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Every day, thousands of well-meaning parents of children with ARFID open a bottle of children’s multivitamins, shake one out, and feel — just for a moment — like they’ve done something right. And they have. The intention is everything. But intention and sufficiency are two very different things.

When your child eats the way children with ARFID eat, the gap between those two words — intention and sufficiency — can quietly become the gap between a child who thrives and one who struggles in ways nobody has yet connected to nutrition. The truth is, a clinical nutrition plan isn’t a luxury for these kids. It is the difference between supplementing and actually protecting them — from well-hidden deficiencies that erode development and daily functioning, from toxicities that build invisibly and create damage, and from nutritional needs so specific that no label on any pharmacy shelf was ever designed to meet them.

Why ARFID in Autism Is a Distinct Nutrition Category

There is a word that well-meaning people use for children with ARFID, and it is the wrong word. That word is “fussy.” Fussy implies choice. It implies a phase, a preference, a habit that can be reasoned with or outgrown. For children with Avoidant/Restrictive Food Intake Disorder (ARFID) — particularly those who are also autistic — food refusal is not a choice any more than a fear of heights is a choice. It is a neurological experience, driven by sensory processing differences, anxiety, an intense need for predictability, and in many cases a history of genuinely distressing encounters with food that the nervous system has quietly logged and refuses to forget.

What this means practically is that the diet of a child with ARFID and autism is often not just narrow — it is architecturally narrow. The same five, eight, or twelve foods. The same brands, the same textures, the same presentation. Any deviation — a reformulated recipe, a slightly different colour, a new batch that smells different — can render a previously safe food completely inaccessible. This is not stubbornness. It is a nervous system doing exactly what it was designed to do: protect the child from what it has learned to perceive as threat.

From a nutrition standpoint, this poses a huge challenge that is unlike anything seen in typical development. When a child’s diet consists of a few beige carbohydrates, a small number of processed foods, and perhaps one or two protein sources, the nutrition gaps are not theoretical. They are structural. They are baked into the diet by the nature of the disorder itself. And they cannot be solved by simply “adding variety” — the standard advice that parents of these children have heard, and been failed by, more times than they can count.

What makes the autism piece particularly significant is that autistic children are not only more likely to have ARFID — they are also more likely to have gastrointestinal differences, atypical metabolic patterns, many genetic variants that affect how certain nutrients are processed, and medication regimens that interact with nutritional status in ways that are rarely discussed at the GP or paediatrician level. This is not a population for whom standard supplementation advice was designed. It is a population for whom standard supplementation advice can, and does, fall short in ways with real developmental consequences; and a very significantly elevated risk of future chronic health problems.

The Deficiency Side — What’s Missing and Why It Matters

”Normal doesn’t always mean enough.”

One of the most important things to understand about nutrition deficiency in children with ARFID is that it rarely looks dramatic — at least not at first. There is no single moment where a parent notices something obviously wrong and connects it to nutrition. Instead, deficiency tends to work slowly, quietly, and cumulatively. A child who is a little more tired than they should be. A little more irritable. A bit more distractible. Growing, but not quite thriving. Concentrating, but with more effort than seems right. These are not the signs of a medical emergency. They are the signs of a child whose developing brain and body are running on insufficient fuel — and they are easily missed, easily attributed to autism, easily attributed to bad sleep or a difficult week.

Every week, I share clinical insights, practical supplement guidance, and the research that parents of children with ARFID and autism rarely get told — written in plain language, with no generic advice. If this article resonated with you, your inbox is the best place to continue the conversation.

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The nutrients most commonly deficient in children with ARFID and autism are not random. They follow directly from the foods these children typically avoid.

IRON

Iron is one of the most clinically significant. Children with ARFID frequently avoid red meat, legumes, and dark leafy vegetables — the primary dietary sources of iron. The consequence is that iron deficiency is common in this population, and its effects on a developing child include: impaired cognitive function, reduced attention and concentration, fatigue, weakened immunity, and in severe cases, disruption to the myelination process that underpins neurological development itself.

What parents are rarely told is that the standard blood test — haemoglobin — is a late-stage marker. A child’s ferritin, which reflects stored iron, can be critically low long before haemoglobin drops. A child can be told their iron is “fine” while their ferritin tells a completely different story.

ZINC

Zinc is another nutrient that deserves far more attention than it typically receives in this population. Zinc is involved in immune function, wound healing, growth, and — critically for this group — sensory processing and appetite regulation. Chronically low zinc is associated with altered taste perception and reduced appetite, which can create a self-perpetuating cycle in children with ARFID: the restricted diet causes zinc deficiency, and the zinc deficiency makes the sensory experience of food even more aversive and appetite even more blunted. Identifying and addressing zinc deficiency is not just a nutrition intervention — it can be a meaningful part of the broader feeding support picture.

VITAMIN D

Vitamin D deficiency is almost universal in children with significantly restricted diets, and its consequences extend far beyond bone health. Vitamin D plays a critical role in immune regulation, mood, sleep, and neurodevelopment. In autistic children specifically, low vitamin D has been associated with increased severity of certain behavioural and developmental symptoms, though the relationship is complex and still being researched. What is clear is that the doses required to meaningfully correct deficiency in a child who has been low for an extended period are almost always higher than what any standard children’s multivitamin provides — and that supplementing without knowing the child’s baseline level risks either under-correcting or, in the case of the fat-soluble vitamins, over-correcting.

CALCIUM

Calcium is a particular concern in children whose safe food list excludes or limits dairy — a common scenario in ARFID, where the texture and temperature of milk and dairy products are frequently reported as intolerable. Without dairy, calcium intake can fall dramatically below the levels needed for healthy bone density at a time in development when that density is being laid down for life. Calcium also plays a role in nerve transmission and muscle function, and chronic inadequacy has long-term implications that extend well beyond childhood.

VITAMIN B12 and FOLATE

Vitamin B12 and folate are most at risk in children who avoid animal products and dark green leafy vegetables — and in ARFID, the avoidance of healthy sources of animal products and dark green leafy vegetables (and legumes) is not uncommon. B12 deficiency affects neurological function, mood, energy, and the production of red blood cells. Folate is critical for DNA synthesis and cell division, making it particularly important during periods of rapid growth. What many parents don’t know is that the synthetic form of folate found in most supplements — folic acid — cannot be efficiently used by a significant subset of children, particularly those with a common genetic variant called MTHFR, which is found at higher rates in autistic individuals. For these children, the supplement they are taking may be providing virtually no usable folate at all.

VITAMIN B6

Vitamin B6 is a nutrient that sits at an interesting and important intersection in this population. B6 is involved in more than 100 enzymatic reactions in the body, including the synthesis of neurotransmitters — serotonin, dopamine, GABA — that are central to mood regulation, anxiety, and sleep. It also plays a key role in immune function and protein metabolism. Children with ARFID who avoid meat, fish, and legumes are at meaningful risk of inadequate B6 intake. In autistic children, there has been longstanding clinical and research interest in B6 supplementation as a potential support for neurological function, and some children in this population are supplemented with B6 — sometimes at significant doses — by parents who have read about it online or been advised informally. The deficiency risk is real and worth addressing. But B6 is also one of the few water-soluble vitamins capable of causing toxicity at doses that are not dramatically above standard supplementation levels, which makes it a nutrient that requires particular clinical attention. This will be explored further in the next section.

OMEGA-3

Omega-3 fatty acids — specifically EPA and DHA — are foundational to brain development, neurological function, and the regulation of inflammation. They are found almost exclusively in oily fish and, in smaller amounts, in eggs and walnuts. In a population that frequently avoids all of these foods, omega-3 status is often significantly compromised. The research on omega-3 supplementation in autistic children is among the more robust in this space, with evidence pointing to benefits for attention, behaviour, and mood — yet it remains one of the most under-addressed deficiencies in clinical practice, partly because it doesn’t show up on standard blood panels.

IODINE

Iodine is perhaps the most overlooked nutrient in paediatric nutrition discussions, and that oversight has real consequences. Iodine is essential for thyroid function, which in turn regulates metabolism, energy, and — critically — cognitive development and brain maturation. Children who avoid dairy and seafood, as many children with ARFID do, have very limited dietary sources of iodine. Unlike many other nutrients, iodine is not routinely tested, not routinely supplemented, and not routinely discussed, despite its outsized role in neurological development during childhood.

The thread connecting all of these deficiencies is the same: they are predictable, they are addressable, and they are invisible without deliberate clinical assessment. A child can be growing adequately, attending school, and functioning in daily life while quietly running low on several of these nutrients simultaneously. And the cumulative effect of multiple subclinical deficiencies on a developing brain and nervous system is not something any standard multivitamin was designed to address.

The Toxicity Side — The Risk Nobody Talks About

”When the supplement and the safe food are both doing the same job.”

Parents of children with ARFID are, as a group, extraordinarily devoted to their children’s health. They research. They advocate. They try things. And in the absence of clear clinical guidance, many of them end up supplementing their children with multiple products — a multivitamin here, an extra vitamin D there, a basic omega-3, a B-complex, something they read about in a Facebook group, something a well-meaning relative recommended. The intention behind all of it is love. The result can sometimes be a nutrient load that significantly exceeds what a child’s body can safely handle.

This is not a common conversation in paediatric nutrition, but it should be. The risks of under-supplementing are well understood and widely communicated. The risks of over-supplementing are not — and in a population where parents are frequently navigating a complex landscape of supplements, fortified foods, and informal advice without clinical support, the risks are real.

FAT SOLUBLE VITAMINS

Fat-soluble vitamins — A, D, E, and K — are the most important to understand in this context, because unlike water-soluble vitamins, they are stored in the body’s fat tissue and liver rather than excreted. This means they accumulate over time.

A child who is taking a daily multivitamin containing vitamin A, eating a safe food that is fortified with vitamin A, and taking an additional supplement that also contains it, may be receiving a cumulative dose that exceeds safe upper limits — not dramatically, not visibly, but consistently. Over weeks and months, that accumulation has consequences. Chronic vitamin A excess can cause headaches, liver damage, bone pain, and in children, premature closure of the growth plates.

Vitamin D toxicity, while less common, causes elevated calcium in the blood, which presents as nausea, weakness, and in serious cases, kidney damage. These are not theoretical risks. They are the predictable outcome of supplementing without accounting for total nutrient load across all sources.

VITAMIN B6

Vitamin B6 deserves particular attention here because it occupies an unusual position among vitamins: it is water-soluble, which most people assume makes it inherently safe in higher doses, yet it is one of the only water-soluble vitamins with a well-documented toxicity syndrome.

High-dose B6 supplementation — and “high dose” in this context can mean doses that are not dramatically above what some over-the-counter supplements provide — has been associated with peripheral neuropathy: tingling, numbness, pain, and sensory disturbance in the hands and feet. In children, this is particularly concerning because the symptoms can be subtle, can be attributed to other causes, and can persist even after supplementation is reduced.

B6 is a nutrient where clinical oversight is not optional. The therapeutic window — the range between adequate and potentially harmful — is narrower than most parents or even many general practitioners appreciate. When a child with ARFID and autism is being supplemented with B6, whether for its potential neurological benefits or to address dietary inadequacy, the dose needs to be determined by someone who understands both the child’s dietary baseline and the relevant upper limits — not sourced from an online forum or a general wellness supplement.

IRON

Iron is another nutrient where the risk of excess is clinically significant. Iron supplementation is often initiated by parents who are concerned — rightly — about the dietary iron intake of a child with ARFID. But iron supplementation without confirmed deficiency, or at doses higher than required to correct a confirmed deficiency, carries real risk.

Iron is pro-oxidant at high levels, and chronic excess can cause gastrointestinal damage, liver stress, and — in children with certain genetic predispositions — more serious iron storage conditions. The appropriate response to suspected iron deficiency is testing, followed by a clinically guided supplementation plan, not a precautionary high dose of iron, “just in case.”

ZINC

Zinc presents its own toxicity paradox. Zinc deficiency is common in this population and worth addressing, but excess zinc supplementation interferes with the absorption of copper — a mineral that plays its own critical role in neurological development and immune function. A child who is supplemented with zinc at doses beyond what their deficiency requires may end up copper-deficient as a consequence, trading one problem for another. This kind of nutrient interaction is exactly the type of consideration that falls outside the scope of a general multivitamin label and squarely within the scope of a clinical nutrition plan.

FOOD FORTIFICATION

The fortification problem is something that deserves its own conversation, because it catches many families completely off guard. Children with ARFID often have safe food lists dominated by processed and packaged foods — certain cereals, crackers, bread products, flavoured milk alternatives — many of which are heavily fortified with vitamins and minerals. This means that a child’s baseline nutrient intake from food, even from a highly restricted diet, may already be elevated for certain nutrients before any supplement is added. When a supplement is then layered on top, the combined load can exceed safe thresholds for nutrients like vitamin A, folic acid, and iron. A clinical nutrition assessment maps the entire picture — food sources and supplements together — rather than considering each in isolation.

The Special Needs — What’s Unique About This Population

“It’s not just what they need — it’s whether they can actually absorb and use it.”

Understanding what nutrients a child with ARFID is missing is only the first layer of clinical assessment. The second — and often more nuanced — layer is understanding whether the supplements designed to address those gaps are actually doing the job. In children with autism and ARFID, the answer is not always yes, for reasons that go beyond diet and into biology, genetics, and physiology.

Nutrient form is a clinical decision, not a labelling detail.

Most parents choose supplements based on what the label says they contain, without any reason to know that the form of a nutrient matters as much as the dose. But it does. Folate is a clear example: synthetic folic acid, found in the vast majority of supplements and fortified foods, must be converted by the body into its active form before it can be used. A significant proportion of the population — estimated at between 40 and 60 percent — carries variants of the MTHFR gene that reduce this conversion efficiency. Among autistic children, the prevalence of MTHFR variants appears to be higher. For these children, a supplement containing folic acid may be providing a fraction of the folate the label suggests, while methylfolate — the bioavailable, active form — would be absorbed and used directly.

Similarly, iron supplements vary significantly in their tolerability and absorption: ferrous sulphate is the most commonly prescribed form but is also the most likely to cause gastrointestinal side effects, which in a child with sensory sensitivities can make compliance virtually impossible. Ferrous bisglycinate offers comparable absorption with considerably better tolerability.

Magnesium glycinate is absorbed and tolerated far better than magnesium oxide — the cheap form found in many multivitamins. These distinctions are not minor. They determine whether a supplement actually works for the individual child, or simply passes through.

Gastrointestinal differences are common and clinically relevant.

Research consistently finds higher rates of gastrointestinal issues in autistic children — including altered gut motility, differences in microbiome composition, and increased intestinal permeability. Each of these can affect the availability and absorption of nutrients and crucial metabolites, regardless of how much is consumed or supplemented.

A child with chronic constipation may absorb nutrients differently from a child with loose stools. A child whose gut microbiome is significantly altered — which is almost universally true for children with almost nil variety of fresh plant foods in their diet — may have compromised absorption of certain nutrients. A clinical nutrition plan considers these factors as part of the total picture, because supplementing adequately on paper does not guarantee adequacy in the body.

Medication interactions are rarely discussed but frequently relevant.

Many children with autism and ARFID are prescribed medications — stimulants for ADHD, SSRIs or SNRIs for anxiety, antiepileptic medications for seizures, or melatonin for sleep. Each of these has known nutritional interactions. Stimulant medications are associated with reduced appetite, which compounds dietary restriction in ARFID, and have also been linked to reduced zinc and magnesium levels. Long-term use of certain antiepileptic medications is associated with depletion of vitamin D, folate, and B12. SSRIs interact with B6 and B12 metabolism.

These interactions do not appear on medication labels. And, they are rarely mentioned at prescription time. But they are clinically meaningful, and a nutrition plan that doesn’t account for a child’s medication profile is an incomplete one.

Supplement delivery is a sensory and practical challenge in its own right.

For a child whose entire relationship with food is governed by texture, taste, smell, and appearance, the idea of swallowing a tablet, tolerating a liquid with a particular aftertaste, or accepting a gummy in an unfamiliar flavour is not a minor inconvenience — it can be a genuine barrier to the entire supplementation plan.

A clinical assessment considers not just what a child needs but what forms they can realistically tolerate, day after day. Powders that dissolve into an existing safe drink, flavourless liquids, specific gummy formulations with tolerable textures, or microencapsulated forms that can be mixed into food without detection — these are clinical decisions as much as practical ones, and getting them right is the difference between a plan that works and a plan that sits unused on the shelf.

Nutritional needs are not static; they constantly change.

A plan built for a six-year-old is not the right plan for an eight-year-old; it might not even be the right plan for the same six-year-old just three months later when they reject a safe food, or when they obsessively become dependent on a previous food/drink, or if chronic constipation worsens, or if they are experiencing flares or rapid deconditioning. Growth spurts, periods of heightened anxiety, medication changes, new illnesses, puberty, or fluctuating gastrointestinal conditions all shift nutrition status and requirements.

A clinical nutrition plan for a child with ARFID is a living document, reviewed and adjusted at regular intervals, not a one-time prescription that runs indefinitely without reassessment.

What a Clinical Nutrition Plan Actually Looks Like

“What ‘individualised’ actually means in practice”

The phrase “individualised plan” appears frequently in healthcare and has been used so often that it risks losing its meaning. In the context of a paediatric dietitian working with a child with ARFID and autism, individualised is not a marketing word. It describes a genuinely specific, evidence-informed, child-centred process — one that looks quite different from a GP appointment where supplements are discussed briefly, or a health food store recommendation based on a parent’s description of their child’s diet.

A comprehensive clinical nutrition assessment for a child in this population typically begins with a detailed dietary analysis. This baseline picture tells the dietitian exactly what the child is already receiving nutritionally — from food — before any supplement is considered. It identifies the gaps, but it also identifies areas where intake may already be adequate, elevated – or excessively high – which is equally important.

Growth data forms a critical part of the assessment. Height, weight, and growth trajectory over time tell a story that a single snapshot cannot. A child who is growing along the 50th centile is nutritionally different from a child who has dropped two centile lines over eighteen months, even if their current measurements look similar. Even when BMI appears healthy, midparental height calculations may reveal stunting in height growth, which is correlated strongly with additional levels of impairment to cognitive development. However, weight and height growth indicators only play a small overall part in assessing nutrition status.

Advanced blood and urine (pathology) investigations are recommended rather than routine panels. A full blood count and iron studies — including ferritin — provide the iron picture. Serum 25-hydroxyvitamin D gives the vitamin D status. Zinc, B12, folate, and iodine can be assessed through blood or urine, depending on the marker and the clinical question. The selection of investigations is guided by dietary analysis, long-term patterns in food choices, clinical presentation, a few standard panels, and a few other targeted ‘no brainers’ (such as always testing for B6 toxicity, as it appears to be far more common in autism). If the child’s diet is heavy in fortified cereals, vitamin A and folic acid load become relevant considerations.

This targeted approach to pathology testing means the child is not subjected to unnecessary testing, and the results inform a plan that addresses actual, confirmed gaps rather than assumed ones. However, a word of caution. There can be substantial differences between blood levels (which look normal) and tissue levels (which may be abnormal) of specific nutrients and other analytes/markers. Nutrition pathology results ideally need interpretation by an experienced clinician with advanced nutrition biochemistry and pathology analysis skills. Unfortunately, this appears to remain an uncommon skillset amongst general practitioners, paediatricians and dietitians. Therefore, I frequently find that nutrition pathology results are often interpreted in very basic ways that underappreciate the enormous complexity of nutrition biochemistry.

The nutrition supplement plan – or the detailed ‘nutrition prescription’ – that emerges from this process is specific in every dimension: nutrient, form, dose, timing, and delivery method. It accounts for the child’s dietary baseline, their pathology, their medications, their gastrointestinal health, clinical presentation, sensory profile, rigid preferences, anxiety and demand avoidance traits. It is shared with the child’s broader clinical team — paediatrician, GP, occupational therapist, psychologist — so that everyone involved in the child’s care has a consistent, coordinated picture of their nutrition management plan.

Review appointments are built into the plan from the outset, because the goal is not to write a plan and discharge the family — it is to monitor, adjust, and respond as the child grows and changes. Retesting at appropriate intervals confirms that supplementation is achieving its intended effect, and that no new gaps or excesses have emerged. This ongoing relationship between the family and their dietitian is, in many ways, as important as the plan itself.

A final word

It is likely that only one per cent of children (1 in 100) with severe ARFID and autism have an evidence-based, individualised clinical nutrition plan in place. If your child has ARFID — especially alongside an autism diagnosis — they need a plan that accounts for who they are, how they eat, what they absorb, and what they need to grow, develop, and feel well. That’s not an impossible standard. It’s just a clinical one.

And it begins not with a multivitamin shaken out of a bottle, but with a detailed assessment of your child’s whole picture and the creation of something designed specifically for them.

You have already done the hardest part — recognising that your child’s needs are specific, and looking for information that meets them at that level. That instinct is right. Keep following it.

Every week, I share clinical insights, practical supplement guidance, and the research that parents of children with ARFID and autism rarely get told — written in plain language, with no generic advice. If this article resonated with you, your inbox is the best place to continue the conversation.

Subscribe now

Through this community, you will have opportunities to participate in Learning Labs. But what are they? Here is a little explainer to get you started.

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Learning Labs. Not a typical webinar, not a consult. What are they?

Learning Labs are webinar-based, group telehealth, problem-solving workshops, designed for parents of children living with ARFID in Autism and complex neuropsychiatric disorders.

Learning Labs transform public access to the very best medical and healthcare specialists, anywhere in the world, at much lower cost. While I have created the Learning Lab methodology and approach for my area of expertise, they can be applied to any very specialist area in medicine.

I hope they become a common feature in the future of medicine. For now, you get to access them here.

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Learning Labs: Transform Your Access to Specialists

I know how difficult it can be to access a doctor or dietitian in paediatrics who truly has specialist expertise in severe ARFID with Autism or complex neuropsychiatric disorders. It is exactly why I have designed the Learning Lab model.

Specialists are limited in number (there are very few of them in any given specialty), they are usually limited by one-on-one consults, and are often booked out many months (or years ahead). Other problems include competence and compassion; not all specialists are great at what they do. And some people have extremely specialist knowledge within a very specific niche (like very severe presentations of ARFID-ASD). Naturally, this severely limits access for parents who are in dire need of highly specialised advice.

Location is also often a big barrier to families who need to travel across large cities, or from rural and regional areas, with one or more disabled children in tow.

Often, parents are left to access local, junior, and generalist clinicians who simply cannot help with some of the more complex problems affecting their child. In children with severe ARFID and Autism or complex neuropsychiatric disorders, this is an enormous, widespread problem amongst families.

This lack of access to specialist expertise is a major obstacle for parents worldwide, even in some of the best healthcare systems, including those in Australia, the USA, Canada, the UK, and across Europe.

Learning Labs are designed to give you better access to a specialist clinician, at the top of their field, usually in a niche. They bring a wealth of lived experience via working with hundreds or thousands of other families with the same problems.

Accessing these specialist clinicians can also be very expensive and unaffordable for the average family. Learning Labs completely change this dynamic of access and affordability.

But how do we move from one-on-one consults with a specialist to meaningful, larger-scale, group telehealth problem-solving workshops on webinar technology? This is not a natural skill for most clinicians as it requires skilful group facilitation, well-designed clinical problem-solving methodology, and suitable technology (the easy part).

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Learning Labs: Not Webinar Lectures

Learning Labs are are not like a traditional webinar lecture, where you typically join a webinar platform, watch slides, listen to an expert, and finish with a brief Q&A.

I find the common form of a webinar lecture is useful for some types of learning, but not for parents who are solving difficult problems with unfamiliar clinical tools and strategies that need to be explained, understood, adapted and then applied in a real-world context at home with a complex child that has their own unique mix of sensory sensitivities, Autistic rigidities and about a hundred other developmental traits, behaviours and daily routines that need to be considered.. phew.

To get into the nitty-gritty of problem-solving, parents need something different.

Instead of webinar lectures, Learning Labs provide parents with a collaborative problem-solving space, guided by skilful group facilitation and supported by the presence of a leading specialist in their field of clinical practice.

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Learning Labs are a very different, innovative way to gather around solving more difficult issues impacting children and teens with complex needs.

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Interactive, Group-Based Problem Solving

Learning Labs are highly interactive. They are facilitated in real time, focused on solving specific problems step-by-step, with opportunities to iterate and refine your personalised solutions through live group coaching and immediate feedback from a very experienced clinician with specialist knowledge. Learning Labs are carefully designed, ‘real-time working sessions’ to deliver practical strategies you can implement at home.

How else can we understand these Learning Labs?

Learning Labs are virtual spaces for rapidly learning how to create something new. As in any kind of design laboratory, there are often specific problem-solving (or solution-design) methods that can be learnt and applied in iterative rounds of experimentation until we obtain a useful result. Labs involve real work (they are not lecture theatres), and the process of tackling difficult problems in a laboratory usually benefits from collaboration as a group, rather than working alone.

In my view, Learning Labs need to be part of the future landscape for healthcare systems around the world. In a future of easy access to medical AI models, I anticipate (hope) that Learning Labs will almost certainly be a feature that defines the future of healthcare, providing millions with scalable access to the very best clinical specialists in the world.

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Learning Labs for ARFID-ASD

I offer parents around the world access to a range of Learning Labs for solving specific problems in ARFID-ASD, with nutrition-focused solutions. One of these Learning Labs focuses on assisting parents to incorporate essential micronutrients (vitamins, minerals, and trace elements) into the daily routine of children with ARFID-ASD.

Over the years in my clinical practice, I have discovered that there are specialist nutrition products, precision dosing strategies, mixing methods, and other approaches that help us get these essential nutrients into the vast majority of kids with ARFID-ASD. However, the application of these is different from child to child in my clinic; there is nothing in ARFID-ASD that is a ‘one size fits all’ approach! Therefore, I have designed a Learning Lab that enables parents to create very specific solutions that are adapted for their child at home.

I also facilitate Learning Labs to address other tough issues I frequently encounter with families in The ARFID Clinic who need advanced medical nutrition therapy for severe and complex problems. For example:

1. Managing chronic vitamin and mineral deficiencies, safely & effectively

2. Extremely limited intake, malnutrition and chronically poor growth

3. Low thirst and living with chronic dehydration

4. Chronic constipation, diarrhoea or discoloured stools

5. Managing nutrient requirements during regressions & flares

6. Nutrition psychiatry for ADHD and Anxiety

7. Nutrition therapy for profound fatigue, deconditioning, withdrawal and increasing immobility

8. Tube feeding: considering and planning for gastrostomy (PEG) feeding

9. Tube feeding: transitioning to whole-food puree diets

10. Managing PANS/PANDAS in kids with ASD-ARFID

To get early registration access to these Learning Labs whenever they are advertised (they fill up fast), make sure you are an email subscriber to the Nutrition Rescue newsletter.

Photo by Brett Jordan on Unsplash

I am on a mission with this newsletter.

For a start, I hope the All About ARFID newsletter helps set the record straight. First, ARFID in complex Autism (ARFID-ASD, as I like to call it for brevity) is not quite the same as ARFID (as a single diagnosis). Second, we cannot leave nutrition deficiencies untreated without significant consequences. This lack of understanding remains as an all-too-common barrier to treatment.

How do I know?

Regardless of age, or treating doctor, no child who arrives at my clinic is getting the minimum essential nutrients they need for brain development, growth, and long-term health. Not one, single child. The treatment gap is staggering.

Instead, these children are often living on only 5-10 ultra-processed foods in their diet – without any vegetables, legumes, fruits, seeds and nuts - and without any suitable supplemental nutrition products. They are profoundly deficient.

Or, they are dependent on a few foods and a single nutrition product (such as Up&Go drinks), which is unsuitable and leaves many hidden nutrient deficiencies running wild; impairing brain development and function. Overuse (excessively high dependence) on nutrition products like these may also a cause of micronutrient toxicity disorders, an increasingly frequent problem with damaging consequences.

Or, parents have been told to continue food exposure therapy at home each night (“why don’t you taste this vegetable today”). Or, they have been told to try ARFID-CBT (cognitive behavioural therapy), or ARFID hypnotherapy, or SOS feeding therapy. Over three decades, I am yet to see any of these strategies work in my clientele of children with severe ARFID-ASD. Again, ARFID is not ARFID-ASD.

ARFID-ASD is also not ‘picky eating.’ Families are regularly advised by their doctor that their child will eventually grow out of ‘picky eating’, and there is nothing to worry about because they are ‘growing.’ This advice remains the prevailing norm; I hear it over and over again from families reaching out to me every week. But, ARFID-ASD is not picky eating.

And, in all of my experience, kids usually won’t simply “grow out of” ARFID-ASD (restrictive feeding) before they reach early adulthood.

And, finally, kids won’t simply “be ok” from chronic deficiencies of essential nutrients. There are substantial lifelong consequences from ignoring nutrient deficiencies that are silently impairing development and crucial physiological functions (deficiencies in essential nutrients cannot wait for 2, 5, 10, 15 or 20 years; they need treatment now). Every biochemical pathway in the human body depends on vitamins, minerals, trace elements and amino acids. As I say to parents and doctors, anything else is ignorant, wishful and magical thinking.

Yet, it really doesn’t need to be like this for many of these children and families.

Despite their severe sensory sensitivities, very rigid food preferences, and other challenging traits, I know (from decades of experience) that there are often things we can do to improve these kids’ nutrition, which will improve their daily functioning and health outcomes, both in the short term and over the long term. It surprises parents (and doctors), but much is often possible.

Therefore, I want this newsletter to provide parents (and clinicians) with fresh insights on how to assess, understand, support, treat, evaluate, and monitor the many nutrition-related complexities associated with ARFID-ASD.

The newsletter will offer a blend of practical wisdom from decades of clinical experience working with parents and kids in hospitals and clinics, woven together with modern research and evidence-based protocols.

It will equip parents with tools for conversations with doctors and pharmacists.

I hope it will also help grandparents, uncles and aunties, and educators at kindergartens and schools to much better understand the nature of ARFID-ASD.

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What else to expect from the newsletter?

Hopefully, a little flair – peppered with colour, imagery and art - and lots of variety. I want this to be a little bit more than just technically useful. Maybe it will provide a moment of inspiration and restoration, while digesting an array of challenging topics on nutrition and medicine, in the midst of your busy life!

I am also going to have a little bit of fun with different forms of writing…

The forms of writing will be mixed, mostly brief (I know you are busy), with short educational articles.

However, over time, the newsletter will also be threaded with longer patient-focused stories about navigating more complex problems that dominate the lives of so many kids in my clinic. ARFID-ASD gets complicated when kids have multiple other diagnoses (the super clusters).

Occasionally, I will include longer-form journalistic essays and perhaps an attempt visual storytelling essays.

Along the way, please tell me what forms of writing you like, and I will adapt as we go.

This year, I will also endeavour to deliver the newsletter in an audio, podcast-style version for easy listening while on the go. If you are like me, a podcast while running about in the car is a great way to soak up some extra learning.

Photo by Etienne Girardet on Unsplash

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A quick hello from me

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First, what are my qualifications?

I am a registered Consultant Paediatric Dietitian (in Australia, we call this an Accredited Practicing Dietitian, or APD) and a clinical biochemist.

My degrees include a Bachelor of Medical Science from the Australian National University (ANU), and a Master’s Degree in Nutrition & Dietetics from the University of Sydney (USyd).

Throughout my career, I have also completed extensive training with some of the world’s best in multi-stakeholder facilitation, high-stakes group dialogue, the art of hosting and gathering, group coaching, and conflict resolution, through programs held at MIT, Harvard University, and elsewhere in the USA, Europe, Australia, Southeast Asia, and South America.

I have read hundreds of books related to groups and group facilitation and - perhaps most crucially - have trained alongside some of the best group facilitators, coaches and mentors in the world. As they say, it is in the trenches where the real learning happens and the most transformative development occurs.

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My career, so far…

I have more than 30 years of experience. I started my career in paediatrics by working in large children’s hospitals – mostly in eating and feeding disorders, neurology, genetic and metabolic disorders.

My work in children’s hospitals was followed by an extensive period as a consultant, working across many wealthy and low-income countries, primarily addressing broken healthcare systems, chronic malnutrition, and diseases related to food and water insecurity, conflict and displacement. These issues are often set amongst complex forces of politics, money and cultural divisiveness. They are issues that I still feel strongly about today.

Over the most recent decade, as founder of The ARFID Clinic, I have been supporting some of the most severely disabled children with ARFID-ASD and complex neurodevelopmental disorders, all over Australia.

I also have a deep passion for the art of hosting meaningful gatherings across many types of very challenging contexts, which has involved working with people from dozens of cultures, countries and communities over the last few decades. It is also integral to my clinical work in facilitating a global network of Learning Labs, where complex specialist care is required in paediatrics, but often hard to access and unaffordable for many; more on that topic in other future posts.

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Who do I work with in my clinic?

I work with parents of children who regularly eat fewer than ten foods. Nearly all the kids in my clinic never eat any fresh vegetables, legumes, fruits, seeds or nuts; they have nil, or almost nil, fresh plant foods in their diet. In fact, most also never eat fresh meat. They only eat processed meats, or none at all.

Their foods are almost always limited to a small range of ultra-processed foods (UPFs) that are high in calories and devoid of many essential vitamins, minerals, trace elements, prebiotic fibres, phytonutrients, and omega-3 fatty acids.

Technically speaking, the kids in my clinic have high severity Avoidant/Restrictive Food Intake Disorder (ARFID) that is caused by complex Autism (ASD L3) or other complex presentations of neuropsychiatric and neuroimmune disorders. They have a high level of disability. More than half cannot attend a mainstream kindergarten or school. About 30-40percent of the ARFID-ASD kids in my clinic require tube feeding through a gastrostomy device (such as a PEG device) in their stomach wall.

What seems poorly understood by clinicians is that ARFID on its own (as a single diagnosis) is very different to ARFID-ASD, or ARFID caused by complex neuropsychiatric disorders.

ARFID-ASD has an increased complexity of internal mechanisms, which demand different approaches. For example, in my clinic, none of the kids with severe ARFID-ASD has ever responded to ARFID-CBT, or ARFID Hypnotherapy, or SOS feeding therapy or any other type of food exposure therapy, regardless of the provider they are using, anywhere around Australia.

This confusion about ARFID-ASD creates many issues for parents trying to get help from their child’s physicians and allied health team. Much more on this in future newsletter articles.

However, ARFID-ASD, is just the starting point for kids in my clinic. At least one third of the kids in my clinic also present with a longer list of rare genetic, autoimmune and inflammatory disorders; complex illnesses that don’t fit any neat framework in the world of medicine.

It is even more complex when they appear as a supercluster; what I generally refer to as experiencing four or more complex disorders all at once. Their nutrition requirements are abnormal (dozens or hundreds of genetic variations that affect biochemistry pathways), highly complex to assess and diagnose, and hard to resolve.

In addition to ARFID-ASD, the superclusters typically present with ADHD, OCD, anxiety, depression, hypermobile Ehlers-Danlos Syndrome (hEDS), ME/CFS (chronic fatigue), PANS/PANDAS, Mast Cell Activation Syndrome, Long COVID (PASC), and a variety of duplication and triplication genetic disorders.

Of course, just like anywhere else in the broader community, some of these kids will also present with other common conditions like Irritable Bowel Syndrome (IBS), Coeliac Disease, Crohn’s Disease, insulin resistance, allergies, intolerances and other issues.

As you can probably tell, kids with ARFID-ASD who are living with a supercluster of other conditions make treatment very challenging, as it is extremely difficult to get anything new or different into them.

Treating a child with hEDS or insulin resistance or chronic constipation, is not the same as treating children with ARFID-ASD and those very same problems. It is profoundly more difficult. They need intensive, expert, ongoing help. But this level of expertise can be extremely difficult for parents to find. I hope the Nutrition Rescue newsletter provides part of the solution.

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How do families find The ARFID Clinic and me?

Families usually find me after feeding therapy has failed (again), or parents have been told “they will grow out of it, or just keep presenting a few vegetables each night” (incredibly common advice, but seriously unhelpful), or there has been a regression in development, or health problems have worsened — constipation, anxiety, tics, stimming, dysautonomia symptoms, school refusal, fatigue, poor growth, chronic illness, aggression, suicidal ideation, or kids who simply can’t cope with daily life anymore.

Mostly, parents find me because other parents have provided a recommendation, or because they have a paediatrician somewhere in Australia who knows me well (or knows about my expertise).

Families in Australia who have NDIS budgets for a paediatric dietitian and want to make a New Patient Inquiry at my clinic, can visit here: The ARFID Clinic

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What else happens in my life?

What happens outside of The ARFID Clinic, Nutrition Rescue, and all things ARFID-ASD?

Well, my world is busy with two teenagers and family life, a prolific garden (we live in a humid climate), and a daily fitness routine— a mixture of swimming, trail running, and regular workouts that combine Animal Flow and Vipr Pro exercises (if you are curious, you can look that up!).

I love immersing myself in nature and the great outdoors. I am fortunate to be surrounded by forests, rivers, lakes, beaches and many national parks for longboard surfing, trail running and camping.

And…, I am a little bit obsessed with fine furniture making. I design and make furniture in a friend’s workshop, we occasionally mill wood together from fallen trees, and we volunteer at a community woodworking club.

I look forward to many conversations ahead with you all.

Michael

Photo by Belinda Fewings on Unsplash

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Welcome. I’m glad you’re here.

This newsletter is about toddlers, children and teens (“kids”) who have a severely avoidant/restrictive food intake disorder (ARFID) associated with Autism. For many kids in my clinic, this usually means they repeatedly eat a limited range of processed foods and have extremely rigid food preferences. Almost none eat any fresh vegetables, legumes, fruits, seeds and nuts in their daily routine - ever.

If this is your child, you are in the right place.

Most of these kids are at a satisfactory weight and height; they eat sufficient amounts of their 5-10 preferred processed foods. Only about one-third will experience chronic malnutrition and very poor growth. However, they all suffer from hidden deficiencies that silently impair physiological systems essential to daily functioning, learning, development, and health. Unfortunately, the long-term consequences are substantial and typically become increasingly obvious as they reach their teenage years and early adulthood.

This type of severely restrictive eating is not simply ‘picky eating’. And this type of eating is rarely responsive to feeding therapies. It cannot be fixed simply by exposure strategies like food chaining. I don’t think I can remember a single case in my clinic where food chaining or any other food-exposure therapy has worked. Trying to increase or expand the intake of real foods is nearly impossible.

A ‘food first’ approach doesn’t work. That’s why this newsletter is all about taking a ‘nutrition first’ approach. Severe ARFID with Autism is long journey of restrictive eating. We can’t wait 10-20 years until a child develops their capacity to get all their essential daily nutrients from a wide range of healthy foods. Instead, using evidence-based approaches, we need to get specialist nutrition products into their everyday routine. It is extremely important to get essential nutrients every day during the developmental years. Brains and bodies cannot develop or function properly without essential nutrients every day.

We need to work within (not against) their serious sensory sensitivities and profoundly rigid preferences to get these essential nutrients in each day. That is what the Nutrition Rescue approach is able to do for more than 80percent of all the kids that present to my clinic (i.e. for all those who don’t need tube feeding); and my clientele represents the most affected kids in Australia with very severe ARFID and complex Autism (what I call high severity “ARFID-ASD” – an informal term I will continue using for convenience).

How we use the Nutrition Rescue approach to get essential nutrients into these young people is what I will share in this newsletter, podcasts and Learning Labs (webinar workshops for parents).

Autism may not be a ‘disability’ for all, but for some – and certainly for all the kids in my clinic – it creates significant levels of disability that have severe impacts on daily functioning, development and health outcomes. Just ask any of the parents in my clinic. The daily impact in their lives is very high.

Thank you for reading.

Until next time,
Michael
Consultant Paediatric Dietitian

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Concept and Scope

Nutrition Rescue represents the medical–nutrition cornerstone of ARFID–ASD care. It is an intensive, evidence‑based form of medical nutrition therapy (MNT) that aims to correct entrenched nutrient deficiencies, stabilise metabolism and other biochemical abnormalities, and resolve clinical problems derived from long‑term restrictive dietary intake.

Unlike conventional feeding therapy, which primarily targets behavioural exposure to new foods, Nutrition Rescue addresses the biochemical foundation of physiological systems necessary for childhood development, daily functioning, and long-term wellness. Almost universally, I have found that feeding therapies do not expand the dietary variety of kids or teens with severe ARFID-ASD. Therefore, Nutrition Rescue becomes essential for long-term nutritional care.

The scope of Nutrition Rescue extends beyond simply replenishing vitamins and minerals. Instead, its scope encompasses nutrition-focused problem-solving for concerns that are prevalent in kids with Autism: constipation, diarrhoea, malabsorption syndromes, gastro-oesophageal reflux, fatigue, immune dysfunction, ADHD‑like hyperactivity, anxiety, depression, debilitating phases of regression, poor growth, insulin resistance and obesity.

However, highly complex presentations of ASD-ARFID may also include a cluster of other multi-system diagnoses such as: genetic duplication or deletion syndromes (e.g. Xq28), Ehlers-Danlos Syndrome (EDS), Postural Tachycardia Syndrome (POTS), Mast Cell Activation Syndrome (MCAS) and Paediatric Acute Neuropsychiatric Syndrome (PANS / PANDAS).

Using medical nutrition therapy to correct some of the underlying biochemical milieu frequently improves symptoms, creating a physiological environment in which other interventions can succeed. Nutrients are used for every biochemical pathway in the body. Without them (as per chronic malnutrition and nutrient deficiencies in ARFID-ASD), the brain and body simply cannot function fully.

A central rationale for Nutrition Rescue is also risk reduction. We want to de-risk the future for these young people living with ARFID-ASD. Diets dominated by ultra-processed foods (UPFs) expose children to chronic low-grade inflammation, oxidative stress, and disrupted gut microbiota, all of which amplify lifetime risks of metabolic disease, cardiovascular disease, and cancer. Therefore, medical nutrition therapy functions concurrently as acute repair and preventive medicine.

Operationally, Nutrition Rescue relies on a precision prescription nutrition rather than food‑based therapy. In my mind, for young people with ARFID-ASD, a “food first” approach to therapy is ineffective and irresponsible. Their bodies need nutrition now, not in 15 years’ time. Therefore, the Nutrition Rescue approach quantifies macronutrient and micronutrient requirements and matches them to medical nutrition formulas, modular powders, advanced compounding of micronutrient blends, or specialist therapeutic beverages that align with child-specific sensory barriers, rigid expectations (zero tolerance for variations from their preferences), synaesthesia, alexithymia, other interoception differences and autistic traits. Sometimes capsules, chewables and gummies are also useful, which helps to deliver some nutrients, but not all.

As much as possible, we use tasteless forms of powders, but we always need to match nutrition products to the very limited list of foods and fluids for each specific child. This usually requires an excellent knowledge of hundreds of specialist nutrition products that can sometimes be adapted for youth with extremely restrictive and rigid preferences.

Not surprisingly, many parents who first arrive at my clinic frequently believe that it won’t be possible to get nutrition products into their complex young person. However, with expert knowledge in these specialist nutrition products, mixing methods and precision dosing strategies, within a year, we find it is usually possible to improve the nutrition status for the vast majority of these kids and teens (stay tuned for an upcoming online course that will provide detailed parent training on how I do this in my clinic).

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The Phases of Nutrition Rescue

In my clinic, the Nutrition Rescue process typically incorporates 5-6 phases of work that often start in a sequential way, but then operate in parallel and iteratively.

Phase 1 – Clinical & Developmental Review

An extensive clinical and developmental review to create a deep understanding of the whole-person. This typically involves a review of medical and developmental diagnoses, psychiatry and behaviours, medications, allergies and intolerances, personal timeline from birth to present, a current multi-system clinical review, daily routines, play and physical activity, functional concerns, current and persistent issues, the effectiveness of existing and previous therapies, current clinical team involvement and types of expertise, previous investigations and unresolved matters.

Phase 2 – Clinical Nutrition Assessment

A comprehensive clinical nutrition assessment, including a full review of the developmental feeding history from birth, detailed dietary history and current dietary intake, anthropometry, gastrointestinal review, eating and feeding disorder assessments, sensory review, feeding skills, existing meal habits and environment, feeding therapy history, serum and urine biochemical analysis, gut microbiome and metabolome analysis, and other factors.

Phase 3 – Personalised Nutrition Prescription

Development of a personalised nutrition prescription with evidence‑based medical nutrition products at calculated doses. This document becomes the guiding framework for gradual implementation over the months ahead. In combination with regular appointments with parents, it is central to our success for each child.

Phase 4 – Nutrition Implementation

The nutrition prescription is introduced incrementally—starting with small accepted volumes, very specific mixing methodologies and gradually scaling up to full requirements. Often we spend a year, or thereabouts, slowly and precisely implementing the nutrition prescription, adapting as we go. This part of the process is very important because - with precision, iteration, patience and persistence - it is how we typically achieve success (whereas before, there have often been many failures for families).

Phase 5 – Continuous Clinical Monitoring

Continuous clinical monitoring, including: blood, urine, and stool analyses to evaluate response and safety, nutrition product progress, food and fluid intakes, developmental progress (e.g. speech, attendance at school, self-care, sleep, meltdowns, participation), symptomatic improvement (e.g. constipation, fatigue, pain), ongoing multi-system reviews, potential drug-nutrient interactions and more.

Phase 6 – Support Enteral Feeding

Organisation and support for enteral feeding routes is required for about 40percent of all young people in my clinic who have complex Autism with severe ARFID, and who cannot sustain sufficient oral intake for development and health. Enteral feeding for these kids typically involves PEG nutrition via a gastrostomy device that is placed in the stomach wall. PEG nutrition is most often used in conjunction with an ongoing oral intake. Crucially, it takes some of the pressure away from eating, and it means we can get essential nutrition in each day.

PEG feeding is usually quite transformational for these young people because we can generally introduce (in stages) a healthy, plant-based, whole-food diet via several puree feeds each day. Most of these children have never had any unprocessed whole foods in their diet, or not for several years or longer. Their bodies have never benefited from 5-7 colourful vegetables per day, 2-3 fresh fruits per day, nor daily amounts of legumes, seeds, nuts and meats.

Young people with PEG feeding in my clinic typically have the very best developmental and health outcomes, particularly if we can introduce healthy, whole foods into their new daily PEG feeding routine.

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The Objectives of Nutrition Rescue

In short, Nutrition Rescue aims to establish physiological improvements first, thereby enabling cognitive, emotional, and behavioural rehabilitation to follow.

The objectives of a Nutrition Rescue program are staged, yet will also often operate as multiple parallel tracks of activity (and always organised around the clinical and developmental priorities of each child, whatever order that might be):

1. Resolution of Gaps in Essential Nutrients.

   This is all about immediate correction of gaps in essential nutrients, including fluids, energy and protein, prebiotic fibres, vitamins, macro-minerals and trace elements. We are aiming for:

   • Balanced electrolytes and essential minimum amounts of daily hydrating fluids to normalise hydration for kidney and liver operations, cardiovascular and muscle performance, and brain functions (fatigue, learning ability, irritability, anxiety, poor sleep). Poor fluid intake is a common problem and it has multiple consequences for child health, development and daily functioning.

   • Adequate energy and protein for catch‑up growth or maintenance.

   • Complete coverage of essential micronutrients (vitamins, macro-minerals, trace elements) to support thousands of biochemical pathways in physiological systems all over the human body.

   • Sufficient prebiotic fibres, phytonutrients and antioxidants to restore healthy bowel functions and develop the gut microbiome, which supports: gut–brain communication, gut-immune system functioning, adaptive immune system competence (for the whole body), and insulin/glucose control.
     
     

2. Recovery of Growth and Body‑Composition. This is all about resolving significant issues such as poor growth, stunting, uncontrolled weight gain and the silent issue of diminished bone mineral density. We are aiming to:

   • Address stunting, poor weight gain and chronic malnutrition by adjusting energy intake, protein, physical activity and monitoring growth. For these children, we also usually consider advanced biochemical and endocrine assessment for unusual factors impacting hormones and energy metabolism.

   • Monitor and intervene early for excessive weight gain and poor metabolic control. In youth with severely restrictive and rigid food preferences, it is imperative to prevent excessive weight gain from developing into obesity. Excessive weight generates a downward spiral of metabolic, physical and psychiatric events that makes it very hard to resolve in children with complex Autism and severe ARFID.

   • Resolve poor development of bone mineral density and unusual fracture risk via corrections to micronutrients, malnutrition and appropriate types of physical activity (strength training). We may also consider additional biochemical, endocrine and radiology assessments. Poor bone mineral density development in childhood becomes a lifelong problem. It is a well-hidden problem that affects many, and it cannot be resolved quickly or fully. Therefore, early intervention in childhood years is crucial.
     
     

3. Stabilisation of Abnormal Biochemistry. When possible, we also want to commence correction of unusual biochemistry issues and laboratory abnormalities. This is beyond resolving basic gaps in essential micronutrients. It is about identifying and targeting more complex biochemistry issues via good knowledge of the research and through laboratory assessments -- vitamins, macro-minerals, trace elements, methylation, sulfation, malnutrition markers, glucose/insulin indices, thyroid panel, organic acid and amino acid screening (mitochondria functioning, glycolytic cycle metabolites, folate metabolism, ketone and fatty acid metabolism, neurotransmitter metabolites, glutathione system, oxalate metabolites, etc) -- until they reach preferred paediatric reference ranges.
   
   

4. Nutrition‑Focused Clinical Problem‑Solving. This objective is about employing targeted investigations and nutrient therapy to mitigate symptomatic burdens that are impairing daily functioning, comfort and daily health. The list of issues can be very extensive, particularly when ARFID-ASD is combined with other diagnoses of EDS, POTS, MCAS, PANDAS, insulin resistance, Crohn’s, Coeliac Disease, neurologic and metabolic genetic disorders.
   
   However, nutrition-focused clinical problem solving frequently addresses: chronic constipation, persistent diarrhoea, discoloured loose stools, allergies and intolerances, malabsorption, persistent fatigue, headaches, irritability, meltdowns, POTS symptoms, attention deficit and hyperactivity, anxiety, low mood, depression, sleep disruption, persistently poor development, ongoing delayed speech, cycles of severe psychiatric and behavioural regression, chronic illness and recurring infections.
   
   

5. Risk Monitoring and Toxicity Prevention. Regular surveillance of nutrient status prevents both under‑ and over‑supplementation. Particular vigilance is required for fat‑soluble vitamins, zinc/copper ratio, Vitamin B6 and iron saturation to avert iatrogenic toxicity. However, toxicities also need to be monitored due to rare genetic variations in Autism that cause unusual types of toxicities and which may occur with low micronutrient intake; these issues are often overlooked and poorly monitored in routine laboratory testing.
   
   

6. Modification of UPF‑Related Risk Factors. Progressive replacement of UPF‑derived calories with nutrient‑dense medical formulations reduces exposure to refined sugars, harmful lipids, and chemical additives. This transition is often not easy in youth who present with complex Autism and severely restrictive and rigid food intakes. However, sometimes changes are possible that improve their life-long risk profile from a diet dominated by UPFs.
   
   

7. Family and Carer Education. Throughout Nutrition Rescue, parents and other caregivers receive guidance in:

   • Precision mixing methodologies for severely restrictive and rigid feeders; this is an extensive part of the work that is done in consultations.

   • Safe dosing, combinations and storage of supplements.

   • Recognition of signs of deficiency or excess.

   • Documentation of tolerance, stool patterns, and behavioural changes.

   • Troubleshooting barriers in the home environment.

   • Low-demand food connection strategies.

   • Clinical problem solving and medical investigations.

   • Building an effective multi-disciplinary team.

   • Educating and engaging doctors in ARFID-ASD for more advanced care.

Continuous education promotes autonomy and ensures consistent implementation of complex, evidence‑based supplementation protocols across home and school settings. It also builds parent capacity to identify and engage doctors (and other clinicians) in more advanced medical care for youth living with ARFID-ASD.

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Conclusion

ARFID in Autism constitutes a complex disorder that more often impacts food variety rather than quantity of intake, where enduring sensory, cognitive and biological factors converge to restrict diet and compromise health.

Diets devoid of vegetables, legumes, fruits, nuts, seeds, and whole grains produce widespread deficits in vitamins, macro-minerals, trace elements, prebiotic fibres and other nutrients, antioxidants, omega-3 fatty acids and often fluids. These shortfalls compromise growth, immunity, cognitive function, metabolic stability, and long-term health outcomes. These restrictive diets are also usually high in ultra-processed foods (UPFs), which carry a significantly increased risk of anxiety, depression, early onset of metabolic and cardiovascular diseases, and some types of cancers.

However, despite chronic selectivity, sustained physiological recovery is often achievable when Nutrition Rescue is implemented, because it extends beyond traditional paradigms of feeding therapy to include systematic medical nutrition therapy that is designed for those with ARFID-ASD who have extremely restrictive and rigid food requirements.

Widespread screening for ARFID should become routine in children with Autism, coupled with funding frameworks for specialist feeding and medical nutrition services. Health and disability systems must prioritise early detection, biochemical monitoring, and parent education to reduce the compounding effects of undernutrition, metabolic fragility and diets high in ultra-processed foods.

Ultimately, success in ARFID–ASD should be measured not solely by dietary breadth but by sustained nutritional competence, improved development outcomes, fewer clinical problems impacting quality of life, and reduced risk of additional chronic diseases and cancers—a goal attainable through Nutrition Rescue.

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Understanding the Long-Term Picture

If your child has both ARFID (Avoidant Restrictive Food Intake Disorder) and Autism, you already know the daily challenge of navigating their rigid food preferences. What you might not fully realize is the impact that prolonged dietary restriction can have on virtually every system in their developing body. While more longitudinal research is needed to fully understand these outcomes, the evidence we do have paints a concerning picture—one that demands urgent attention and intervention.

The good news is that solutions often exist for modifying these risk factors. This article examines what happens when ARFID in Autistic children goes unaddressed, while the next blog will introduce an approach to Nutrition Rescue that I use in my clinic for children with severely restrictive and rigid food intakes.

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Recovery Rates and Realistic Expectations

Research shows that approximately 50–60% of mixed ARFID groups achieve partial improvement at 12 months, but the picture looks quite different for Autistic children. In ASD cohorts, full recovery rarely exceeds 20%, and in children with complex Autism, food variety often remains stagnant until late adolescence or adulthood.

These statistics might feel discouraging, but they underscore an important point: recovery should be defined as persistent nutritional adequacy, not necessarily full dietary normalization. Your child doesn’t need to eat everything—they need to eat their limited range of foods in combination with a variety of paediatric nutrition products that are designed for extremely restrictive and rigid eaters.

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The Nutritional Reality: What These Diets Actually Look Like

Typical ARFID-ASD diets consist of approximately 60% refined carbohydrates, less than 15% protein, and negligible fibre. In clinical practice, it is almost universal to see food repertoires of fewer than ten items—white bread, chips, cookies, crackers, pasta, processed dairy, and occasionally processed meats.

These monotonous menus of ultra-processed foods (UPFs) provide calories without nutrients, creating what researchers call a “double burden” of malnutrition and metabolic excess. These diets contain many hidden nutrient deficiencies that linger for years, impairing lifelong development and nurturing long-term serious health problems.

Without vegetables, legumes, fruits, whole grains, seeds, or nuts, multiple micronutrient categories fall below recommended daily allowances by more than 50%.

This is not just about missing one or two vitamins—it is a comprehensive nutritional deficit affecting virtually every essential nutrient your child needs. It has impacts across multiple physiological systems, often contributing to a long-term road to chronic disease and gradually reducing psychiatric functioning in adolescence and adulthood. Nutrition in the developmental years is vital for long-term health and functioning.

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The Cascade of Deficiencies

1. Water-Soluble Vitamins

The absence of fruits and vegetables creates a complete void in vitamin C intake. Case reports have documented scurvy-like lesions and anaemia in severely restricted children.

B vitamins, essential for everything from energy production to neurotransmitter synthesis, are similarly depleted. Vitamin B6 deficiency can contribute to seizures and resistance to anxiety treatments. Folate deficiency, caused by excluding greens and legumes (and fortified flour products), leads to elevated homocysteine levels and macrocytic anaemia. Each B vitamin plays a distinct role, and each is typically deficient in ARFID-ASD diets.

2. Fat-Soluble Vitamins

Vitamin D deficiency is particularly severe, affecting more than 90% of ARFID-ASD cohorts. For children who avoid fortified foods and have limited sun exposure, the vulnerability to vitamin D insufficiency is high, with serious implications for both skeletal health and mood regulation.

Vitamin A deficiency impairs vision and immune defence. Vitamin E deficiency - from lack of nuts, seeds, and vegetable oils - increases oxidative stress (with implications for every system, including the brain).

Vitamin K deficiency, resulting from green leafy vegetable exclusion, increases bruising and bone fragility. In my clinic, the rates of unusual fractures (e.g. from simple falls) appears particularly high due to poor development of bone mineral density.

3. Major Minerals and Trace Elements

Calcium levels are often borderline despite selective dairy consumption. Magnesium deficiency, common when whole grains and greens are absent, causes irritability, muscle spasms, and cardiac arrhythmias. Potassium intake frequently falls below 50% of guidelines, contributing to fatigue and constipation.

Iron deficiency, exacerbated by poor vitamin C absorption, causes ferritin depletion and cognitive impairment. Zinc deficiency creates a vicious cycle—it blunts taste and appetite, perpetuating the very selectivity that caused the deficiency in the first place.

Selenium, iodine, copper, manganese, chromium, molybdenum, boron, and fluoride are all collectively diminished, compromising enzyme systems, glucose tolerance, thyroid function, and dental integrity (to name just a few of the problems).

4. The Metabolic Bottleneck: How Deficiencies Interact

These aren’t isolated deficiencies—they create what researchers call a “metabolic bottleneck.” Combined shortfalls in B vitamins, zinc, magnesium, and iron disrupt the synthesis of crucial neurotransmitters: dopamine, serotonin, and GABA.

This biochemical insufficiency perpetuates anxiety, sleep disruption, and irritability—symptoms that are often misinterpreted as purely behavioural rather than having a nutritional component.

Meanwhile, concurrent deficiencies in vitamin D, calcium, and vitamin K accelerate bone loss. Research using dual-energy X-ray absorptiometry has documented lower bone mineral density in affected adolescents.

Zinc, selenium, and iodine deficiencies additionally impair thyroid function, slowing metabolic rate and worsening fatigue.

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Gastrointestinal Consequences

Chronic fibre and magnesium deficiency results in severe constipation, which independently predicts feeding refusal through pain-avoidance conditioning. This creates another vicious cycle: children avoid eating because it causes discomfort, but the restricted diet perpetuates the very constipation causing that discomfort.

Restoration of prebiotic fibres through gradual introduction of selective types of tasteless fibre supplements can improve appetite regulation, bowel function, and metabolic control while reducing cancer risk associated with high ultra-processed food consumption.

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Brain Development and Cognitive Function

Micronutrient-poor diets influence brain function both directly and indirectly. Low B vitamin and iron levels can decrease acetylcholine and dopamine synthesis. Magnesium deficiency heightens neural excitability, lowering seizure thresholds. Inadequate omega-3 intake compromises neuronal membrane fluidity and attention span.

Collectively, these neurochemical consequences can worsen the cognitive features of Autism—reduced working memory, increased hyperactivity, and social withdrawal—creating bidirectional reinforcement between Autism severity and restricted eating.

In school-age children, sustained iron and B12 deficiency correlates with lower reading and motor scores, even after controlling for IQ. These are not abstract concerns—they affect your child’s ability to learn, concentrate, and engage with their world.

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Hydration: The Overlooked Crisis

Fluid intake among Autistic children with ARFID often falls below half of the recommended volumes, with typical intakes of only 400–800 mL per day. This is almost universally the case in clinical practice.

Beyond worsening constipation, chronic dehydration reduces urinary volume, elevating infection and kidney stone risk. It impairs cardiovascular function, muscle performance, kidney clearance of toxins and routine metabolites (including medications), and tissue perfusion—the flow of fluids in and out of tissues, including brain tissue.

Because sensations of thirst can be poorly integrated in Autism, children will not necessarily tell you they are thirsty. Proactive hydration protocols become essential rather than optional.

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The Ultra-Processed Food Dilemma

Ultra-processed foods comprise more than 90% of caloric intake in some ARFID-ASD samples and in clinical populations with complex Autism and severe ARFID, this figure can exceed 90% (UPFs are often almost 100% of caloric intake for the children in my clinic).

These hyper-palatable ultra-processed foods reinforce rigid brand loyalty while providing negligible micronutrient density, almost no prebiotic fibres, and virtually no antioxidants. Ultra-processed foods can provide Autistic children with a source of foods that are highly predictable in taste and appearance, every time.

The long-term consequences are sobering for diets high in UPFs. Each 10% increase in ultra-processed food consumption correlates with a 10–15% increased risk of cardiovascular and cancer mortality later in life. For children consuming 70–90% of their calories from ultra-processed foods, this translates to very high future risk indeed for early-onset cardiovascular problems and multiple cancers.

A diet that is almost exclusively ultra-processed foods will also increase risk of poor metabolic control, including early onset of insulin resistance and childhood type-2 diabetes. Early onset insulin resistance and pancreatitis is another common issue for children in my clinic (which I find is routinely overlooked by many clinicians in this cohort of children).

Because these children with ARFID and ASD cannot change their food intake, insulin resistance and diabetes create a very problematic situation that requires intensive intervention. Under managed insulin resistance and diabetes leads to very serious issues for the cardiovascular system, peripheral circulation, kidney function and the brain.

Recent systematic reviews and meta-analyses converge on another alarming finding: high intake of ultra-processed foods is associated with approximately 40–50% increased risk of depression and 25–40% increased risk of anxiety or psychological distress. These relationships persist even after adjusting for energy intake, BMI, and socioeconomic variables, and demonstrate dose-response effects—the more ultra-processed foods consumed, the higher the risk.

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Dental Health and the Feeding Cycle

The avoidance of fibrous foods and reliance on sticky starches increases dental caries prevalence. Reduced saliva stimulation from soft processed foods decreases natural remineralization. Deficiencies in vitamins A, C, and D weaken gingival and dental structures.

Frequent exposure to sugar from sweetened dairy or beverages provides fermentable substrates for cavity-causing bacteria. These dental challenges can trigger additional feeding avoidance due to oral discomfort, perpetuating the restrictive cycle, yet again.

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The Breadth of Impact

What becomes clear when examining the research is that ARFID in Autism isn’t simply a feeding problem—it’s a multi-systemic health crisis affecting neurological development, skeletal integrity, immune function, cardiovascular health, gastrointestinal comfort, dental health, cognitive performance, and psychiatric wellbeing.

The sheer number of interrelated deficiencies creates compound effects where one deficit amplifies another, and where symptoms once attributed purely to Autism may actually reflect treatable nutritional insufficiency.

Families often experience this as guilt, exhaustion, and isolation. School meal participation becomes impossible, limiting your child’s inclusion and independence. Behavioural “meltdowns” that you’ve been told are simply part of Autism may coincide with biochemical instability rather than defiance associated with rigidity or sensory exhaustion.

The frustration of watching your child eat the same five foods day after day, knowing they are missing essential nutrients, is compounded by healthcare providers who may not fully understand the complexity of ARFID in the context of Autism.

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Why This Demands Urgent Action

The collective evidence demonstrates that diets devoid of vegetables, legumes, fruits, nuts, seeds, and whole grains produce widespread deficits in vitamins A, B-complex, C, D, E, K, and essential minerals including iron, zinc, magnesium, calcium, selenium, iodine, manganese, chromium, and many others. These shortfalls compromise growth, immunity, cognitive function, metabolic stability, and long-term health outcomes.

Recognition of the breadth and depth of these deficiencies underscores the crucial requirement of medical nutrition therapy and ongoing nutrition intake analysis and biochemical monitoring in the management of ARFID-ASD. This isn’t something that can be addressed through generic dietary advice or waiting for your child to “grow out of it.”

The multi-systemic nature of the impact justifies urgent nutritional intervention—what I call Nutrition Rescue—led by clinical professionals who are proficient in evidence-based nutrition and advanced prescribing of medical nutrition products suitable for children with severely restrictive and rigid food intakes.

Your child’s dietary restriction is not a phase, nor is it a behavioural problem to be disciplined away, or something you have caused through inadequate parenting. It is a complex medical condition requiring sophisticated intervention.

The outcomes described in this article are not always inevitable—they are what happens when ARFID goes unaddressed. With appropriate support, many of these risks can be modified, nutritional status can be improved, and your child’s long-term health trajectory can be changed.

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Photo by Crawford Jolly on Unsplash

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ARFID – The Hidden Nutrition Crisis in Autism

Avoidant/Restrictive Food Intake Disorder (ARFID) is emerging as one of the most serious health issues in children with Autism Spectrum Disorder (ASD). This is not just a case of picky eating, nor does it usually occur with weight or growth concerns. For many (particularly with complex Autism), it is a persistent, treatment-resistant problem that appears to increase the risk of life-long psychiatric and health consequences from a well-hidden mixture of multiple chronic nutrient deficiencies and a high dependence on ultra-processed foods (UPFs) that span a decade or two of the most crucial years of physiological and social development.

Chronic nutrient deficiencies and diets high in UPFs are a near-guaranteed recipe for a constellation of inner health problems throughout life. They silently impair neurodevelopment and the daily functioning of brains and all physiological systems. They significantly increase the risk of: learning and behavioural difficulties, lifelong mental health and psychiatric disorders, multiple types of cancers (linked to diet), gastrointestinal issues, cardiometabolic decline (obesity, diabetes, early onset pancreatic fatigue), cardiovascular disease, unusual fractures (low bone mineral density), and reduced recovery from infections and illness. They also have a complicating role in the progression of complex inflammatory and autoimmune diseases.

Recent research reveals that approximately 8-22% of autistic children meet the criteria for ARFID (and possibly up to 33% when including sub-threshold cases). Given this relatively high level of prevalence of ARFID in autistic children, it seems pertinent that more training is necessary for medical practitioners and other healthcare professionals to enable improved screening, along with enhanced referral practices to paediatric dietitians who have relevant expertise.

Despite the severely limited variety of foods in their diet, children approaching my clinic generally do not have doctors who have recommended or actively referred them to a paediatric dietitian (the mantra seems to be, “if they are growing, they will be ok”). On occasions when doctors have recommended a dietitian, children are presenting to my clinic with a progressed state of nutrition-related clinical issues; typically, they have already missed years of essential nutrition. They have been experiencing a hidden nutrition crisis – overlooked, diminished or dismissed - which has silently and gradually impacted their development. Their overlooked feeding problem has also embedded an increased life-long risk of future chronic health problems.

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We really need to do better.

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We need radically better screening of ARFID in Autism, but there is a twist. ARFID in Autism (what I call, ARFID-ASD) is not the same as ARFID. The mechanisms of ARFID-ASD are more complex and varied. In my experience, the presentation of ARFID in ASD is also typically more severe. And, it is frequently treatment resistant with a long trajectory of poor recovery, at least until the early adult years. Crucially, children with ARFID-ASD require better initial screening by general medical practitioners and paediatricians, who then refer to practitioners with specialist skill sets in ARFID-ASD and nutrition rescue.

A nutrition rescue approach, provided by qualified paediatric dietitians experienced in advanced medical nutrition prescription practices and neuro-affirmative care, is a lifeline that can significantly improve lifelong outcomes for children with ARFID-ASD — and reduce the economic and social burdens of predictable healthcare issues that lie ahead. A nutrition rescue approach is a nutrition-first approach, rather than a food-first approach. Nutrition rescue means meeting all essential nutrition requirements by providing a comprehensive nutrition strategy, not just a patchwork of several nutrients. It is also grounded in high standards of evidence-based clinical practice.

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So, What is ARFID? | Diagnostic Criteria You Should Know

Formally recognised in the DSM‑5 (APA 2013) and DSM‑5‑TR (APA 2022), ARFID is characterised by persistent restriction or avoidance of food that results in one or more of the following:

1. Significant weight loss or poor growth

2. Nutrition deficiency, confirmed biochemically and/or clinically

3. Dependence on nutrition supplements or enteral feeding

4. Marked interference with psychosocial functioning, such as family stress or school limitations

Unlike anorexia nervosa or bulimia, ARFID is not motivated by body‑image concerns. It usually presents through one or more overlapping profiles:

• Sensory‑based avoidance: strong reactions to taste, texture, smell, or temperature

• Fear‑based avoidance: conditioned avoidance due to choking, gagging, or illness

• Low‑interest type: muted hunger signals or interoceptive dysfunction

Autistic children most often fall under the sensory‑based profile.

An ARFID diagnosis must also rule out that the pattern of avoidant/restrictive feeding is not due to cultural practices (e.g. religious fasting, or extreme dietary regimes), food insecurity or a co-occurring medical diagnosis that may be reasonably expected to cause restrictive feeding (e.g. irritable bowel syndrome, reflux, allergies, cancer).

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Understanding Autism and Its Connection to ARFID

Autism markedly amplifies ARFID through heightened sensory defensiveness, cognitive rigidity, an overactive threat response, demand avoidance traits, poor predictive processing, and reduced hunger or thirst awareness from diminished interoception, alexithymia and dysautonomia.  Poor clinical awareness of these phenomena contributes to underdiagnosis and either delayed or unsuitable interventions.

ARFID-ASD is commonly further complicated when associated with ADHD and an almost inevitable presence of secondary issues such as constipation/diarrhoea, gut microbiome dysbiosis and disruptions to the gut-immune-brain axis.

ARFID-ASD gets even more complex when it coincides with food allergies and intolerances, Mast Cell Activation Syndrome (MCAS), hypermobile Ehlers-Danlos Syndrome (hEDS), Eosinophilic oesophagitis (EoE), genetic neurological disorders (e.g. Xq28), or various autoimmune and neuropsychiatric disorders (e.g. PANDAS).

For some, ARFID-ASD overlaps with not just one of these issues, but several. This becomes a supercluster of multiple, co-occurring diagnoses that profoundly compound one another. Clinically, these supercluster kids present with a highly complex constellation of issues when attempting to diagnose, treat and provide supports for improved daily functioning and wellbeing. My clinic is full of these supercluster kids.

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The Clinical Implications of ARFID-ASD

In ARFID-ASD, the amplifying mechanisms associated with Autism and the typical presence of additional complicating factors, make ARFID more complex than most clinicians currently recognise.

ARFID-ASD often involves an interplay of overlapping mechanisms that necessitate a comprehensive understanding of diagnostic and treatment frameworks, grounded in a strong foundation in complex systems medicine and an empathetic appreciation of neuro-affirmative care.

We need medical practitioners and other clinicians to grasp that conventional feeding or exposure-based therapies are rarely effective for this cohort of kids, and that severely restrictive feeding is likely to be a very long-term problem. This means that practitioners need to refer families to experienced paediatric dietitians for advanced medical nutrition therapy and avoid perpetuating simple fixes such as:

• “He will grow out of it eventually. It’s just a phase of picky eating. There is nothing to worry about.”

• “Your child is growing fine (on the growth charts). There is no problem.”

• “Let’s make sure we get some extra iron into their routine with an iron supplement.”

• “Your child’s pathology results don’t show any deficiencies in iron, folate or B12, so you have nothing to be concerned about.”

• “If they are drinking Up&Go (or similar) every day, they will be getting enough nutrition for now.”

• “Just keep providing regular exposure to fruits and vegetables and they will eventually start eating them.”

• “Don’t keep providing their preferred foods until they eat healthy family foods. If they get hungry enough, they will eat anything.”

• “You need to persist with SOS (or similar) feeding therapy. Eventually, they will start eating fruits and vegetables.”

• “Let me teach you about feeding your child ‘the rainbow colours’ every day…”

• “We just need to adjust their anxiety or ADHD medications and eventually they will start eating a wide variety of healthy foods.”

All of these are usually wrong, with detrimental consequences for childhood development, daily functioning and an elevated risk for early adult onset of life-long problems (chronic health disease, psychiatric disorders and cancer). This is particularly true for all the children in my clinic who present with severe ARFID-ASD.

Unfortunately, these types of responses (above) still dominate the majority of clinical advice given to parents. Every week of the year, I continue to witness this trend via online groups and through the influx of new inquiries arriving at my clinic. It remains a pervasive problem that highlights the need for further training of medical practitioners and other healthcare professionals, including dietitians.

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Conclusion

ARFID-ASD is a pervasive problem that affects up to 22% of autistic children. When feeding problems are overlooked or dismissed, diets high in UPFs with multiple nutrient deficiencies have detrimental consequences for childhood development, daily functioning and an elevated risk of life-long psychiatric dysfunction, chronic health problems and cancers. Failure to screen, refer and provide nutrition rescue generates a hidden nutrition crisis that silently erodes mental and physical health during the first decade or two of the most important developmental years, physiologically and socially.

Medical practitioners and other healthcare practitioners need training to improve initial screening and referral of children with ARFID-ASD. In the meantime, parents may need to educate their child’s clinicians and seek out appropriate support.

While awareness of the definition and diagnostic criteria of ARFID is a good starting point for clinicians and parents alike, we also want to cultivate a much better understanding that Autism markedly amplifies ARFID through heightened sensory defensiveness, cognitive rigidity, an overactive threat response, demand avoidance traits, poor predictive processing, diminished interoception, alexithymia and dysautonomia. This will often mean that practitioners need to refer children to other clinicians with advanced knowledge in diagnostic approaches and treatment pathways for ARFID-ASD.

When children get early access to nutrition rescue, through a neuro-affirmative nutrition-first approach, we can often correct deficiencies in energy, protein, essential fatty acids, vitamins, minerals, prebiotic fibres and fluids. A nutrition rescue approach enables us to modify multiple factors that impact child development outcomes, daily functioning, and some types of clinical problems. Access to nutrition rescue also means we can modify the life-long risk of psychiatric dysfunction, chronic disease and various cancers.