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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 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) is defined by persistent failure to meet appropriate nutritional and energy needs associated with one or more of the following:
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.
Anorexia nervosa and ARFID share many symptoms a provider can look for, including:
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.
Parents who are concerned about their child's eating habits will likely have many questions. When meeting with parents about eating disorder concerns:
Below are additional eating disorder resources for professionals.