Daniela Ciciulla, APD, CEDC, MDiet, a PhD candidate at the University of Melbourne.

Daniela Ciciulla, APD, CEDC, MDiet

Possible Avoidant/Restrictive Food Intake Disorder (ARFID) occurs at similar rates in children with and without 

, a recent study found.¹ Many clinicians assume allergy-related dietary restriction raises eating-disorder risk, but the standard screening tool used in this study may still miss fear specific to food allergy.¹

In a population-based Australian birth cohort study, investigators followed 951 10-year-olds from the HealthNuts using the Eating Disorders in Youth Questionnaire (EDY-Q), including 102 with current, allergist-confirmed food allergy.¹ Possible ARFID prevalence was 23% (95% CI, 15-32) in children with food allergy and 21% (95% CI, 18-24) in those without (odds ratio [OR], 1.09; 95% CI, 0.67-1.80).¹ Because the EDY-Q does not capture fear of allergic reactions, investigators added a food allergy anxiety item, raising possible ARFID prevalence to 32% (95% CI, 24-42) among children with food allergy.¹

Possible ARFID inclusive of food allergy anxiety (ARFID-FAA) occurred more often in children with anaphylaxis (38% vs 26%) or an autoinjector prescription (36% vs 20%).¹ Current hay fever, not eczema or asthma, was linked to higher rates of both possible ARFID (27% vs 13%) and ARFID-FAA (40% vs 18%; 

Reported ARFID prevalence among children with food allergy has ranged widely, from 5% to 63%, across prior clinical samples, reflecting small cohorts, inconsistent screening instruments, and considerable risk of bias.¹ A 2024 meta-analysis pooled general-population ARFID prevalence at 4.51%, underscoring how far behind population-based estimates in food allergy cohorts remain.² Data directly comparing ARFID risk between children with and without food allergy in a general community sample have remained scarce until now.

Untreated ARFID carries nutritional, developmental, and psychosocial risk, reinforcing the need for a multidisciplinary approach combining dietetic and psychology expertise with allergy-specific clinical knowledge.¹ In the following Q&A, investigator Daniela Ciciulla, APD, CEDC, MDiet, a PhD candidate at the University of Melbourne, discusses the clinical implications for allergists integrating ARFID awareness into routine food allergy care.

Q&A: Possible Avoidant/Restrictive Food Intake Disorder (ARFID) occurs at similar rates in children with and without food allergy, a recent study found.¹ Many clinicians assume allergy-related dietary restriction raises eating-disorder risk, but the standard screening tool used in this study may still miss fear specific to food allergy.¹

Q&A: 1 in 5 Children with Food Allergy Screen Positive for Possible ARFID

 For allergists, what's the main clinical takeaway from this study on ARFID prevalence in children with food allergy?

 In our study, 10-year-old children completed the EDY-Q. This tool screens for common ARFID variants including fear of aversive consequences, lack of interest in food and/or sensory sensitivity. Our findings show 1 in 5 10-year-olds screen positive for being at risk of “possible ARFID,” suggesting it is a common problem.

A similar proportion of children with and without food allergy were identified as being at risk of possible ARIF. However, the EDY-Q may not be suitable to detect symptoms of ARFID in individuals with food allergy because it does not capture fear of aversive consequences specific to food allergy, such as fear of allergic reactions. We measured food allergy anxiety using an additional questionnaire, and when we included food allergy anxiety as a variant of ARFID, the prevalence of ARFID in children with food allergy was higher. 

 Your data show that overall ARFID prevalence was similar between children with and without food allergy, roughly 23% versus 21%. Was this surprising given the field's assumption that food allergy drives elevated ARFID risk?

 Previous research suggests that individuals with health conditions which require dietary management may be at increased risk of developing eating disorders. There is limited research on whether individuals with food allergy are more likely to have an eating disorder.

It is important to note that food allergy anxiety can occur without disordered eating or excessive dietary restriction. However, when food restriction or avoidance is associated with growth, nutrition or psychosocial compromise beyond that required food allergy management, referral to other services and assessment of ARFID risk, may be considered.

 Possible ARFID-FAA was notably higher among children with a history of anaphylaxis or an adrenaline autoinjector prescription. How should that inform which food allergy patients clinicians prioritize for closer feeding and mental health follow-up?

 Among children with current food allergy, we found that possible ARFID inclusive of food allergy anxiety (ARFID-FAA) occurred more often in children with a history of anaphylaxis or had been prescribed adrenaline autoinjectors, compared to those without. This trend wasn’t observed when we examined possible ARFID without considering food allergy anxiety. However, our study was not designed to determine whether these factors increase the risk of ARFID and further research is needed.

 Hay fever, more than eczema or asthma, was associated with higher ARFID and ARFID-FAA prevalence in your cohort. Do you have a hypothesis for why this particular comorbidity stood out?

 A large Swedish twin study found children with ARFID were more likely to have allergic conditions (allergic rhinitis, asthma, allergic gastroenteritis, allergic contact dermatitis and urticaria) than those without. It is possible that nasal congestion and loss of smell, associated with hay fever, may influence eating experiences in some children. More studies are needed to investigate the relationship between hay fever and the risk of ARFID.

 Given that no validated ARFID screening tool has yet been tested specifically for sensitivity in food allergy populations, what should clinicians do now when they suspect ARFID in a patient?

 The recognition and treatment for ARFID is multidisciplinary, ideally involving dietitians and psychologists with expertise in both food allergy and ARFID management. Our study was not designed to inform the clinical management of ARFID.

If there are concerns about restrictive eating beyond what would be expected for food allergy management, referral for further assessment should be considered. While not all children who report having symptoms of ARFID will meet diagnostic criteria, they may benefit from additional support. More research is needed to develop and validation of ARFID screening tools appropriate for clinical use in individuals with food allergy.

 What's your overarching message for the allergy community about integrating ARFID awareness into routine food allergy care?

 For children with food allergy, clinicians should remain alert to maladaptive eating behaviors that extend beyond what is necessary for safe allergen avoidance. If clinicians suspect maladaptive eating behaviors in their patients, referral to a multidisciplinary team for further assessment should be considered.

Ciciulla D, Koplin JJ, Yeo M, et al. Prevalence of Avoidant/Restrictive Food Intake Disorder (ARFID) in children with and without food allergy. 

Nicholls-Clow R, Simmonds-Buckley M, Waller G. Avoidant/restrictive food intake disorder: systematic review and meta-analysis demonstrating the impact of study quality on prevalence rates. Clin Psychol Rev. 2024;114:102502. 

Articles

Population-based data from 951 Australian 10-year-olds showed similar EDY-Q–defined possible ARFID prevalence in children with allergist-confirmed food allergy (23%) and without (21%; OR 1.09). Because EDY-Q omits fear of allergic reactions, adding a food-allergy anxiety item increased possible ARFID prevalence in food-allergic children to 32%. ARFID-FAA was more frequent with anaphylaxis history and autoinjector prescription, and hay fever correlated with higher ARFID and ARFID-FAA rates. Findings support multidisciplinary evaluation when restriction exceeds safe avoidance needs.

A study found children with and without food allergy screen positive for possible ARFID at similar rates, Daniela Ciciulla, APD, CEDC, says.