Merve Karaca Şahin, from University of Health Sciences, Prof. Dr. Cemil Tascioglu City Hospital in Istanbul, Turkey.

Merve Karaca Şahin

are often more selective about food than medically necessary, and clinicians frequently lack a systematic way to flag this pattern during follow-up. Restrictive eating driven by fear or picky eating, rather than allergen avoidance alone, can affect growth and long-term nutrition.

A prospective controlled study compared 117 children with physician-diagnosed food allergy and 117 age- and sex-matched healthy controls, all aged 2 to 9 years.

 Parents completed the Nine Item Avoidant/Restrictive Food Intake Disorder Screen-Parent Report (NIAS-PR), a tool validated to assess picky eating, appetite, and fear subscales.

 Median total NIAS-PR scores were greater in the food allergy group than controls (17 vs 12;

 <.001), driven by picky eating and fear subscale scores, while appetite scores did not differ (

Fear subscale scores were higher among children with a history of urticaria or anaphylaxis, and children with food allergy showed lower weight-for-age and height-for-age z-scores than controls.¹ Within the food allergy group, children with comorbid asthma had higher total NIAS-PR scores than those without asthma (19 vs 16;

These findings suggest fear and picky eating, rather than appetite loss, drive restrictive eating in food allergies, and follow-up may need to extend beyond deciding which foods to avoid or introduce.

In the following Q&A, investigator Merve Karaca Şahin, MD, of the department of pediatric allergy and immunology at Prof. Dr. Cemil Tascioglu City Hospital in Istanbul, Turkey, discusses what a positive NIAS-PR screen should prompt for referral and what allergists can do now to identify ARFID-related behaviors in children with food allergies.

Q&A: Fear, Not Appetite Loss, Drives ARFID Eating Patterns in Food Allergy

What's the key takeaway for clinicians managing pediatric food allergy from this study on ARFID-related eating behaviors?

 The idea for this study came from our daily clinical observations. We often saw children with food allergy who were very selective or avoided more foods than medically necessary, so we wanted to assess these behaviors more systematically. We used the NIAS-PR, which screens 3 ARFID-related domains: picky eating, poor appetite, and fear of negative consequences from eating.

We found children with food allergy had higher overall scores, mainly because of greater fear around eating and more picky eating. Their appetite scores were similar to those of healthy children, so the main issue may not be low appetite. Instead, fear and picky eating may limit the foods children feel safe eating.

For clinicians, this means follow-up should go beyond identifying which foods need to be avoided or introduced. They should also consider ARFID-related behaviors.

What does the higher fear subscale score in children with a history of urticaria or anaphylaxis suggest about reaction severity and eating behavior?

 Previous studies suggest allergic reactions to food can increase anxiety around eating, and this anxiety may continue even after the reaction itself. In our study, children with a history of urticaria or anaphylaxis had higher fear-related scores. This makes sense clinically. Anaphylaxis can be life-threatening and very frightening, while urticaria is often sudden, visible, and memorable, and these reactions make children and their families feel eating is unsafe. Over time, this may lead to more food avoidance.

Appetite-related items didn't differ between groups. Does this challenge assumptions that food allergy uniformly suppresses a child's interest in eating?

 A child may enjoy eating but eat only a limited range of foods, or avoid foods that are actually safe, because of fear. If we ask only about appetite, we may miss the main difficulty.

How much of the lower weight- and height-for-age z-scores in food allergy patients is attributable to ARFID-related eating versus the elimination diet?

 Our study was not designed to determine how much of the growth difference is related to ARFID versus how much is related to the elimination diet. We did not collect detailed dietary intake data or formally diagnose ARFID, so we cannot separate these effects.

Why might asthma specifically, rather than other atopic comorbidities, be associated with greater ARFID-related burden?

 There are several possible explanations. Asthma may increase the overall burden of chronic disease and vigilance, and respiratory symptoms are central to both asthma attacks and severe allergic reactions. Families may see food-related symptoms as especially threatening, which could contribute to more anxiety or restriction around eating. However, our study was not designed to explain this association. Only 34 children in the food allergy group had asthma, and the difference was modest. For now, I frame it as an interesting finding for future studies.

Since the NIAS-PR is a screening tool, when should a positive screen prompt referral for formal psychiatric or feeding evaluation?

 I would not refer based on the score alone, especially because no validated NIAS-PR cutoff has been established for diagnosing ARFID in this population. The screen should prompt a focused assessment of consequences and functioning. Referral is appropriate when restriction is accompanied by faltering growth, weight loss, suspected nutritional deficiency, a very narrow food list, persistent fear, social impairment, or avoidance that extends beyond confirmed allergens. Difficulty reintroducing a food after tolerance or a negative food challenge test is another important signal.

Given the lack of established guidelines for ARFID in pediatric food allergy populations, what practical steps can allergists take now?

 An allergist can ask a few questions about fear, food variety, and unnecessary avoidance. A validated screening tool can support this assessment, but it should not replace clinical judgment. If concerns are identified, early referral to feeding and mental health professionals may be helpful.

What's your main message for allergists and pediatricians not currently screening for ARFID-related behaviors in food allergy patients?

 Greater awareness of ARFID-related behaviors] can enable clinicians to recognize warning signs earlier during follow-up. A few brief questions about ARFID-related behaviors may be valuable. The NIAS-PR, or another screening tool, may provide a practical way to support screening, and early recognition allows clinicians to offer nutritional or psychological support before these behaviors become more severe or persistent.

Watch our interview with Karaca Şahin here: 

Food Allergy Linked to ARFID-Related Eating Behaviors in Children

Karaca Şahin M, Çalışkan N, Şarman HT, et al. Fear and picky eating-related ARFID behaviors in children with food allergy. 

Karaca Şahin M. Food Allergy Linked to ARFID-Related Eating Behaviors in Children. 

. Published August 6, 2026. Accessed August 7, 2026. 

https://www.hcplive.com/view/food-allergy-linked-arfid-related-eating-behaviors-children

Zickgraf HF, Ellis JM. Initial validation of the nine item avoidant/restrictive food intake disorder screen (NIAS): a measure of three restrictive eating patterns. 

Articles

Children with physician-diagnosed food allergy demonstrate higher avoidant/restrictive eating behavior scores than healthy peers, largely attributable to fear of adverse consequences and picky eating rather than reduced appetite. Fear is amplified in those with prior urticaria or anaphylaxis, and overall growth indices (weight- and height-for-age z-scores) are lower than controls, though causality versus elimination diets remains unresolved. Comorbid asthma is associated with a modestly higher restrictive-eating burden. Screening should extend beyond allergen lists to functional impairment and unnecessary avoidance, guiding timely feeding or mental-health referral.

Merve Karaca Şahin, MD, discusses fear- and picky-eating-driven ARFID behaviors in children with food allergy.

avoidant/restrictive food intake disorder (ARFID)

-related eating behaviors than healthy peers, driven primarily by picky eating and fear-based avoidance rather than appetite loss, according to a recent study.

 Food Allergy Linked to ARFID-Related Eating Behaviors in Children

Feeding difficulties in pediatric food allergy have been reported across a wide range, from 13.6% to 40%, but prior studies relied on heterogeneous terminology and diagnostic instruments and skewed toward non-IgE-mediated phenotypes.

No prior study had applied the Nine Item Avoidant/Restrictive Food Intake Disorder Screen–Parent Report (NIAS-PR) to an IgE-mediated food allergy population, leaving a gap in standardized data for allergists managing selective or avoidant eaters.¹

“Importantly, their appetite scores were similar to those of healthy children, so the main issue may not be low appetite,” Merve Karaca Şahin, from Prof. Dr. Cemil Tascioglu City Hospital in Istanbul, Turkey, told 

 “Instead, fear and picky eating may limit the foods children feel safe eating.”

NIAS-PR Scores and Eating Behavior Domains in Food Allergy

The single-center, prospective, controlled study enrolled 234 children aged 2 to 9 years, including 117 with physician-diagnosed food allergy and 117 age- and sex-matched healthy controls, evaluated at the Pediatric Immunology and Allergy Outpatient Clinic of University of Health Sciences, Prof. Dr. Cemil Tascioglu City Hospital between September 2025 and February 2026.¹ Parents completed the NIAS-PR, a validated tool assessing 3 domains: picky eating, appetite, and fear of aversive consequences from eating.¹

Median total NIAS-PR scores were significantly greater in the food allergy group than in controls (17 [IQR, 11-24] vs 12 [IQR, 7-18]; 

 <.001).¹ The difference was driven by picky eating and fear subscale scores (both 

 <.001), whereas appetite subscale scores did not differ significantly between groups (

 =.311).¹ Karaca Şahin said this pattern challenges assumptions that food allergy uniformly suppresses interest in eating, noting a child may enjoy eating yet restrict intake to a narrow list of foods perceived as safe.

Growth, Asthma, and Reaction Severity Tied to ARFID Risk

What did the NIAS-PR study find in children with food allergy?

Children with food allergy had significantly higher NIAS-PR total, picky eating, and fear subscale scores than healthy controls, while appetite scores did not differ.

Does food allergy suppress appetite in children?

Not according to this study; appetite-related items were similar between children with food allergy and controls, suggesting fear and picky eating, not appetite loss, drive ARFID-related behavior.

When should a positive ARFID screen prompt referral in children with food allergy?


Karaca Şahin recommends referral when restriction is accompanied by faltering growth, weight loss, a narrow food list, persistent fear, or difficulty reintroducing tolerated foods, rather than from the score alone.

Children with food allergy also demonstrated significantly lower weight-for-age (−0.20 ± 1.10 vs 0.26 ± 1.05; 

 =.001) and height-for-age z-scores (−0.40 ± 1.18 vs 0.15 ± 1.18; 

 <.001) compared with controls. BMI z-scores did not differ significantly between groups (

 =.117).¹ Karaca Şahin said the study could not separate how much of this growth difference stemmed from ARFID-related behaviors versus the elimination diet itself, calling the effect likely multifactorial given the absence of detailed dietary intake data.

Within the food allergy group, children with comorbid asthma (n = 34) had greater total NIAS-PR scores than those without asthma (19 [IQR, 14-39] vs 16 [IQR, 10-22]; 

 =.043).1 Karaca Şahin cautioned against overinterpreting the modest link, noting that the study was not designed to explain the association and that, for now, it should be viewed as an intriguing lead for future research. Children with a history of urticaria (

 =.014) also scored significantly greater on the fear subscale.

“This makes sense clinically because anaphylaxis can be life-threatening and very frightening, while urticaria is often sudden, visible, and memorable,” Karaca Şahin said. “These reactions make children and their families feel that eating is unsafe. Over time, this may lead to more food avoidance.”

Because no validated NIAS-PR cutoff exists for diagnosing ARFID in this population, Karaca Şahin said a positive screen alone should not trigger referral; instead, she flags faltering growth, weight loss, a very narrow food list, persistent fear, or difficulty reintroducing a food after a negative oral food challenge as signals warranting evaluation by feeding and mental health specialists.

Related Research on ARFID Risk in Pediatric Food Allergy

separate research showing children with and without food allergy screened positive for possible ARFID at similar rates

 (23% vs 21%) underscoring ongoing uncertainty about how allergy-specific this risk truly is.

 In a population-based Australian birth cohort study, possible ARFID among children with food allergy was more common in those with anaphylaxis or an epinephrine autoinjector prescription, and current hay fever was linked to greater rates of both possible ARFID and possible ARFID inclusive of food allergy anxiety.

Karaca Şahin has no reported disclosures.

Karaca Şahin M, Çalışkan N, Şarman HT, et al. Fear and picky eating-related ARFID behaviors in children with food allergy. 

Hill SA, Nurmatov U, DunnGalvin A, et al. Feeding difficulties in children with food allergies: An EAACI Task Force Report. 

Ciciulla D. Q&A: 1 in 5 children with food allergy screen positive for possible ARFID. HCPLive. Published August 6, 2026. Accessed August 6, 2026. 

https://www.hcplive.com/view/1-in-5-children-food-allergy-screen-positive-possible-arfid

Videos

A prospective controlled study of 234 children finds food allergy raises ARFID-related picky eating and fear scores, but not appetite loss, Merve Karaca Şahin says.