Children with food allergies 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.1,2 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.3 Median total NIAS-PR scores were greater in the food allergy group than controls (17 vs 12; P <.001), driven by picky eating and fear subscale scores, while appetite scores did not differ (P =.311).¹

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; P =.043).¹

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

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

Karaca Şahin: 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.

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

Karaca Şahin: 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.

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

Karaca Şahin: 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.

HCPLive: 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?

Karaca Şahin: 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.

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

Karaca Şahin: 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.

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

Karaca Şahin: 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.

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

Karaca Şahin: 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.

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

Karaca Şahin: 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.

References

1. Karaca Şahin M, Çalışkan N, Şarman HT, et al. Fear and picky eating-related ARFID behaviors in children with food allergy. Pediatr Allergy Immunol. 2026. doi:10.1111/pai.70403

2. Karaca Şahin M. Food Allergy Linked to ARFID-Related Eating Behaviors in Children. HCPLive. Published August 6, 2026. Accessed August 7, 2026. https://www.hcplive.com/view/food-allergy-linked-arfid-related-eating-behaviors-children

3. Zickgraf HF, Ellis JM. Initial validation of the nine item avoidant/restrictive food intake disorder screen (NIAS): a measure of three restrictive eating patterns. Appetite. 2018;123:32-42. doi:10.1016/j.appet.2017.11.111