Feeding difficulties in pediatric food allergy have been reported across a wide range, from 13.6% to 40%, but prior studies relied on heterogeneous terminology and diagnostic instruments and skewed toward non-IgE-mediated phenotypes.2 No prior study had applied the Nine Item Avoidant/Restrictive Food Intake Disorder Screen–Parent Report (NIAS-PR) to an IgE-mediated food allergy population, leaving a gap in standardized data for allergists managing selective or avoidant eaters.¹
“Importantly, their appetite scores were similar to those of healthy children, so the main issue may not be low appetite,” Merve Karaca Şahin, from Prof. Dr. Cemil Tascioglu City Hospital in Istanbul, Turkey, told HCPLive. “Instead, fear and picky eating may limit the foods children feel safe eating.”
NIAS-PR Scores and Eating Behavior Domains in Food Allergy
The single-center, prospective, controlled study enrolled 234 children aged 2 to 9 years, including 117 with physician-diagnosed food allergy and 117 age- and sex-matched healthy controls, evaluated at the Pediatric Immunology and Allergy Outpatient Clinic of University of Health Sciences, Prof. Dr. Cemil Tascioglu City Hospital between September 2025 and February 2026.¹ Parents completed the NIAS-PR, a validated tool assessing 3 domains: picky eating, appetite, and fear of aversive consequences from eating.¹
Median total NIAS-PR scores were significantly greater in the food allergy group than in controls (17 [IQR, 11-24] vs 12 [IQR, 7-18]; P <.001).¹ The difference was driven by picky eating and fear subscale scores (both P <.001), whereas appetite subscale scores did not differ significantly between groups (P =.311).¹ Karaca Şahin said this pattern challenges assumptions that food allergy uniformly suppresses interest in eating, noting a child may enjoy eating yet restrict intake to a narrow list of foods perceived as safe.
Growth, Asthma, and Reaction Severity Tied to ARFID Risk
Frequently Asked Questions
What did the NIAS-PR study find in children with food allergy?
Children with food allergy had significantly higher NIAS-PR total, picky eating, and fear subscale scores than healthy controls, while appetite scores did not differ.
Does food allergy suppress appetite in children?
Not according to this study; appetite-related items were similar between children with food allergy and controls, suggesting fear and picky eating, not appetite loss, drive ARFID-related behavior.
When should a positive ARFID screen prompt referral in children with food allergy?
Karaca Şahin recommends referral when restriction is accompanied by faltering growth, weight loss, a narrow food list, persistent fear, or difficulty reintroducing tolerated foods, rather than from the score alone.
Children with food allergy also demonstrated significantly lower weight-for-age (−0.20 ± 1.10 vs 0.26 ± 1.05; P =.001) and height-for-age z-scores (−0.40 ± 1.18 vs 0.15 ± 1.18; P <.001) compared with controls. BMI z-scores did not differ significantly between groups (P =.117).¹ Karaca Şahin said the study could not separate how much of this growth difference stemmed from ARFID-related behaviors versus the elimination diet itself, calling the effect likely multifactorial given the absence of detailed dietary intake data.
Within the food allergy group, children with comorbid asthma (n = 34) had greater total NIAS-PR scores than those without asthma (19 [IQR, 14-39] vs 16 [IQR, 10-22]; P =.043).1 Karaca Şahin cautioned against overinterpreting the modest link, noting that the study was not designed to explain the association and that, for now, it should be viewed as an intriguing lead for future research. Children with a history of urticaria (P =.009) or anaphylaxis (P =.014) also scored significantly greater on the fear subscale.
“This makes sense clinically because anaphylaxis can be life-threatening and very frightening, while urticaria is often sudden, visible, and memorable,” Karaca Şahin said. “These reactions make children and their families feel that eating is unsafe. Over time, this may lead to more food avoidance.”
Because no validated NIAS-PR cutoff exists for diagnosing ARFID in this population, Karaca Şahin said a positive screen alone should not trigger referral; instead, she flags faltering growth, weight loss, a very narrow food list, persistent fear, or difficulty reintroducing a food after a negative oral food challenge as signals warranting evaluation by feeding and mental health specialists.2
Related Research on ARFID Risk in Pediatric Food Allergy
The findings arrive alongside separate research showing children with and without food allergy screened positive for possible ARFID at similar rates (23% vs 21%) underscoring ongoing uncertainty about how allergy-specific this risk truly is.3 In a population-based Australian birth cohort study, possible ARFID among children with food allergy was more common in those with anaphylaxis or an epinephrine autoinjector prescription, and current hay fever was linked to greater rates of both possible ARFID and possible ARFID inclusive of food allergy anxiety.
References
Karaca Şahin M, Çalışkan N, Şarman HT, et al. Fear and picky eating-related ARFID behaviors in children with food allergy. Pediatr Allergy Immunol. 2026. doi:10.1111/pai.70403
Hill SA, Nurmatov U, DunnGalvin A, et al. Feeding difficulties in children with food allergies: An EAACI Task Force Report. Pediatr Allergy Immunol. 2024;35(4):e14119. doi:10.1111/pai.14119
