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Dr Sarah Garwood: Hello, I'm Dr. Sarah Garwood. I'm an adolescent medicine physician with St. Louis Children's Hospital, and I'm a mom doc.

Melanie Cole (Host): For many parents, having young children means negotiating to get them to eat their vegetables, taste new foods or finish what's on their plate. Picky eating is absolutely nothing new. But what happens when it involves many foods, never goes away or really gets worse? There are different types of restrictive eating behaviors that vary in severity. They range from general picky eating to more extreme eating disorders, such as avoidant restrictive food intake disorder or ARFID.

Welcome to Mom Docs, the podcast from St. Louis Children's Hospital. I'm Melanie Cole. Dr. Garwood, I'm so glad to have you join us today because picky eating is something so many parents face. However, there are, as I said in the intro, various forms of it. So can you start with sort of a basic definition of picky eating for us and when that is something that we need to really concern ourselves about?

Dr Sarah Garwood: Sure. So picky eating in a really common thing in young children, infants and into early childhood. Picky eating typically involves really strong food preferences for young kids. Sometimes that means that they might not eat enough variety of foods. So they may sort of get stuck on a couple of safe foods that they really want to eat all the time. And they may do that at the expense of other types of foods, fruits and vegetables for example. They might restrict certain food groups like they won't eat anything that is white or red or something like that occasionally. They may also eat a limited amount of food or not be willing to try new foods. So it may be really hard for them to accept a new food that's brought to the table. Sometimes we call that neophobia or kind of fear of new foods. But the thing with picky eating is that that tends to improve or resolve by the time we get into late childhood. So it's unusual for people to continue to have significant picky eating problems once they're closer to that 9, 10, 11 age range.

Melanie Cole (Host): Yeah, this is such, you know, an interesting topic for parents because some parents don't know whether they should be forcing these things or hiding the healthy, nutritious foods inside smoothies. We'll talk a little bit more about general picky eating, but tell us a little bit about how ARFID and picky eating are different. Do we know what causes this? Is it something physiological or is it more psychological? Tell us a little more about it.

Dr Sarah Garwood: Sure. So, there is a group of eating disorders that are kind of under this umbrella that we call ARFID, which is avoidant restrictive food intake disorder. And when kids actually fall under that ARFID category, these are kids who have an eating or feeding disturbance that really interferes with their life in some ways. So they may be nutritionally deficient. They may not have enough protein, for example, or enough carbohydrates or enough calcium or other nutrients. Or their picky eating is at a level that it causes actual weight loss or failure for children to gain weight as expected during that rapid growth that happens in childhood. Or they may not function well because they can't really manage their eating issues in social situations. So if they have difficulty with eating anything at school, or they can't do things with friends because their eating concerns are so restrictive. Or if the child is dependent on a supplement like Boost or Ensure or PediaSure drink in order to maintain their health. Without supplements, they would not be able to grow and develop appropriately.

Those are all signs that it's sort of crossed from just a regular garden variety picky eater into more of someone who would meet the criteria for ARFID. The other thing about ARFID is that it tends to get worse over time and progressively the children become more restricted in their eating that the problems worsen and the food choice narrow over time. Whereas with picky eating, as I mentioned, that tends to resolve sort of by the time you're in that late childhood age.

Also, we don't want to confuse ARFID with other types of what we think of as classic eating disorders, like anorexia, where the person has a distorted belief that they are overweight when they're really normal or underweight. Patients with ARFID do not actually have a distortion in the way they experience their body image. So that's another important distinction.

When people have ARFID, they usually have one of a couple of subtypes. We recognize actually different subtypes. So one of those subtypes is that kids just don't seem interested in food or eating. So it looks like they just don't really have much of an appetite. They're kind of disinterested in food. They might easily get distracted and skip meals. They may take a long time to complete meals, tend to be pretty distractible. So if they're doing something else, they'll just forget to eat.

The second subtype is kids who have really significant sensory issues around eating, or sometimes they are what we call supertasters or they are very sensitive to taste like bitter or other strong spice or flavors. This is kind of what you think of as like that picky eating, that classic picky eating kid. But the difference again with the sensory type is that it's usually very longstanding and doesn't resolve. They might avoid foods because of smell or taste or texture pretty frequently. But sometimes kids with this type of ARFID actually are really rigid about the process of eating. So they want foods to be prepared in a certain way every single time.

And then there is a third subtype of ARFID, which is fear of aversive consequences. So this tends to be a type that happens more abruptly. So a normally developing kid who has an experience like choking on a piece of pizza or something like that and then, following that experience, becomes very phobic about having that experience happen again. So this could be a fear about choking. It could be a fear about vomiting, could be a fear about abdominal pain. So sometimes kids are afraid their stomach will hurt if they eat and that over time leads to more and more restriction.

Melanie Cole (Host): Wow. Thank you for that very comprehensive answer. So then, tell us about some of the treatments. I mean, as we've learned over the years with picky eating, they tell you to keep trying the same foods or new foods and, you know, having a role model, the kids seeing other kids and parents eating these foods. But with this, it's a little bit different. Tell us what the treatments are like.

Dr Sarah Garwood: Right. So with kind of garden variety picky eating, as I call it, I guess, the best well-known way to approach that is through Ellyn Satter's feeding dynamics model. So there's even a website about Ellyn Satter's Institute and this kind of feeding dynamics model, which basically divides responsibility for feeding into the parent group and the child group. The parent's responsible for what, when and where; the child is responsible for how much and whether. And this type of division of responsibility encourages parents to not pressure, cajole, bribe, shame, put any kind of pressure on a child during meals and to continue to present food at meal times in a pleasant manner and allow children to then choose to eat. But also part of this is also that you don't let kids kind of snack or graze. You present food really only at meal times and snack time. So that's kind of our general messaging about healthy eating for young kids and for how to avoid or treat some cases of picky eating.

But when we're talking about ARFID, and if a child really meets those clinical criteria, it's unlikely that that sort of model is going to be effective. So if we're concerned that the intake is not good enough, if the intake is not going to sustain a child's growth, if the problem is having an impact on their development or a negative impact on family functioning, it's a good idea to talk to your pediatrician and have an assessment. If we really believe that someone meets a diagnosis for ARFID, treatment is really part of a multidisciplinary team typically. So that would include your doctor, but it's also going to include a mental health professional who has experience in managing ARFID and sometimes involvement with a dietician as well. There are. Different specific techniques that are used depending on what type of subtype of ARFID that the child has. So it often involves education for the child to understand that their brain is connecting food with fear. And then that fear kind of sets off a response in their body that makes them want to avoid food. And over time, they keep avoiding, which helps the anxiety in the short term, but over the longterm, it leads to more and more avoidance. So trying to educate patient and parent about that connection. And then doing some things like systematic desensitization to the things that cause anxiety or setting up a reward system to kind of reward food approach and experimentation with food types that might be anxiety-provoking, for example. As you can tell, this is something that really needs expertise of someone who has a lot of, knowledge and experience in dealing with these types of eating disorders, because this is not something that a lot of therapists have experience in.

Melanie Cole (Host): Certainly not. And so is it something that can turn into something dangerous? Can it turn into an anorexia or a bulemia or no, they're really not related in that way?

Dr Sarah Garwood: There are occasions that we do see sort of combination of what looks like ARFID and may develop then into anorexia nervosa or other eating problems. One of the common patterns we see is that someone who has lost a significant amount of weight with ARFID, then when we are expecting weight restoration and weight gain, the person starts to kind of put up some resistance to that and they might be afraid of gaining weight too fast or saying, "I only want to gain a certain amount" or "I don't want to gain enough that I'll be overweight." So sometimes we do see that.

ARFID itself can be very serious. I mean, patients with ARFID can be very ill. Sometimes patients with ARFID end up needing to have feeding tubes placed because they have so much struggle eating enough quantity of food. So it can actually be a very serious condition all on its own. ARFID patients typically have one or the other in terms of decrease. ARFID patients typically have a decrease either in volume, which is the amount total, or in variety. And some patients have a decrease in both, both in volume and variety. So it can be a challenge to treat and can lead to specific nutrient deficiencies or to chronically underweight and poor growth, or even in some cases, as I mentioned, chronically depending on supplements or even NG feeding.

Melanie Cole (Host): Wow. What an interesting topic and something that I think that not many people know about, but it's probably a little more common than we even would realize. If you had to give parents, Dr. Garwood, your best advice about when they start to notice the picky eating in their children. And of course, all children develop some of that texture taste, look, whatever it is at some point. What would you tell them about really the time to perk up, to take notice? And if you want to give some best advice about picky eating in general, that would be very welcome too.

Dr Sarah Garwood: Right. So I think picky eating in general, my best resource and suggestion is to go back to that model that I mentioned, Satter's Feeding Dynamics Model, which is the division of responsibility for eating and gives some really good guidelines and rules for how to approach meals and snacks to help your child become a healthy eater. So for general picky eating, that would be my best suggestion. And also to let parents know that this is likely to pass. As I mentioned, as kids get older into older childhood, most cases of picky eating will improve or resolve, and you can help that by making mealtimes pleasant, present foods, don't cater to the picky eating per se, but you can be considerate in your meal planning, have at least one or two foods that you know that they accept as part of the meal and be consistent with those strategies and things typically will get better.

In terms of deciding whether your child has a concern more than just the picky eating, picky eating is not going to lead to extreme weight loss or malnutrition or problems in growth unless it really has crossed over into more of a disorder like ARFID. So I think anytime you're concerned about appropriate weight gain or if the child is actually losing weight, those would be times, I mean, you should be more alarmed.

And then I think also if your child is not eating, at least from every food group. It doesn't have to be every day, but within a week's time or within several days' time, if they're not getting some foods from each food group, that would be another reason I would be concerned enough to talk to a medical provider to assess. And then if there are major impacts on functioning, so is it hard for the child to do anything socially? Do they have issues at school because of the eating? Is the whole family routine disrupted because of the accommodations that have to be made for the child's eating. Those are other sort of red flags to think about. Parents definitely do not cause ARFID in their children, but parents can accommodate to the eating preferences of kids. And sometimes that accommodation can actually make things worse over time, rather than better.

Melanie Cole (Host): Thank you so much, Dr. Garwood, for sharing your expertise with other parents today. Really interesting information and also great advice. Thank you again. And for more advice and articles, you can always check out the Mom docs website at childrensmd.org.

And that wraps up another episode of Mom Docs with St. Louis Children's Hospital. If you found this podcast informative, please share on your social channels. Be sure to check out all the other interesting podcasts in our libraries as we're all learning from the experts at St. Louis Children's Hospital together. I'm Melanie Cole.