Avoidant/Restrictive Food Intake Disorder (ARFID)
This 5-year-old boy's presentation is most consistent with Avoidant/Restrictive Food Intake Disorder (ARFID), as evidenced by failure to gain weight and signs of severe nutritional deficiency (purpuric lesions, gingival edema, bleeding gums) without any body image distortion or fear of weight gain. 1
Why ARFID is the Correct Diagnosis
The clinical presentation demonstrates the hallmark features of ARFID according to DSM-5 criteria 1:
- Significant nutritional deficiency: The purpuric lesions and gingival edema with bleeding during tooth brushing are classic signs of scurvy (vitamin C deficiency), indicating severe malnutrition 1
- Failure to meet expected weight gain: The child is struggling to gain weight, meeting the criterion of failure to meet expected weight or height gain in children 1
- Marked interference with psychosocial functioning: Generalized weakness, malaise, and sadness indicate functional impairment 1
- Absence of body image distortion: There is no mention of fear of weight gain, body image concerns, or distorted perception of body shape—the defining feature that distinguishes ARFID from anorexia nervosa 1
Why Other Eating Disorders Are Excluded
Anorexia nervosa, restrictive type is ruled out because this diagnosis requires intense fear of weight gain or being fat and body image distortion 1. This 5-year-old shows no evidence of these cognitive distortions.
Bulimia nervosa is excluded because it requires recurrent binge eating episodes (consuming larger amounts of food within a 2-hour period compared to peers) followed by compensatory behaviors, occurring at least once weekly for 3 months 1, 2, 3. There is no evidence of binge eating or purging behaviors in this case.
Binge eating disorder is eliminated because it requires recurrent episodes of binge eating at least once weekly for 3 months without compensatory behaviors 1. This child has the opposite problem—inadequate food intake leading to malnutrition.
Age-Appropriate Context
ARFID is particularly relevant for this age group, as eating disorders are increasingly recognized in children as young as 5 to 12 years 1. Unlike anorexia nervosa (peak onset in early to mid-adolescence) and bulimia nervosa (peak onset in late adolescence), ARFID has no age limitations and is specifically designed to capture restrictive eating presentations in younger children 1, 4, 5, 6.
Critical Clinical Pitfall
The most common diagnostic error would be missing the nutritional emergency while focusing on psychiatric classification. The purpuric lesions and gingival bleeding represent scurvy from vitamin C deficiency—a medical emergency requiring immediate nutritional intervention 1. This child needs urgent assessment of vital signs, complete blood count, comprehensive metabolic panel with attention to electrolytes, and nutritional supplementation 1, 3, 7.
Management Priorities
Immediate treatment should focus on 1, 4, 5:
- Medical stabilization: Address the nutritional deficiencies with vitamin C supplementation and comprehensive nutritional support
- Multidisciplinary team: Assemble a physician, mental health provider, and dietitian 8
- Family-based approach: Given the young age, treatment must involve caregivers in establishing appropriate feeding practices 4, 5
- Rule out medical causes: Ensure the feeding problem is not attributable to another medical condition 1
The absence of body image concerns and the presence of severe nutritional deficiency in a young child make ARFID the only appropriate diagnosis among the options provided 1, 4, 5.