Kapphahn C, Peet B, Gao J, Chan A, Farhadian B, Ma M, Silverman M, Tran P, Schlenk N, Thienemann M, Frankovich J. Sudden Onset Disordered Eating Behaviors and Appetite Issues in a Local Clinical Cohort of Children With Pediatric Acute-Onset Neuropsychiatric Syndrome (PANS). Int J Eat Disord. 2025 Jul;58(7):1219-1232. doi: 10.1002/eat.24388. Epub 2025 Mar 31. PMID: 40165330.
- 130 youth with PANS (ages 4–18) reviewed at a specialty clinic
- 56% developed abrupt-onset restrictive eating during flares
- Eating restriction patterns mirrored ARFID presentations
- Most affected youth had severe concurrent neuropsychiatric symptoms
- 12% had baseline eating restriction, often worsened during flares
Abrupt-Onset Eating Restriction in PANS
Youth experiencing flare-associated eating restriction exhibited a substantial burden of concurrent neuropsychiatric symptoms, such as emotional lability or depression, irritability or aggression, cognitive impairment, sensory amplification, and behavioral regression. These findings indicate that eating changes in PANS generally occur as part of a broader inflammatory neuropsychiatric exacerbation rather than as an isolated feeding disorder. Additionally, a subset of patients demonstrated baseline restrictive eating, with more than half experiencing altered or worsened eating patterns during flares, suggesting increased vulnerability rather than exclusion of PANS.
These findings support the conceptualization of restrictive intake in PANS as
state-dependent and immune-mediated, rather than developmentally fixed. Clinically, abrupt changes in eating behavior should prompt assessment for PANS-related exacerbation, particularly when accompanied by multisystem neuropsychiatric symptoms. Distinguishing flare-driven restriction from primary ARFID is essential for diagnostic clarity, treatment prioritization, and effective interdisciplinary care planning.Study Overview
- Retrospective chart review of 130 youth with PANS, ages 4–18
- Patients evaluated at initial presentation to a specialty PANS clinic
- Data drawn from medical records, parent reports, symptom ratings, and psychometric measures
- Focused on both baseline eating behaviors and abrupt changes during PANS flares
How Common Is Eating Restriction in PANS?
- 56% of patients developed abrupt-onset restricted food intake during a PANS flare
- Eating restriction was often a key factor prompting clinic referral
- 12% had evidence of baseline eating restriction prior to flare onset
- More than half of those with baseline restriction changed or worsened eating behaviors during flares
Patterns of Eating Restriction
Among youth with restricted intake during flares, eating behaviors aligned closely with the three core ARFID presentations:
- Selective eating: 48%
- Low appetite or low interest in food: 41%
- Fear of aversive consequences: 37%
- Fear of choking, vomiting, or swallowing: 26%
- Fear of contamination: 16%
- Weight or shape concerns were uncommon (4%)
This pattern suggests that eating restriction in PANS is driven primarily by neuropsychiatric and sensory factors, rather than body image concerns.
Associated Neuropsychiatric Features
Youth with PANS-related eating restriction showed high rates of concurrent symptoms during flares:
- Emotional lability and/or depression: 96%
- Irritability, aggression, or oppositional behavior: 89%
- Cognitive impairment: 69%
- Sensory amplification: 64%
- Behavioral or developmental regression: 60%
These findings reinforce that eating restriction in PANS rarely occurs in isolation and is typically part of a broader neuropsychiatric flare.
How This Relates to ARFID
- The reasons for food restriction in PANS closely mirror ARFID criteria
- The key distinction is timing and context
- In PANS, eating restriction often emerges abruptly during immune-mediated flares
- In ARFID, restriction is typically more persistent and not flare-driven
- This overlap highlights the importance of assessing medical and immune triggers when restrictive eating begins suddenly
Clinical Takeaways
- Abrupt-onset eating restriction is common in PANS flares
- Restriction patterns resemble ARFID but occur in a state-dependent, episodic context
- High psychiatric and sensory symptom burden accompanies eating changes
- Baseline restrictive eating does not exclude PANS and may worsen during flares
- Careful timing, history, and symptom trajectory matter for accurate diagnosis and treatment planning
Gabriella True
