My daughter is so terrified of vomiting, she stopped eating. She had to get a feeding tube because she lost so much weight.

• Carolyn Rickert's tween was diagnosed with emetophobia — a fear of vomiting that stopped her eating.
• The mom said Vivi was severely underweight and was put on a feeding tube to get essential nutrients.

This as-told-to essay is based on a conversation with Carolyn Rickert. It has been edited for length and clarity.

My daughter, nicknamed Vivi, came home from school one day in September 2021 and said: "I'm never going to eat school lunch. It's gross."

She said she'd been eating her lunch in the cafeteria when another kid pointed at her burger and fries and said, "You know they poison the food here, don't you?"

It was typical sixth-grade humor. But the boy had unwittingly reinforced Vivi's fear that food would make her sick.

She already had anxiety about going to middle school. It was a much bigger building and overcrowded, and she had to get used to walking there. Her anxiety got worse as the semester went on.

We'd always pack her lunch — the usual type of kids' stuff like mac and cheese, Goldfish crackers, fruit snacks, maybe a cookie — but Vivi, who was 11 at the time, would come home with the lunchbox untouched.

I'd say, "Honey, why aren't you eating?" but she'd shrug it off.

She talked about things in the cafeteria that really bothered her — like somebody chewing and a bit of food or saliva flying out of their mouth. One day a mom called to say that her daughter, who was bringing in extra cookies for Vivi to eat at lunch, was worried about her.

I guess that at the time, we didn't realize the situation was so bad. But we contacted the school, and they were wonderful. They said, "What can we do to help?" But there's only so much you can do.

We switched her to online schooling in January 2022. We hoped this would be the answer because she wouldn't be in those anxious situations in the school cafeteria.

Vivi told us at the eating-disorders clinic that she was concerned about throwing up

Nothing really changed. She stopped eating breakfast as well as lunch. Then she refused to eat dinner. She'd take a few bites of something like chicken nuggets — like a lot of kids, she didn't like fresh fruits and vegetables — and then want to skip to dessert. She was only comfortable eating sweets like ice cream and Oreos.

We got professional help in March last year. She was 5-foot-2 and 65 pounds. She was on the zero percentile for weight and had developed lanugo on her body — soft, downy hairs that can indicate malnourishment.

Her primary-care provider did lab work and said it was anorexia. But it seemed strange to us because she had a healthy body image and never counted calories. She ate desserts and didn't exercise obsessively.

Vivi was admitted to a residential center for eating disorders soon afterward. She was immediately diagnosed with avoidant/restrictive food intake disorder and not anorexia. We were relieved that body image wasn't part of her diagnosis. It can play such a big part of self-esteem.

But nobody seemed to know what was causing her ARFID.

Early on, when my husband, Shawn, and I were visiting the facility, Vivi said that she was very concerned about throwing up. She'd eat with her therapist, not the other patients, because she didn't want anyone to see her vomit, she said.

Shawn did some research. He read about emetophobia — the extreme fear of vomiting. We'd never heard of the condition but wondered if it was related to the ARFID. We mentioned it on a Zoom call with Vivi's dietitian and therapist. They acknowledged it but didn't suggest treatment.

On her 12th birthday in early April, the clinic served Vivi her favorite meal — Wendy's chili and a Frosty dessert. It came with French fries and chocolate milk. It's a lot of food for anyone to eat. But she told us she felt pressured to eat it all and "do the right thing" to please the staff. She threw up everywhere.

She's only really vomited about five times before in her life. But we heard that she was hysterical. She told us she'd never go back to Wendy's. "I can't eat chili anymore," she said. She used to love it when I fixed chili. But it's off the list now — along with every other meat or fish.

The technique at the center was trying to get Vivi to eat as much as she could on her own. They'd give her so-called "bolus" feeds after meals she couldn't complete. The formula was administered manually via a nasal-gastric tube — something she hated. Then she'd have "continuous feeds" that were automatically pumped into her body during the night while she slept.

Vivi said that she hated the gag reflex of vomiting

She threw up three times during the feeds and began to refuse them. She had the right to pull out the NG tube when she wanted. It usually happened when her stomach felt very full. She gained only eight pounds during her 3½ months at the center.

That summer, when we talked about ARFID, she once again said how embarrassed she was about the thought that people would see her throwing up. She said she hated the gag reflex and the sense of lack of control. She'd had anxiety and stomachaches since she was in kindergarten, and we suspected they were all connected.

An eating-disorder specialist confirmed she had emetophobia in August last year when Vivi was an outpatient at another facility. He said that he believed emetophobia was the underlying cause of her ARFID. She had counseling and a very small amount of "exposure" therapy. She watched a clip of a cartoon car throwing up, for example. But she quit after a month because she'd simply had enough of being in therapy.

Vivi's weight was relatively stable until earlier this year. She was admitted to a third clinic in February. She'd increased in height to 5-foot-6 but was only 80 pounds. This time, thankfully, she is doing much better. She got on very well with a particular nurse who helped her get used to the NG tube. She's doing some more exposure therapy to help with the ARFID and emetophobia. At the moment, she said, she's watching cartoons showing characters throwing things up like rainbows.

Vivi has been making a lot of progress

They recently removed her feeding tube after she got to 95 pounds. The doctors said that in an ideal world, her weight should be between 97 to 113 pounds. She's now eating regular meals, getting 2,000 calories a day from food like buttered noodles, Nutella sandwiches, and yogurt.

Last week, Shawn and I helped her move her things to a different unit at the center. The care is less intensive because she's made a lot of progress. She picked up a bucket that had always been next to her bed and put her books and portable sound machine in it for storage. She said, "This was my barf bucket, and I've never used it!"

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