 2017.

(8). Kurz S, van Dyck Z, Dremmel D, Munsch S, Hilbert A. Early-onset restrictive eating disturbances in primary school boys and girls. Eur Child Adolesc Psychiatry 2015 7;24(7):779–785. [PubMed: 25296563]

Brigham et al. Page 8

Curr Pediatr Rep. Author manuscript; available in PMC 2019 June 01.

A u th

o r M

a n u scrip

t A

u th

o r M

a n u scrip

t A

u th

o r M

a n u scrip

t A

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o r M

a n u scrip

t

(9). Forman SF, McKenzie N, Hehn R, Monge MC, Kapphahn CJ, Mammel KA, et al. Predictors of outcome at 1 year in adolescents with DSM-5 restrictive eating disorders: report of the national eating disorders quality improvement collaborative. J Adolesc Health 2014 12;55(6):750–756. [PubMed: 25200345]

(10). Norris ML, Robinson A, Obeid N, Harrison M, Spettigue W, Henderson K. Exploring avoidant/ restrictive food intake disorder in eating disordered patients: a descriptive study. Int J Eat Disord 2014 ;47(5):495–499. [PubMed: 24343807]

(11). Ornstein RM, Rosen DS, Mammel KA, Callahan ST, Forman S, Jay MS, et al. Distribution of eating disorders in children and adolescents using the proposed DSM-5 criteria for feeding and eating disorders. J Adolesc Health 2013 ;53(2):303–305. [PubMed: 23684215]

(12). Nicely TA, Lane-Loney S, Masciulli E, Hollenbeak CS, Ornstein RM. Prevalence and characteristics of avoidant/restrictive food intake disorder in a cohort of young patients in day treatment for eating disorders. J Eat Disord 2014 8 2;2(1):21-014-0021-3. eCollection 2014.

(13). Ornstein RM, Essayli JH, Nicely TA, Masciulli E, Lane-Loney S. Treatment of avoidant/ restrictive food intake disorder in a cohort of young patients in a partial hospitalization program for eating disorders. Int J Eat Disord 2017 9;50(9):1067–1074. [PubMed: 28644568]

(14). Mammel KA, Ornstein RM. Avoidant/restrictive food intake disorder: a new eating disorder diagnosis in the diagnostic and statistical manual 5. Curr Opin Pediatr 2017 8;29(4):407–413. [PubMed: 28537947]

(15). Thomas JJ, Brigham KS, Sally ST, Hazen EP, Eddy KT. Case 18-2017 - An 11-Year-Old Girl with Difficulty Eating after a Choking Incident. N Engl J Med 2017 6 15;376(24):2377–2386. [PubMed: 28614676]

(16). Marild K, Stordal K, Bulik CM, Rewers M, Ekbom A, Liu E, et al. Celiac Disease and Anorexia Nervosa: A Nationwide Study. Pediatrics 2017 5;139(5):10.1542/peds.2016-4367. Epub 2017 Apr 3.

(17). De Souza MJ, Nattiv A, Joy E, Misra M, Williams NI, Mallinson RJ, et al. 2014 Female Athlete Triad Coalition Consensus Statement on Treatment and Return to Play of the Female Athlete Triad: 1st International Conference held in San Francisco, California, May 2012 and 2nd International Conference held in Indianapolis, Indiana, May 2013. Br J Sports Med 2014 2;48(4): 289-2013-093218.

(18). Setnick J Micronutrient deficiencies and supplementation in anorexia and bulimia nervosa: a review of literature. Nutr Clin Pract 2010 ;25(2):137–142. [PubMed: 20413694]

(19). Society for Adolescent Health and Medicine, Golden NH, Katzman DK, Sawyer SM, Ornstein RM, Rome ES, et al. Position Paper of the Society for Adolescent Health and Medicine: medical management of restrictive eating disorders in adolescents and young adults. J Adolesc Health 2015 1;56(1):121–125. [PubMed: 25530605]

(20). Bryant-Waugh R, Micali N, Cooke L, et al. The Pica, ARFID, and Rumination Disorder Interview: Development of a multi-informant, semi-structured interview of feeding disorders across the lifespan. In preparation

(21). Hilbert A, van Dyck Z. Eating Disorders in Youth-Questionnaire. English version . 2016 6 21; Available at: http://nbn-resolving.de/urn:nbn:de:bsz:15-qucosa-197246. Accessed Feb 28, 2018.

(22). Zickgraf HF, Ellis JM. Initial validation of the Nine Item Avoidant/Restrictive Food Intake disorder screen (NIAS): A measure of three restrictive eating patterns. Appetite 2018 4 1;123:32– 42. [PubMed: 29208483]

(23). Strandjord SE, Sieke EH, Richmond M, Rome ES. Avoidant/Restrictive Food Intake Disorder: Illness and Hospital Course in Patients Hospitalized for Nutritional Insufficiency. J Adolesc Health 2015 12;57(6):673–678. [PubMed: 26422290]

(24). Brown J, Kim C, Lim A, Brown S, Desai H, Volker L, et al. Successful gastrostomy tube weaning program using an intensive multidisciplinary team approach. J Pediatr Gastroenterol Nutr 2014 6;58(6):743–749. [PubMed: 24509305]

(25). Sharp WG, Stubbs KH, Adams H, Wells BM, Lesack RS, Criado KK, et al. Intensive, Manual- based Intervention for Pediatric Feeding Disorders: Results From a Randomized Pilot Trial. J Pediatr Gastroenterol Nutr 2016 4;62(4):658–663. [PubMed: 26628445]

Brigham et al. Page 9

Curr Pediatr Rep. Author manuscript; available in PMC 2019 June 01.

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(26). Sant’Anna AM, Hammes PS, Porporino M, Martel C, Zygmuntowicz C, Ramsay M. Use of cyproheptadine in young children with feeding difficulties and poor growth in a pediatric feeding program. J Pediatr Gastroenterol Nutr 2014 11;59(5):674–678. [PubMed: 24941960]

(27). Thomas J, Eddy K. Cognitive-behavioral therapy for avoidant/restrictive food intake disorder: Children, adolescents, and adults Cambridge, UK: Cambridge University Press; In press 2018.

(28). Kardas M, Cermik BB, Ekmekci S, Uzuner S, Gokce S. Lorazepam in the treatment of posttraumatic feeding disorder. J Child Adolesc Psychopharmacol 2014 6;24(5):296–297. [PubMed: 24813692]

(29). Brewerton TD, D’Agostino M. Adjunctive Use of Olanzapine in the Treatment of Avoidant Restrictive Food Intake Disorder in Children and Adolescents in an Eating Disorders Program. J Child Adolesc Psychopharmacol 2017 12;27(10):920–922. [PubMed: 29068721]

(30). Mueller C editor. The ASPEN Adult Nutrition Support Core Curriculum 3rd ed. Silver Spring, MD: American Society for Parenteral and Enteral Nutrition; 2017.

(31). Office of Dietary Supplements, National Institutes of Health (US). Folate 2016 4 20; Available at: https://ods.od.nih.gov/factsheets/Folate-HealthProfessional/. Accessed Feb 6, 2018.

(32). Office of Dietary Supplements, National Institutes of Health (US). Calcium 2016 11 17; Available at: https://ods.od.nih.gov/factsheets/Calcium-HealthProfessional. Accessed Feb 6, 2018.

(33). Office of Dietary Supplements, National Institutes of Health (US). Iron 2016 2 11; Available at: https://ods.od.nih.gov/factsheets/Iron-HealthProfessional/. Accessed Feb 6, 2018.

(34). Office of Dietary Supplements, National Institutes of Health (US). Vitamin A 2016 8 31; Available at: https://ods.od.nih.gov/factsheets/VitaminA-HealthProfessional/. Accessed Feb 6, 2018.

(35). Office of Dietary Supplements, National Institutes of Health (US). Vitamin B12 2016 2 11; Available at: https://ods.od.nih.gov/factsheets/VitaminB12-HealthProfessional/. Accessed Feb 6, 2018.

(36). Office of Dietary Supplements, National Institutes of Health (US). Vitamin C 2016 2 11; Available at: https://ods.od.nih.gov/factsheets/VitaminC-HealthProfessional/. Accessed Feb 6, 2018.

(37). Office of Dietary Supplements, National Institutes of Health (US). Vitamin D 2016 2 11; Available at: https://ods.od.nih.gov/factsheets/VitaminD-HealthProfessional/. Accessed Feb 6, 2018.

(38). Office of Dietary Supplements, National Institutes of Health (US). Vitamin K 2016 2 11; Available at: https://ods.od.nih.gov/factsheets/VitaminK-HealthProfessional/. Accessed Feb 6, 2018.

(39). Office of Dietary Supplements, National Institutes of Health (US). Zinc 2016 2 11; Available at: https://ods.od.nih.gov/factsheets/Zinc-HealthProfessional/. Accessed Feb 6, 2018.

(40). Office of Dietary Supplements, National Institutes of Health (US). Riboflavin 2016 2 11; Available at: https://ods.od.nih.gov/factsheets/Riboflavin-HealthProfessional/. Accessed Mar 1, 2018.

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Table 1:

Signs and symptoms of specific vitamin and mineral deficiencies due to dietary restrictions.

Foods avoided

Potential vitamin & mineral deficiencies

Potential signs & symptoms

Meat and animal products

Vitamin B12 Megaloblastic or Macrocytic anemia, low energy, weakness, numbness or tingling in hands or feet, trouble walking or unsteadiness, constipation, anorexia, confusion and poor memory, mood changes, psychosis, mouth/tongue discomfort

Zinc Poor growth and development, anorexia, weakened immune system, impaired night vision, taste and smell changes, hair loss, diarrhea, poor wound healing

Iron Microcytic anemia, pallor, weakness, fatigue or sleepiness, irritability, poor concentration, learning and cognitive difficulties, mood changes, decreased exercise endurance, headaches, temperature intolerance, weakened immune system

Animal products and/or dairy

Riboflavin/ Vitamin B2

Low energy, poor growth, dry skin /skin problems, hair loss, dry cracked lips or cracks at the corners of mouth, swollen magenta-colored tongue, itchy and/ or red eyes, sore throat, anemia and cataracts

Dairy Calcium A deficiency is rarely detected by lab values. The body closely regulates serum levels despite intake. Food history is the best way to assess for a deficiency. Prolonged inadequate intake can result in decreased bone mineral density, osteopenia, weak or broken bones and osteoporosis.

Vitamin D Low bone mineral density, hypocalcemia, accelerated bone loss, bone pain, osteomalacia, rickets

Fruits and vegetables

Vitamin C Petechiae and easy bruising, bleeding and swollen gums, anorexia, anemia, feeling unwell, muscle and joint pain, corkscrew hair, perifollicular hemorrhage, impaired wound healing, hyperkeratosis, weakness, mood disturbances

Fruits, vegetables and/ or overall low quality diet

Folate Megaloblastic or Macrocytic anemia, persistent fatigue, pallor, palpitations, shortness of breath, headaches, oral ulcerations, increased risk of birth defects, poor concentration, increased irritability, weight loss

Very low fat or protein diet

Vitamin A Poor night vision/ night blindness, weakened immune system, follicular hyperkeratosis, impaired wound healing

Vitamin K Bruising and easy bleeding, increased prothrombin time

Protein Loss of lean body mass, decreased energy

Fat Weight loss, amenorrhea

Sources: (30–40)

Curr Pediatr Rep. Author manuscript; available in PMC 2019 June 01.