Prakash Chandran (Host): Parents know that children can be picky eaters, reluctant to try new foods and refusing to eat a few especially hated vegetables. But what are you supposed to do when your child's eating habits become so restrictive that it starts to affect them on a daily basis?

Joining me today is Dr. Michelle Bowden, Medical Director of the Eating Disorder Program at Le Bonheur Children's Hospital. We'll be discussing the difference between picky eating and ARFID, an eating disorder characterized by very selective eating.

Welcome to The Peds Pod by Le Bonheur Children's Hospital. I'm your host, Prakash Chandran. So, Dr. Bowden, thank you so much for joining us today. I really appreciate your time. I wanted to start by asking what exactly is ARFID, what does it stand for, and what does it look like in kids?

Michelle Bowden, MD: Yeah, great question. So, it's actually a diagnosis that's kind of a new kid on the block. We really didn't have a diagnosis for this before 2013 even though people have experienced it for a really long time. So, ARFID stands for avoidant restrictive food intake disorder. The ARFID is the first letter of each of those words. And so really, what it's describing is this condition in which kids are incredibly picky eaters. And so, we know that there are picky eaters who are kind of normal picky eaters in that toddler, young childhood age. And then, there are people who become picky eaters kind of for a lifetime.

And so, ARFID is really kind of this diagnosis that encapsulates that idea that picky eating can sometimes be normal and sometimes it's not. And when picky eating is not normal, it often falls into this category of ARFID. It's important to know that it is a diagnosis that has a couple of different ways that it presents. So, sometimes it presents as a kid who's kind of, "I've always been picky. Maybe I have sensory issues. Maybe I'm on the autism spectrum. And I've kind of always been picky, but instead of it getting better over time, it actually gets worse over time." So, that's one kind of characteristic of ARFID. Sometimes though, it presents really acutely. And so, we have a kid who maybe has a negative experience with food, like they have a choking event or a vomiting event. And then, all of a sudden they're really fearful of eating lots of different kinds of foods and become really restrictive in how they eat.

And then, there's a third type that is really just the kid that just doesn't have any interest in food. So, they just don't really seem to feel hungry, eating feels like a chore. And so, they tend to just kind of under eat because, "I mean, I'd rather be doing something else." And so, that's really what we're thinking about, is one of those three categories. Most of the time, there are some combination of those when we're talking about ARFID.

Host: Okay. Understood. And so, I understand that it's a disorder where generally it's like there might have been an eating event or it's a natural tendency to it. You talked about maybe there's a spectrum consideration there. And so in terms of the causes of it, it's not necessarily that you are just born with it, but it's generally something that is, I guess, adapted or adopted over time.

Michelle Bowden, MD: Yeah. Sometimes I think that's a fair way to think about it. But I would say, you know, there do seem some kids who really never in their whole lives have like a normal eating spectrum. But that's not true of every kid with ARFID. And often, we do see kids who kind of become more picky over time. Even if they were kind of "normal eaters" as an infant and even very early toddlerhood, they pretty quickly become more restrictive.

But they do seem to run and have hacks with some other diagnoses. So, we often see, as I've mentioned already, this is a pretty common diagnosis in kids who also experience autism. And that can be kind of the full spectrum of autism, whether that's really severe or even on the milder kind of side of an autism diagnosis. We often see this in collaboration with behavioral health diagnoses, like anxiety. So, kids who are really high anxiety often kind of put that anxiety into the ways that they eat and we'll see that manifest as ARFID.

And sometimes as kids get older, we even see this overlying with like OCD, so obsessive compulsive disorder, where the fixation really becomes about food, either food safety or kinds of food, or even an obsession about how food feels in my throat or going down into my belly. And so, the OCD piece can really overlap the ARFID diagnosis as well. You can have both of those diagnoses of any of these. You can have autism and ARFID, you can have OCD and ARFID, because not everybody that has OCD also has ARFID. And so, it's important to have both of those diagnoses to get appropriate treatment.

Host: Okay, understood. You know, I have a three-year-old son who I would consider an extraordinarily picky eater. So, I have two questions. Like, how do you delineate between a picky eater and someone with ARFID? And generally, at what age is it appropriate to diagnose ARFID?

Michelle Bowden, MD: Oh, great question. Thanks for asking this. I have a four-year-old who's also a picky eater. Her only vegetable currently is what she calls white broccoli, also known as cauliflower. Green broccoli is not okay, but white broccoli is good. So, I feel your pain in that. But there really are some nice things that we can kind of help to differentiate these kids who are kind of typical picky eaters. Three-year-olds are the peak of picky eating. There's also lots of just like control issues in a three-year-old that they're just trying to exert their ability to say, "Hey, I'm a human too. I want to make my own decisions. And so, I'm going to not eat this today or not eat that tomorrow." And so, picky eating is really a very common occurrence. Maybe 50% of kids experience picky eating, especially in those ages between like two and four, two and five. And so, I very rarely would diagnose a kid with ARFID really at less than about six because picky eating can be normal. And even for a kid who's an extremely picky eater in those early childhood years, we're typically talking about something like oral aversion that may eventually develop into ARFID, but doesn't quite meet the diagnostic criteria yet.

So as your child gets older, what we're really looking for to differentiate a kid between just kind of standard picky eating and ARFID is really understanding that for a kid who's a picky eater, it's really about preference. It's really about exerting kind of like, "This is what I like and I want to eat what I want." But there's not really an anxiety around, "You know, that's annoying that you put food on my plate, but it doesn't induce fear in me that you put this food on my plate," right?

And so, kids who have ARFID typically have anxiety around trying new foods. They feel like something terrible is going to happen if I have to eat that food, not just like, "Oh, it's kind of gross. I don't like it," but there's a much more intense response to trying new foods. And because of that, what often happens over time is that kids with ARFID, they go to school, you know, as a kindergarten or first grader and a typical picky eater will go to school and see the kid next to them, try eating something that they've never tried before. And the picky eater will be like, "Hey, that looks kind of good and my friend likes it, so maybe I should try it." A kid with ARFID will see, smell, maybe even taste a food that a friend at school has and totally eliminate that food for the foreseeable future, right? It's like that fear of, "I'm afraid of what's going to happen to this" really dictates their ability to ever try new foods and often even leads to restricting more foods.

So, one thing that can be helpful as a kid as they get older into that early elementary years, if they're becoming more picky over time, that's typically a red flag for me, because most kids who are picky eaters are actually going to get better about eating as they enter elementary school. So, that's something that we can really pay attention to that can help us understand.

The other piece is really looking at growth, right? As a kid who's picky, even though they may not have a great variety in foods that they eat, should still typically grow well, right? But a kid who's got ARFID often will become so restrictive over time that they're not meeting the same growth parameters that they were in previous years.

And the third thing that I think about that really influences ARFID is really how much social impairment is this causing? So, a picky eater can typically go to a birthday party and find something that they'll eat, right? Some goldfish, a cupcake, something. A kid with ARFID, because that anxiety around food is so high, often can't eat in social situations, right? They can only eat at home or this one restaurant. And there's really a lot of limitations for the patient and for the family in terms of the social implications of what they're able to eat. So, those would all be some red flags that I'd worry about for a kid who's maybe more than just a picky eater.

Host: Yeah, that's really helpful. I think that as a parent, I think you also mentioned this, they obviously worry that their kid isn't eating that variety of food to keep them healthy and growing. And so, I think what I heard you say there is if you are noticing that your child is getting more picky over time, right? They're not able to find that snack at a party. You know, they only feel comfortable eating at home and it's very, very restrictive. That's the time to potentially seek help. That's what I'm assuming is, are there any other parameters that parents should be aware of to say, "Hey, I may want to take my child in?"

Michelle Bowden, MD: Yeah. Again, I think there's a real key there to pay attention to growth, which is something as pediatricians, we love to do. But it means that we've got to have parents bring their kids in regularly, right? So if we've missed an appointment and we don't realize that, "Hey, they've actually fallen off the growth curve or they're really falling down the growth curve," that's a problem that we would want to address. And so even if your kid, you know, maybe they're not losing weight, but kids should be gaining weight, right? To get taller, to go through puberty, all those things.

And so really, it's important to make sure that we've got those regular well-child checks so that we can check on growth. We can make sure that we're continuing to meet the appropriate milestones over time. And then, as a kid gets older, I'm often looking at kids who should be starting to go through puberty, you know, 10, 11, 12 is kind of that age. And if a kid who has ARFID is really restrictive, maybe they've gotten enough nutrition to get them up to this point, but they're not getting that. extra nutrition that really gets them through puberty. So, delayed puberty can be another symptom of ARFID. And that's something that, again, your pediatrician could help you navigate. But it's important to bring them in for care if you're noticing those things that like, "Man, it just doesn't seem like we're growing or developing the ways that we should."

And then, of course, you're seeing a provider when the anxiety gets really high. If this is something that we're having breakdowns about, we're having fights about food because your kid is so restrictive, then that's another reason to go ahead and get that child evaluated, because there's certainly things that your pediatrician or maybe a psychologist or other provider can help navigate in those situations.

Host: Yeah. So, what I'm hearing you say is that If there is a concern, you should definitely contact your pediatrician. Tell me a little bit about what the process of evaluation is and some of the treatments that are available for ARFID.

Michelle Bowden, MD: Yeah. In our eating disorder clinic here at Le Bonheur, we see cases of ARFID pretty often. And the way that we approach that is really trying to get an understanding of is this on the spectrum of normal eating or does this really meet ARFID criteria? And the way that we do that is we look at a few things. We look at growth charts, like I just mentioned. We also have a dietician embedded in our clinic who can help us understand exactly what kinds of food this child is willing to eat. Sometimes we talk about red, yellow, and green foods. What are the foods that they're always going to accept that are green? What are the foods that they'll sometime accept? And what are the foods that they're never going to accept? And so, understanding, man, there's a lot of red foods that this kid's never going to eat. And only a handful of foods in the green list really helps us get a better understanding of kind of, are there any micronutrient deficiencies that we need to be concerned about? And so, that can be something that we can follow up with lab values if we need to in a clinic like ours.

The other piece that's often helpful is having a psychologist or a therapist evaluate the child as well who help us understand, again, is there underlying anxiety? Is there underlying OCD? Should we have an autism evaluation to better understand kind of what's going on? And then, that will help us develop a treatment plan. And so, treatment plans often are multidisciplinary. So, I, as the medical provider, can offer things like medication for anxiety, which can be helpful. And often just doing a lot of education around kind of what this diagnosis looks like and how do we move forward, but they're really good therapies available from community therapists, from our psychologists, that focus on things like if cognitive behavioral therapy is an appropriate intervention that's something that may be helpful for a child who's experiencing ARFID.

And of course, there are other therapy modalities that could be helpful. Often, having a dietician is very helpful because they can help us understand how to maximize the nutrition that the child's getting so that they continue to grow well and then help us develop a plan over time about, "Okay. Maybe we do want to incorporate new foods. What's a way that we can do that actually doesn't cause more trauma?" Because what we see in ARFID often is that we'll really push, push, push foods that the child's not ready to take. We heighten that anxiety and then there's more anxiety around food. So, we can actually make things worse if we're not using an ARFID-informed approach. And there are dieticians who do a great job at this, including here at Le Bonheur.

The other pieces often we're going to need to involve are occupational therapists, speech therapists, even physical therapists who can us really determine what are some of those sensory issues that we need to address to help us be more effective at really helping this child make the progress that they need to be successful in the long-term.

Host: Okay. You've mentioned a lot of amazing things just around therapy and help for children that might be diagnosed with ARFID. I think like the big question that I have, and I know a lot of parents are going to have is, "Hey, is this going to stick around with my child for the longterm if my child has this?" If through that hard work and some of the therapies and modalities that you mentioned, will this go away with work and over time? So, what would you say to that?

Michelle Bowden, MD: Yeah. I think it depends. I think for some kids, having ARFID is a lifelong diagnosis. The good news is that for, you know, especially kids who may have sensory issues, they may never be a "typical eater." But that doesn't mean that they can't live long, healthy, successful lives when they really know how to get in the nutrition that they need by engaging with some of these therapies and services over time.

I often tell my parents ARFID is kind of a long game. It's not something that is going to get better in a week or even in a month. It's something that we're going to need to work on probably for the next few years. And even after that, we may need accommodations to really always get the full spectrum of nutrition that we need as a person who has ARFID. And the good news is that I see patients all the time though, who come in as extremely picky eaters, can only eat at home, only have a handful of foods. And over time, they do make really good progress.

And what I think is super interesting, one of my favorite things about ARFID is that often, we really want our kids to develop these robust skills in early childhood so that they have all these foods by the time they're teenagers. But with kids with ARFID, often what I'm seeing is that their nutrition stays kind of the same. They eat the same food through elementary school, but then they get to middle school. And in middle school, it becomes important to be able to go get pizza with your friends. And so, I often see kids who are really leaning into, "Okay, I've never wanted to do pizza before, but now I'm interested in trying pizza because that means that I could go out to dinner with my friends on a Friday night." And so, really focusing on helping your child grow and thrive with the foods that they're able and willing to eat. And then, honestly letting them kind of direct what foods they want to add over time and not pushing with specific foods becomes an important part of the treatment process. But if we're willing to do that, slow down, take our time, follow our kids' lead, get them the therapies they need. I do see kids make great progress and live long, healthy fulfilled lives with a diagnosis of ARFID.

Host: Yeah. That's a really assuring point there. Just to close it out, I think that maybe some parents that are listening to this are listening to it because their children are just picky eaters. You know, know coming into this interview, I was like, "I wonder if my son might have this." So, I think just in general, do you have any tips to just gently encourage our kids to try more of a variety of foods?

Michelle Bowden, MD: Yeah, absolutely. And I'll just say it one more time because I don't want anyone to like really get anxious about this. Most kids don't have ARFID, okay? Most three and four-year-olds, like your kid and my kid, are picky eaters, and it is unlikely that it will eventually be ARFID. So, most of us are just dealing with picky eaters, and that's an important thing to address as well.

But some things that, you know, are evidence-based that really show good efficacy and raising kids who have a good variety of foods is, number one, just having really healthy adults model what healthy eating looks like, right? It's important for us to sit down at the table with our kids as often as we can. We know that that's super protective against eating disorders. It's also super protective against obesity. So, either side of the scale, we're looking at, "Man, that's something productive that we can do for our kids and our families." It also helps reduce anxiety and improves family relationships. And so, I think if I could say one thing that I would recommend everybody walk away with is if you can share a family meal as often as you can, that's going to be a really important thing to do.

The second thing is really making sure that meals are low pressure when you do have them, right? Everybody gets the food on their plate. It's my job as a parent to put the food on the plate. It's my kid's job to put it in his mouth. I'm not going to force them to eat anything that they're not ready to eat. And anytime I serve a meal with a picky eater, what I'm always doing is I'm thinking," Okay, what's on this plate that this kid loves? And what's on this plate that is kind of a stretch for this kid," right? Like, I'm not going to stop giving my kid broccoli because she thinks she only likes white broccoli. I'm going to put a couple of bites of broccoli on her plate when I have broccoli for the rest of my family. You know, she also loves a good slice of a roll. I'm also going to put a roll on the plate, because I know that's something that she'll feel comfortable with. And that's one good way to reduce anxiety around food, is always having a food that is a comfortable food on the plate, even when you're offering foods that may be a little bit more uncomfortable for your picky eater.

The other thing to keep in mind is that when you're putting that food on the plate, it may take 10 or 20 times of trying that food. She may have to put that broccoli in her mouth 10 or 20 times before she actually likes it. And so, that's okay to see your kids say no over and over and over again that they don't like this food. It doesn't mean you stop offering it, so just keep offering it again, but in a low pressure environment, always with something that feels comfortable with them. And I would just say, you know, as a point of how you talk about food as kind of a last recommendation is that it's important for us as families to understand that we can assign value to food by the way that we talk about it, right? If I've got a roll on the plate and I've got broccoli on the plate and I'm saying, "Well, you're only eating the unhealthy stuff, because she's eating the roll," right? Often what our kids hear is, "Oh, well, I'm doing something bad or wrong," when really my kid's giving her body what it needs because she needs that nutrition from the roll, right? And so, really avoiding labeling foods as good or bad, or even sometimes healthy and unhealthy can be a little bit sticky in that situation. But definitely trying to avoid those ideas that like, "Man, you only eat the bad foods," right? Because our kids are gonna hear that as maybe I'm bad because I only eat bad foods. And we don't want them to hear that. We want to hear them know that they are beautiful and wonderful and know what their body needs, and still brave enough to try new foods, right? And so, those are conversation pointers that I would say as you're sitting around the table together, just be mindful of how you're talking about food and continue to encourage your kids to try all kinds of foods, enjoy all kinds of foods, and that there's really no bad food that they could eat as long as they're giving their body the fuel that it needs.

Host: Dr. Bowden, perfect place to end. Thank you so much for your time and advice today.

Michelle Bowden, MD: My pleasure. Thanks for having me.

Host: If you found this podcast helpful, consider sharing us on your socials and check out the full podcast library at leBbonheur.org/podcast for more topics of interest to you. I'm Prakash Chandran, and this has been the Peds Pod by Le Bonheur Children's Hospital. Thanks for listening.