Determination of significant nutritional deficiency (Criterion A2) is also based on clin- ical assessment (e.g., assessment of dietary intake, physical examination, and laboratory testing), and related impact on physical health can be of a similar severity to that seen in anorexia nervosa (e.g., hypothermia, bradycardia, anemia). In severe cases, particularly in infants, malnutrition can be life threatening. "Dependence” on enteral feeding or oral nu- tritional supplements (Criterion A3) means that supplementary feeding is required to sus- tain adequate intake. Examples of individuals requiring supplementary feeding include infants with failure to thrive who require nasogastric tube feeding, children with neuro- developmental disorders who are dependent on nutritionally complete supplements, and in the absence of an underlying medical condition. Inability to participate in normal social activities, such as eating with others, or to sustain relationships as a result of the distur- bance would indicate marked interference with psychosocial functioning (Criterion A4).
food intake related to lack of availability of food or to cultural practices (e.g., religious fast- ing or normal dieting) (Criterion B), nor does it include developmentally normal behaviors (e.g., picky eating in toddlers, reduced intake in older adults). The disturbance is not better medical factors or mental disorders (Criterion D).
In some individuals, food avoidance or restriction may be based on the sensory char- acteristics of qualities of food, such as extreme sensitivity to appearance, color, smell, texture, temperature, or taste. Such behavior has been described as ”restrictive eating,” "selective eating," ”choosy eating,” ”perseverant eating, chronic food refusal,” and “food neophobia” and may manifest as refusal to eat particular brands of foods or to tol- erate the smell of food being eaten by others. Individuals with heightened sensory sensi- tivities associated with autism may show similar behaviors.
sociated with food intake following, or in anticipation of, an aversive experience, such as choking; a traumatic investigation, usually involving the gastrointestinal tract (e.g., esoph— agoscopy); or repeated vomiting. The termsfunctional dysphagia and globus hystericus have also been used for such conditions.
Several features may be associated with food avoidance or reduced food intake, including a lack of interest in eating or food, leading to weight loss or faltering growth. Very young infants may present as being too sleepy, distressed, or agitated to feed. Infants and young children may not engage with the primary caregiver during feeding or communicate hun- ger in favor of other activities. In older children and adolescents, food avoidance or restric- tion may be associated with more generalized emotional difficulties that do not meet diagnostic criteria for an anxiety, depressive, or bipolar disorder, sometimes called ”food avoidance emotional disorder.”
Food avoidance or restriction associated with insufficient intake or lack of interest in eat- ing most commonly develops in infancy or early childhood and may persist in adulthood.
Likewise, avoidance based on sensory characteristics of food tends to arise in the first de- cade of life but may persist into adulthood. Avoidance related to aversive consequences can arise at any age. The scant literature regarding long—term outcomes suggests that food avoidance or restriction based on sensory aspects is relatively stable and long-standing, but when persisting into adulthood, such avoidance / restriction can be associated with rel- atively normal functioning. There is currently insufficient evidence directly linking avoid- ant/restrictive food intake disorder and subsequent onset of an eating disorder.
Infants with avoidant/ restrictive food intake disorder may be irritable and difficult to console during feeding, or may appear apathetic and withdrawn. In some instances, par- ent-child interaction may contribute to the infant’s feeding problem (e.g., presenting food inappropriately, or interpreting the infant’s behavior as an act of aggression or rejection).