Is It Picky Eating or an Eating Disorder?

Kids of all ages have different patterns of eating behavior. Most families manage feeding and nutrition without significant challenges, but some kids develop disordered eating behavior that can affect their emotional and physical growth and development. Parents might have a hard time telling if their child is showing signs of picky eating or eating disorders. They will likely turn to pediatricians and primary care providers first when they have concerns about a child or teen's weight or eating behavior.

Primary care providers should consider several important eating disorder diagnoses when evaluating a child or teen when families have a concern about weight and malnutrition. Important components to identifying risk of eating disorders in children and adolescents include: review of growth curves at each visit, looking for changes in weight and growth patterns and discussion of parents' concerns and observations, including changes in food preferences and eating behavior. Below you will find information on restrictive eating disorders, but bulimia nervosa and binge eating are also eating disorders children and adolescents might face.

Anorexia nervosa

Anorexia nervosa is characterized by increasingly restrictive eating, weight loss and efforts to continue losing weight even when family members and doctors express concern. Anorexia nervosa is most common in teenage girls, but can affect individuals of any age, including younger children and boys. Individuals with this disorder try to avoid weight gain by restricting what and when they eat, and may engage in excessive exercise. They often avoid eating with others and are preoccupied with appearance and weight.

At Children's Hospital Colorado, we have seen an increasing number of teens who were previously overweight and develop unhealthy, severely restrictive eating behaviors resulting in rapid weight loss of 30 to 60 pounds in just a few months. Weight loss-focused behaviors often include purging and excessive exercise.

Although these teens may have an average body mass index or weight range, the disordered eating behavior associated with their weight loss is dangerous. It can lead to the same medical and psychiatric complications found in patients with anorexia, including malnutrition, amenorrhea in girls, bradycardia (with a resting heart rate lower than 45 beats per minute), body image dissatisfaction and distortion and severe preoccupation with food and weight.

Avoidant restrictive food intake disorder (ARFID)

Avoidant restrictive food intake disorder (ARFID) is defined by persistent failure to meet appropriate nutritional and energy needs associated with one or more of the following:

• Significant weight loss
• Failure to achieve expected weight gain
• Faltering growth
• Significant nutritional deficiency
• Dependence on enteral feeding or oral supplements
• Marked interference with psychosocial functioning

ARFID can also be diagnosed at any age but is more common in children and early teens. These children or teens have typically been well below their growth curve for several years, sometimes since early childhood and are often described as "picky eaters." Some kids develop ARFID in response to the smell or appearance of food or a choking or vomit phobia. Some simply show little interest in food and eating. Children and teens with ARFID can have a range of food avoidance behaviors, including complaints of stomach pain, anxiety, tantrums or food refusal due to feeling "not hungry" or "too full." ARFID differs from anorexia, as the behaviors are not associated with fear of weight gain or body image distortion.

Warning signs of anorexia nervosa and ARFID

Anorexia nervosa and ARFID share many symptoms a provider can look for, including:

• Weight loss or failure to gain weight during periods of rapid growth
• Eating a narrow variety of foods: Patients with anorexia often begin by eliminating desserts and snack foods, or becoming vegetarian, gluten-free, lactose-free or vegan in an effort to restrict variety and calories. Patients with ARFID often have long-standing narrow food preferences.
• Emotional distress and anxiety when eating

Some more serious symptoms are associated with anorexia nervosa:

• Depressed mood and challenges managing anxiety and distress
• Regularly isolating for long periods of time, especially following a bad day, negative consequences or conflicts with peers/family
• Self-injurious behavior and suicidal ideation

Treatment for anorexia nervosa and ARFID

Treatment of anorexia and ARFID is similar and includes medical monitoring by the primary care provider (weekly to monthly, depending on severity) and therapy with a therapist experienced in family-based therapy (FBT) for eating disorders. A dietitian is often a helpful addition to the treatment team to support the parents in providing adequate nutrition for weight restoration and supporting their child in reaching a healthier weight, but teens shouldn't see just a dietitian without also seeing the providers mentioned above. Parents need to be empowered to make decisions about food and managing food avoidance behaviors. Kids with disordered eating often experience anxiety and depression and providers should screen for and address these conditions.

Kids with ARFID often benefit from an evaluation with a feeding team that includes a speech- language pathologist, occupational therapist, developmental pediatrician and dietitian to evaluate underlying developmental issues that may contribute to the feeding problems. This is especially critical if the eating problems began in infancy or toddlerhood. Picky eating that results in plateaued growth or weight loss, nutrient deficiencies or reliance on supplements is never a normal part of child eating development. Treatment is customized for the child and family depending on the age of the child and context with other underlying problems.

Talking with parents about eating disorders

Parents who are concerned about their child's eating habits will likely have many questions. When meeting with parents about eating disorder concerns:

• Express your concerns, review the growth curve and discuss observations about barriers to weight gain and optimal nutrition.
• Empower parents to increase their involvement in food selection and eating with the child or teen with the goal of improving intake and restoring weight gain.
• Work to rule out other possible medical causes of weight loss, while also talking with parents about the possibility of an eating disorder.
• Explain that professional involvement is almost always necessary to treat ARFID or anorexia nervosa and they should consult with a therapist experienced in family-based therapy. A therapist will help families manage food refusal and emotional outbursts, and will improve the child or teen's motivation to work with their parents to improve their health.
• Don't let it go. The longer a child continues in an underweight state, the more significant the impact on growth and development and the higher the risk of malnutrition and medical complications.

Additional eating disorder information

• Children's Hospital Colorado Eating Disorders Program: 720-777-6200
• Children's Hospital Colorado Feeding and Swallowing Program: 720-777-6168
• National Eating Disorders Association

Books and articles on childhood eating disorders

Below are additional eating disorder resources for professionals.

Research articles:

• Practice Parameter for the Assessment and Treatment of Children and Adolescents with Eating Disorders. Lock J, et al. Journal of the American Academy of Child and Adolescent Psychiatry 2015;54(5):412-425.
• Update on Eating Disorders: Current perspectives on avoidant/restrictive food intake disorder in children and youth. Norris M, Spettigue W, Katzman D. Neuropsychiatric Disease and Treatment 2016;12: 213-218.
• Characteristics of ARFID in children and adolescents: A "New" disorder in DSM 5. Fisher MM, et al. Journal of Adolescent Health 2014;55:49-52.

Books:

• What causes eating disorders and what do they cause: An essential introduction for anyone who would like to understand eating disorders and how to overcome them. By Guido Frank, MD
• Skills based learning for caring for a loved one with an eating disorder. By Janet Treasure, Grainne Smith and Anna Crane