Immediate priorities

• Assess medical stability urgently: weight trajectory, orthostatic vitals, electrolyte abnormalities, signs of malnutrition and ability to take oral intake. Admit if unstable.
• Identify primary maintaining factors (sensory, lack of interest, fear of aversive consequences) to tailor treatment components.
• Start basic nutritional support and safety planning while arranging multidisciplinary assessment.

Stepped care model

1. Stage 0 — Primary care/early intervention: education, brief dietary advice, monitor growth and initiate simple behavioural strategies (structured meals, avoidance of pressure) for mild cases.
2. Stage 1 — Outpatient multidisciplinary care: dietitian + psychologist + speech/OT as needed for moderate cases—deliver CBT‑AR, FBT adaptations, feeding therapy and sensory desensitisation.
3. Stage 2 — Day programme/intensive outpatient: for significant nutritional risk or failure of outpatient therapy—structured meal support, daily therapy, and medical monitoring.
4. Stage 3 — Inpatient care: for medical instability (rapid weight loss, severe electrolyte disturbance, inability to sustain oral intake) or psychiatric risk—medical stabilization and initiation of intensive feeding plans and behavioural work.

Core therapeutic components

• Exposure‑based feeding therapy: graded hierarchy of food exposures with repeated, supported trials aimed at increasing acceptance and reducing anxiety/sensory aversion. Use small, frequent steps and reinforce progress.
• CBT‑AR / CBT adaptations: address cognitive barriers (beliefs about choking, disgust), behavioural avoidance, and involve interoceptive or imaginal exposure for fear‑based ARFID.
• Family‑based approaches (FBT adaptations): empower caregivers to support meals, provide structured meal plans and reduce accommodation of avoidant behaviours (especially in young children).
• Applied Behaviour Analysis (ABA): use reinforcement schedules, shaping and antecedent control in children with developmental disorders.

Feeding & sensory strategies (OT / SLT)

• Occupational therapy: sensory desensitisation, graded texture introduction, environmental modifications (lighting, seating) and sensory diets to reduce aversive responses.
• Speech & language therapy: oral‑motor assessment and exercises for dysphagia or poor chewing skills; safe swallow strategies and graded texture progression.
• Behavioural mealtime structure: predictable routines, neutral caregiver responses to refusal, visual schedules and use of social stories for children.

Nutritional management

• Dietitian‑led plans to restore calories, correct deficiencies and set achievable targets (weight gain, increased variety). Use high‑energy oral supplements when necessary.
• Monitor labs and micronutrients; replace deficiencies (iron, vitamin D, B12) as indicated.
• Enteral feeding (NG/gastrostomy) as a time‑limited bridge for severe malnutrition—integrate with behavioural therapy to transition to oral intake and avoid dependence on tube feeds long‑term.

Pharmacologic adjuncts

• No medication is specifically approved for ARFID. Consider pharmacotherapy for comorbid conditions (anxiety, OCD, depression) that maintain avoidance—SSRIs, anxiolytics where indicated.
• Limited evidence for appetite stimulants or olanzapine in weight gain—use cautiously and usually within specialist settings, monitoring metabolic side effects.
• Medications should never replace behavioural feeding work; consider only as adjuncts when necessary for engagement or medical stability.

Delivering exposure safely

1. Assessment: identify triggers, feared consequences and preferred safe foods. Start hierarchy from mildly challenging items.
2. Dosage: short, frequent exposures (e.g., 30–60 seconds or one bite) with immediate reinforcement and gradual progression.
3. Context: provide exposures in a calm, predictable setting with caregiver support; combine sensory accommodation (e.g., temperature, cut size) when helpful.
4. Record progress: food logs, behavioural charts and measurable targets (number of accepted foods, portion sizes, weight trajectory).

School and community integration

• Provide brief care plans for schools: safe meal access, discreet supports, avoidance of pressure, and reinforcement strategies consistent with home practice.
• Train school staff on non‑punitive approaches and liaise with school dietitians or counselors where available.

Practical tips for clinicians

• Set small, measurable goals (e.g., add one new food/week), document baseline metrics and review weekly for progress.
• Start with low‑pressure exposures, use caregiver coaching, and celebrate small wins to maintain engagement.
• Coordinate regular MDT meetings and clear communication with schools and community services to ensure continuity of care.