A Focus on feeding was the theme of a comprehensive and thoughtful Masterclass delivered by Dr Rachel Bryant-Waugh of Great Ormond Street Hospital.
This was the tenth Masterclass of the series and brought a well-received focus on ARFID (Avoidant/Restrictive Food Intake Disorder) as a distinct diagnostic term.
Dr Bryant-Waugh, who is Joint Head of the Feeding and Eating Disorders Service at GOSH, began by describing how ARFID developed from the “muddle” of presentations which did not fit standard eating disorder diagnostic criteria.
“There can be many similarities with anorexia: restrictive eating, low weight, sudden weight loss and an emotional component,” explained Dr Bryant-Waugh. “But critically, in ARFID, the disorder is not driven by weight and shape issues.”
Dr Bryant-Waugh described the three elements which drive the feeding or eating disturbance in ARFID as: low interest, sensory difficulties, fear/trauma.
ARFID can be seen in very young children, but it is not a child and adolescent disorder; it can occur at any age and affected individuals can also be within a normal or high weight range, emphasised Dr Bryant-Waugh.
It is essential that patients with ARFID are accurately diagnosed and appropriately treated.
“You can make things worse if you treat an ARFID patient as if they have anorexia,” explained Dr Bryant-Waugh.
There was a wide-ranging discussion about how patients can be referred to eating disorders services as the first ‘port of call’, although their pathways are often designed for patients with anorexia.
In terms of treating ARFID, Dr Bryant-Waugh cautioned that as a relatively new part of the diagnostic lexicon, there is very little evidence base. She described the treatment tool kit required and the core principles of explore, understand, accept, challenge, change.
“The end-point is unlikely to be eating a full Sunday Roast, but it is often having a ‘good enough’ diet and a reduction in social impairment.”
In the afternoon session, Dr Bryant-Waugh shared her work with an adult eating disorders service where she observed a third of service users were also mothers responsible for feeding children.
“They were very low in confidence about their role as a mother; there was a lot of anxiety about doing the right thing and particularly concerns about passing an eating disorder on to their child/children. Equally however, there was very high motivation to be a good mother.”
Dr Bryant-Waugh described common issues and behaviours arising through the three pregnancy trimesters and the need for a realistic approach to questions like breast-feeding, when a mother has an eating disorder. Targeted support for these mothers is very beneficial; they are unlikely to access regular parenting groups due to shame about their eating disorder.
The final session considered the risk of intergenerational transmission of eating difficulties.
“For children to learn how to eat, parental modelling is vital. It is important for children to see their parents eating a range of foods, including new foods,” said Dr Bryant-Waugh.
There was discussion about how a parent’s eating disorder can affect feeding decisions and how preparing food and supervising children at mealtimes can impact upon the parent’s eating.
“It is complex; it is not one but many different interactions, one after another. My own reading is that the one thing that may dispose to future eating disorders in children is high levels of parental anxiety and conflict at mealtimes.”
Professor Hubert Lacey, Medical Director of Newbridge House concluded the Masterclass by thanking Dr Bryant-Waugh for leading an excellent day.
“You have explained, with great depth and clarity, not only the pathogenesis of ARFID but also the different aspects required in treatment. Your work on intergenerational transmission risk was illuminating and very well received.
“It was evident throughout the day how many participants came and spoke to you to seek guidance about issues they are seeing in their services ‘at the coalface’. This is what Masterclasses are all about: a really high quality educative experience and a genuine opportunity to share experiences and draw on specialist advice and support.”