How to diagnose the child who “won’t eat”

This blog will be short as I am preparing to attend and speak at the F.E.A.S.T. conference in Texas this week.  Very exciting!

Recently I was asked to consult on a child who “won’t eat” and who hasn’t eaten for several weeks. Her situation is complicated by English not being the family’s first language and by her entrance into the medical “system” being through the emergency room, but it did remind me how complicated making the correct diagnosis can be in a child who won’t eat. This girl is 11 years old, she has always been a robust eater and a happy kid.  Early this year, she got sick with a viral infection and vomited several times.  Nearly simultaneously she started her first period and expressed severe anxiety about this to her mother.  Thereafter she refused to eat, citing fear that she would vomit again and saying her throat hurt.  The ER doctors examined her throat extensively and could find nothing.  She would accept only sips of water from them or anyone else.  Quite understandably, her parents were frantic.

So what’s the diagnosis?  Mother and ER social worker were very fixated on the appearance of this food refusal and the timing of her period.  Could she be afraid to “grow up?”

So I decided to write a few simple ways to sort out the major eating disorder diagnoses of childhood from each other, as there are a few useful sorting points.

There are basically three big diagnostic categories pertinent to this and similar presentations:

  1. Anorexia Nervosa and ARFID (treated as one for the first level of sorting, as the treatment is the same).

  2. Food Phobia

  3. Selective Eating

The initial sorting point is what we call “acuity” or speed of onset.

If the refusal to eat has been since early childhood and is actually “refusal to eat normally or in adequate amounts” the diagnosis is likely selective eating.

If the onset is abrupt in a child who formerly ate normally, the diagnosis is highly unlikely to be selective eating, so now we must sort anorexia nervosa and its relatives from food phobia.  The distinction is important as the treatment and natural history of the illnesses will be different.

If the child refuses to swallow anything solid regardless of food composition (i.e. not restricting on the basis of fat or caloric content) this is likely to be food phobia.  In food phobia the onset will be abrupt in a child who formerly ate normally.

Commonly, food phobia is preceded by either a choking episode or a viral illness involving vomiting, as in the patient above.  Older children may tell you directly that they are afraid of choking, or believe their throat to be blocked or may report being afraid they will vomit. Younger children may refuse to tell you “why” they won’t swallow.  But crucially, the onset will be abrupt, and this is an important sorting point.

If only young children with anorexia nervosa (AN) always told you that they were afraid to get fat, or were afraid they were already fat, the diagnosis of AN would be easy.  But famously, children do not behave as miniature adults, and the world of pediatric eating disorders is not unlike the world of other pediatric illnesses in this regard. “Non-fat/weight phobic” childhood AN has finally been reflected in the DSM 5, which makes diagnosis more complicated even while it is a better reflection of reality.

However, for initially distinguishing AN (and ARFID) from food phobia, the reported speed of onset of symptoms will be critical.  AN has a more insidious onset.  Children with AN may report “stomach ache” or “too full”, but not fear of choking.  They will eat and drink, just highly edited foods or highly edited amounts.  A child who expresses no overt fear of fat, but who has gradually cut back on the amounts of food eaten and/or avoids sweets and fats, is likely to have anorexia nervosa. Of course, in medicine, as the Germans say: “es gibt nichts was es nicht gibt” (roughly, “anything is possible”), but these basic sorting points should help guide parents and practitioners through any diagnostic dilemma in their quest to decide what to do next.