Transcutaneous auricular vagus nerve stimulation paired with task-specific training for improving walking and balance in chronic stroke: a double-blind, randomised controlled feasibility trial.

Avoidant/Restrictive Food Intake Disorder (ARFID) presents a multidimensional model of food refusal, which includes food avoidance due to sensory sensitivity or “picky eating,” fear of negative consequences, and low interest or lack of hunger []. Patients commonly present with symptoms from more than one phenotype []. The present case highlights a unique presentation in a pediatric patient with a longstanding aversion to solid food. Her eating challenges dated back to the attempted transition from breastfeeding to solids. Interviews with the patient suggested that eating difficulties were the direct result of fears of aversive consequences–specifically fear of choking–leading to functional impairment, emotional distress, and food avoidance. While it is not uncommon for feeding and eating challenges to begin within a child’s first year of life [] the prolonged duration of illness posed specific clinical challenges and risk factors, given the increased prevalence of psychological and functional impairments in older patients []. Further, due to her young age and lack of prior ability to articulate the underpinnings of her aversion to solid food, interventions for this case previously emphasized dietary-expansion focused food exposure rather than a fear-based exposure approach. Treatments that simultaneously address weight gain, growth, and medical complications of eating disorders alongside the resolution of food/eating-based phobias such as choking are scarcely available. The treatment manual for Cognitive Behavioral Therapy for ARFID (CBT-AR), published in 2019, outlines in vivo and interoceptive exposures to manage phobic responses to conditioned fears []. Through gradual, real-world exposure to less preferred foods and eating situations, as well as internal body sensations that trigger fear, children learn that they can tolerate discomfort and remain safe. Strategic use of medication to optimize the benefits of therapy has shown promise in treating ARFID. Because ARFID is heterogeneous, medication choices should be guided by the specific phenotype (e.g., fear of choking vs. low interest vs. sensory sensitivity) and any comorbidities that medications might also target. There are no randomized trials of medication for ARFID; evidence is limited to case reports/series, often with mixed ARFID subtypes. In reports examining patients with ARFID and additional comorbidities (i.e. anxiety), small series suggest medications such as selective serotonin reuptake inhibitors (SSRIs), olanzapine, mirtazapine, and cyproheptadine may support weight gain and reduce distress [–].