Avoidant/Restrictive Food Intake Disorder-Related Symptoms and Food Neophobia in Children with Food Allergy: A Mixed-Methods Study of Frequency Estimates, Diet Quality, and Food-Related Psychological Experiences.

Background: Children with food allergy (FA) may develop eating difficulties that extend beyond medically required allergen avoidance, including food neophobia, selective eating, and avoidant/restrictive food intake disorder (ARFID)-related symptoms. This mixed-methods study aimed to assess ARFID symptoms, food neophobia, diet quality, and food-related psychological experiences in children with FA. Methods: Seventy children with confirmed FA were enrolled in an observational cross-sectional mixed-methods study conducted at a tertiary pediatric allergy center. Quantitative assessment included the Eating Disorders in Youth-Questionnaire (EDY-Q), the Italian Child Food Neophobia Scale (ICFNS), and the Mediterranean Diet Quality Index for Children and Adolescents (KIDMED). Qualitative data were collected from a purposive subsample of 26 children through semi-structured child-friendly interviews and drawing-based elicitation activities and were analyzed using inductive thematic analysis. Results: A positive EDY-Q screening result for ARFID-related symptoms was observed in 3 children (4.3%). Selective Eating showed the highest median EDY-Q domain score (median 1.50, IQR 0.67-4.00), followed by Food Avoidance Emotional Disorder (median 1.00, IQR 0.00-2.00) and Functional Dysphagia (median 0.00, IQR 0.00-2.00). Moderate food neophobia was observed in 45 children (64.3%), while 24 children (34.3%) were classified within the high food-neophobia category. KIDMED score was negatively correlated with EDY-Q total score (Spearman's ρ = -0.302; p = 0.011), Selective Eating (ρ = -0.356; p = 0.002), and Functional Dysphagia (ρ = -0.238; p = 0.048). In an exploratory hierarchical regression, Selective Eating remained inversely associated with KIDMED after adjustment for demographic and FA-related covariates (β = -0.386; p = 0.002); however, the overall model did not reach statistical significance (p = 0.081), and the additional clinical covariates did not significantly improve model fit. Accordingly, the fully adjusted findings should be interpreted as exploratory. Qualitative analysis identified five themes: anticipatory fear of food and tasting, emotional memory of allergic reactions and generalization of risk, selective avoidance and food rigidity, reassurance-seeking and decision-making dependence, and ambivalent parental dynamics. Conclusions: Within this tertiary-care sample, positive EDY-Q screening results were uncommon, whereas broader food-related difficulties were identified. Pediatric FA assessment may benefit from attention to eating behavior, diet quality, and avoidance extending beyond confirmed allergens.