Detecting cases of ARFID with three practical tools.
Avoidant Restrictive Food Intake, or ARFID, is a restrictive eating disorder that typically occurs nearly two years earlier than anorexia nervosa (AN). Unlike patients with AN, ARFID patients are not motivated by concerns about body shape or size; instead, they are afraid of aversive consequences of eating, or have little interest in food, but enhanced sensory sensitivity.
Drs. Anna B. Tanner and Tracy K. Richmond, of Emory University, Atlanta, Boston Children’s Hospital and Harvard Medical School, Boston, recently noted a new urgency over identifying and managing patients with restrictive eating disorders (J Eat Disord. 2024. 12:82). The researchers also pointed out helpful guidelines and tools to help identify children with ARFID.
Subtypes
ARFID has multiple subtypes—fear of aversive consequences, little interest in food, and sensory sensitivity. Children and adolescents with undiagnosed ARFID can present in diverse ways, which can delay identification and treatment. However, recognizing the early signs, using growth charts and curves, linear height measurements, and calculating mid-parental height (MPH) are tools that can help clinicians and families improve long-term outcomes once ARFID is detected. These three types may also overlap.
Unlike patients with other ARFID subtypes, patients with the fear of aversive consequences subtype typically have an abrupt change in weight that can be easily noted on weight and growth charts. Patients often present with an acute change in eating patterns, frequently following a frightening event, such as choking on food.
For example, in one study at a tertiary care program, the most common signs were a fear of vomiting (50%) and of choking (23%); 57% of the patients had significant direct medical complications that required acute medical hospitalization (J Eat Disord. 2018. https://doi.org/10.1186/ s40337-018-0193-3). a limited variety of accepted foods. These patients or their caregivers may report that the child or adolescent avoids eating certain foods due to taste, texture, smell, appearance, or temperature, or that they have difficulty digesting certain foods. These patients may report that they can only eat certain foods or can only eat preferred foods under specific conditions.
Growth charts
In the US, World Health Organization (WHO) growth charts are used until a child is 2 years old; then Centers for Disease Control and Prevention (CDC) growth charts are applied until 20 years of age.
MPH calculations
The MPH is a pediatric tool that can be useful in assessing growth rates. Calculation of the MPH helps predict a child’s likely growth potential based on parental patterns and genetics. Growth and pubertal delay in patients with ARFID may be dismissed as constitutional growth delay. However, these patients do not have additional late growth and thus do not catch up. Clues that this may not be constitutional growth delay are based on normal parental pubertal timing and normal parental growth timing.
According to Drs. Tanner and Richmond, the MPH uses the following formula: for biologic females [(Father’s height (in) – 5) + Mother’s height (in)] , divided by 2. For biologic males, the following calculation is made: [Father’s height (in) + (Mother’s height (in) + 5)], divided by 2. The predicted range is: +/- 3 in.
Monitoring height as well as weight for ARFID
The authors note that weight targets cannot be static in patients with ARFID with growth potential but should be adjusted with age to ensure linear growth continues. Once normal growth has been restored, patients with ARFID will need ongoing medical supervision to gain enough weight to influence their height. Although monitoring weight is a key feature of all treatments for patients with eating disorders, for children and adolescents with ARFID, monitoring linear growth may be a better predictor of illness and more important for long-term outcomes.
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