Pediatric Feeding Disorder – a new picky eating diagnosis

I feel the more educated we are as a parent, the better placed we are to support our child.

Recently there have been some new developments in the picky eating sphere. 

Being armed with this information and understanding the terms, what they are for and how they are used is important. Especially if you feel your child is finding food and feeding more challenging than just the normal childhood likes and dislikes or fluctuating phases that are part of development.

What is picky eating?

Internationally there has been little consensus around what constitutes picky eating. This creates difficulties for both parents and medical professionals. With no firm definition of picky eating how do we know when the fabled phase is actually a problem?

Also, if there is no firm definition how can researchers report on it accurately? What, for example, should and shouldn’t be included as the traits of a picky eater?

Moreover, how can researchers or medical personnel compare studies if there is no consensus?

ARFID

ARFID, Avoidant Restrictive Food Intake Disorder, was added to the DSM-5 (The Diagnostic and Statistical Manual of Mental Disorders) in 2013. This manual is used by many medical professionals to diagnose mental challenges, like eating disorders.

However, as ARFID is a fairly new diagnosis, there is as yet no recommended and scientifically proven path for treatment. Also, as it is classified as an eating disorder alongside anorexia nervosa or bulimia nervosa treatment has sometimes followed similar methodology.

Given the difference between ARFID and other eating disorders, this is not necessarily appropriate for children who are refusing food not due to body image but because of an overwhelming anxiety or other challenge in accepting new foods.

As there has been little alternative as a diagnosis for children who are on the extreme end of the picky eating spectrum, some have been given an ARFID diagnosis even if they are not meeting all the criteria (listed at the bottom of the page #).

Other parents have found that many health professionals are not familiar with ARFID and that again, even among those who are, there is often little consensus as to what and who should and shouldn’t be included.

I have spoken to many parents who in reading about ARFID, are worried that their child has this.

However, there is now a new diagnosis that has been released by the ICD which seems a better fit for many of the families I have spoken to.

ICD

The ICD, International Classification of Diseases is the globally utilized diagnostic tool for epidemiology, health and clinical management for the World Health Organisation (WHO). The WHO operates within the United Nations system.

PFD

Pediatric Feeding Disorder – PFD – is a new classification for diagnosing feeding difficulties for children 0-17 years old. It is one that I feel is probably a better fit for many of the families I have worked with.

It is effective as of Oct 2021 and so can be used for current diagnosis.

New Zealand hospitals use the ICD classification system, modified for Australian Government purposes for use in the ANZAC countries.

Criteria for PFD

– A child’s nutrition is not appropriate for their age (eg. eats baby food at 3 years old)
– Eats 15 foods or less
– Had difficulty feeding as a baby or toddler *
– Eating difficulties have been longer than 2 years **
– Shows signs (no matter how small) of difficulty with oral motor skills, sensory processing ***, or physical challenges.
* Difficulties as an infant or toddler is not required for this diagnosis but is an indicator.
** Children can still receive this diagnosis if they fit the other categories and eating problems have not persisted for more than 2 years.
***Sensory processing difficulties would apply not just to those with obvious sensory challenges, but also to a child who has a very rigid approach to certain aspects of food, like a preference for specific colours or textures for example.

Acute PFD = less than 3 months duration

Chronic PFD = more than 3 months duration

American Academy of Pediatricians on PFD

I thought this quote regarding PFD from the American Academy of Pediatricians – James A. Phalen MD, FAAP said many of the things that I have been frustrated about for years!

“Pediatricians may believe that because a child is growing well, that a child doesn’t have PFD; however, good growth does not indicate appropriate feeding. Similarly, ‘picky eating’ is often overlooked. Pediatricians must ask the right questions to detect PFD”.

YES YES YES YES YES!!!

I think this is a universal frustration from feeding advisors. That many medical professionals are looking for growth metrics to evaluate feeding challenges, rather than gaining an understanding of the full picture of a child’s eating competency.

Growing adequately, is often not a good indicator of feeding well, or feeding within normal developmental parameters.

Eating peanut butter on crackers for breakfast, lunch and dinner may enable a 10 year old to grow, but there are definitely unresolved issues if they are unable to accept new foods, share in family meals or competently eat when away from home.

Many parents share this frustration as they have frequently sought help from their doctor, for example, and had their worries invalidated as their child ticks height and weight charts.

I also love Dr Phalen’s observation that pediatricians must ask the right questions to detect PFD. Absolutely!

Where to from here?

Many parents communicate to me their frustration as they know that their child is not eating well. They know this is not a ‘phase’ and they can see challenges either not improving dramatically, or commonly even getting worse.

Finding labels for what is happening for a child doesn’t necessarily provide a magical solution, but it can empower you to communicate what their challenges are in universally understood terminology.

Will most GP’s or even pediatricians know about the new PFD criteria and diagnosis? Probably not.

But it is a great way to educate those who are caring for your child as to feeding parameters that are internationally recognised.

I know that in the US, having these diagnoses can mean funded help for your child.

I believe that as a parent, the more educated we are, the better placed we are to advocate for our child and lobby for change in a system that is currently not geared to adequately either recognise or support eating challenges.

Does your child fit the criteria for PFD?

# ARFID definition

Diagnostic Criteria for ARFID (Based on the DSM-5)

1. An eating or feeding disturbance (e.g., apparent lack of interest in eating or food; avoidance based on the sensory characteristics of food; concern about aversive consequences of eating) as manifested by persistent failure to meet appropriate nutritional and/or energy needs associated with one (or more) of the following:
Significant weight loss (or failure to achieve expected weight gain or faltering growth in children).
Significant nutritional deficiency.
Dependence on enteral feeding or oral nutritional supplements.
Marked interference with psychosocial functioning.

2. The disturbance is not better explained by lack of available food or by an associated culturally sanctioned practice.

3. The eating disturbance does not occur exclusively during the course of anorexia nervosa or bulimia nervosa, and there is no evidence of a disturbance in the way in which one’s body weight or shape is experienced [body image].

4. The eating disturbance is not attributable to a concurrent medical condition or not better explained by another mental disorder. When the eating disturbance occurs in the context of another condition or disorder, the severity of the eating disturbance exceeds that routinely associated with the condition or disorder and warrants additional clinical attention.