New Horizons:
eating disorders in Children and
Adolescents
Anna B. Tanner, MD, FAAP, FSAHM, CEDS The Teen Center at GPAM,
Gwinnett Pediatrics and Adolescent Medicine Adjunct Assistant Professor of Pediatrics, Emory University School of Medicine
Children’s Healthcare of Atlanta | Emory University
Why learn about Eating Disorders?
• Eating disorders are the most lethal psychiatric illness
–Mortality in adolescents with Anorexia Nervosa is almost 2%
–Most deaths are due to medical complications
• Best outcomes for patients with eating disorders hinge upon:
–Early recognition
–Early intervention
–Weight restoration
• Treatment requires a multi‐disciplinary team approach
–Nutritionist
–Therapist
–Psychiatrist
–Physician – that’s you!
Role of the Physician
• Lead the health care team
–Be a source of accountability
–Ensure proper follow‐up with members of the team
• Relay seriousness of the illness to family and patient
–Need to be knowledgeable about eating disorders
–Need to be familiar with the screening guidelines for disordered eating
• Recognize and manage medical complications
–Constantly assess for adequate level of care
Children’s Healthcare of Atlanta | Emory University
Case Study
• Your next patient is a 14 year old male. He is a new patient to your practice. The family just moved here from another state. The mother of the patient states that she is worried her son has lost weight.
• Should you be worried that this patient has an eating disorder? –A. Yes
–B. No
–C. I don’t know yet
Children’s Healthcare of Atlanta | Emory University
Answer A. Yes
• At any visit be concerned and evaluate further for an eating disorder any child or adolescent with:
–Pattern of weight loss
–Excessive concern over weight
–Inappropriate dieting
–Failure to achieve appropriate increases in height or weight in a growing child
–Amenorrhea, primary or secondary
Children’s Healthcare of Atlanta | Emory University
But this patient is a boy!
• Remember that eating disorders:
–Can affect boys as well as girls
•Increasing rates in males
•Estimates that 15 to 30% of eating disorder patients overall are male
–Can be present in younger and older patients than previously thought
•Increasing rates in very young children
•Increasing rates in older adults
–Can affect people of all ethnicities and backgrounds
•Increasing rates in minorities •Not limited to any one socio‐economic group
–Can be present in people at normal weight
•Increasing rates of Anorexia Nervosa in patients that were previously obese •Most patients with Bulimia Nervosa are at normal weights
Children’s Healthcare of Atlanta | Emory University
Further history
• You are concerned so you ask for more information. You learn that: – Six months ago at a check up he weighed 180 pounds.
– He was teased by his peers for being “chubby” in middle school – He started to eat “healthier” after a talk in his health class.
– At first he ate more fruits and veggies. Then he stopped eating desert. He has
continued to eliminate whole food groups including all breads and pastas.
– His mother is not sure how much weight he has lost but says his clothes look very
loose.
– Also his mother does not think he has eaten anything the last 5 days but an apple a
day and he will only drink water.
• What would you do next?
– A. Get more history and do a targeted physical exam – B. Ask for old growth charts
– C. Get a blind weight and orthostatic vital signs – D. All of the above
Children’s Healthcare of Atlanta | Emory University
Answer D. All of the above
• Understand the Goal of Medical Evaluation
–Briefly rule out other disorders
–Evaluate the patient’s medical, nutritional, and psychosocial status
–Determine severity of the condition
–Make plan of care
Targeted Medical Evaluation
• Understand your differential diagnosis
– GI, Endocrine, Infectious, Substance Use or Psychiatric disorder
• Ask a comprehensive history
– Weight history, exercise history, purging history, past mental illness, suicidality
• Review old growth charts (if possible)
• Perform a targeted physical exam
– Look for common findings in eating disorders: lanugo, acrocyanosis, Russell sign
• Obtain weight and vital signs
– Blind weight, height, oral temperature, orthostatic vital signs
• Consider laboratory evaluation
– CMP, CBC, Magnesium, Phosphorous, TFTs, EKG, and HCG – Remember normal labs do not rule out a serious eating disorder
Children’s Healthcare of Atlanta | Emory University
Your findings
• Differential Diagnosis – no concerns
• Comprehensive history
– Pt admits to restricting and wanting to lose weight – his goal weight is 100 pounds
– Pt admits that he often feels hopeless and wishes he was dead
• Growth chart
– None available but mom thinks his growing has slowed
• Targeted physical exam
– Very thin appearing with bradycardia, and cold, blue hands and feet
• Weight and vital signs
– Height 70 inches, Blind gown weight 120 pounds
– BMI 17.2, 72% IBW
– Temp 96.8 degrees F
– Orthostatic vital signs
• Supine HR 41 BP 80/52
• Sitting HR 43 BP 82/48
• Standing HR 42 BP 78/50 • What next?
– A. Send him to the lab to get labs drawn
– B. Ask him to eat more and come back in a month
– C. Refer him to cardiology
– D. Admit to him to CHOA for medical stabilization
Children’s Healthcare of Atlanta | Emory University
Answer D. Admit to CHOA
• Why admit?
–Follow the 2003 AAP Criteria for Hospitalization
• Some patients with weight loss will need medical admission for medical stabilization
• Some patients with purging will need medical admission for medical stabilization
–Minimize the risk of Refeeding Syndrome
• Patients who have lost significant weight and have greatly reduced intake are at risk for potentially fatal complications when they try to eat again
• These high‐risk patients must be medically monitored and supported in an inpatient setting
• How to admit
–CHOA Transfer Center
• Identify the patient as having a known or suspected Eating Disorder
• If possible, send to the Emergency Department at Scottish Rite
–Emergency Department
• Ask staff to use the Emergency Department Eating Disorder Guideline
• Patients will have labs, vital signs and EKG done – admission to floor or ICU
–Inpatient Eating Disorder Team
• Staff will use the Inpatient Eating Disorder Guideline – multidisciplinary team approach
• Patients will be monitored medically and treated for complications such as hypoglycemia, hepatitis, congestive heart failure and refeeding syndrome
American Academy of Pediatrics Policy Statement, Committee on Adolescence, “Identifying and Treating Eating Disorders”,Pediatrics, January 2003, Vol 111, Issue 1.
Children’s Healthcare of Atlanta | Emory University
AAP Medical Criteria for Hospitalization
•
Anorexia
Nervosa
–<75% ideal body weight
–Heart rate <50 beats per minute
•<45 beats per minute nighttime
–Systolic blood pressure <90
–Orthostatic changes
•in pulse (>20 beats per minute)
•or blood pressure (>10 mm Hg)
–Temperature <96 degrees F
–Arrhythmia
–Electrolyte abnormalities
–Refusal to eat
–Ongoing weight loss despite
intensive outpatient therapy
–Suicidality
•
Bulimia
Nervosa
–Syncope
–Electrolyte disturbances:
• Serum potassium < 3.2 mmol/L • Serum chloride < 88 mmol/L
–Esophageal tears
–Cardiac arrhythmias including
prolonged QTc
–Hypothermia
–Intractable vomiting
–Hematemesis
Children’s Healthcare of Atlanta | Emory University
What is Refeeding Syndrome?
• Refeeding syndrome is:
–A. A potentially lethal drop in phosphorous, magnesium and potassium in
starving patients who start to take in glucose
–B. More likely in patients who are at very low weights, in patients who have
lost a significant amount of weight, and in patients who have recently had
very little intake
–C. More likely in patients who have diabetes and are also misusing their insulin
–D. All of the above
Children’s Healthcare of Atlanta | Emory University
Answer: D. All of the above
• The Risk of Refeeding Syndrome is Increased in Patients with:
• ONE of the following: –BMI < 16
–Weight loss of greater than 15% over the past 3‐6 months
–Little or no nutritional intake for the past 10 or more days
–Low levels of phosphorous, magnesium or potassium before refeeding
• OR TWO of the following:
–BMI < 18.5
–Weight loss of greater than 10% over the past 3‐6 months
–Little or no nutritional intake for the past 5 or more days
–History of abuse of alcohol or drugs including insulin or diuretics
Refeeding Syndrome
The source website is:
http://lookfordiagnosis.com/mesh_info.php?term=ref eeding+syndrome&lang=4
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Before they leave your office…
• The patient’s mother agrees to take him to the hospital but she wants to ask you a few questions before they go. She has read a lot about eating disorders and she is worried about his long term health.
• You tell her that:
–A. Almost all medical complications of anorexia nervosa improve with weight
restoration
–B. Some of the medical complications such as bradycardia, hypoglycemia and
refeeding syndrome can be lethal but can be managed in the hospital setting
–C. He will need his bone density checked by DEXA while he is in the hospital.
Bone loss is the one medical complication that may not be fully reversible.
–D. All of the above
Children’s Healthcare of Atlanta | Emory University
Answer D. All of the above
• In Anorexia Nervosa
–The medical complications are the direct result of starvation and weight loss
–Most medical complications reverse with complete weight restoration
•Cardiac – bradycardia, hypotension, congestive heart failure •GI – gastroparesis, constipation, abnormal liver function
•Endocrine – euthyroid sick syndrome, amenorrhea, down‐regulation of HPG axis
•Hematologic – leukopenia, anemia, thrombocytopenia
–One exception – osteopenia and osteoporosis
• In Bulimia Nervosa
–The medical complications relate to the method and frequency of purging
–Most medical complications reverse with cessation of purging
•GI – rebound constipation, esophagitis, sialoadenitis, Mallory‐Weiss tears •Metabolic – electrolyte imbalances
•Renal – pseudo Bartter’s syndrome
–One possible exception – Barrett’s esophagus/risk for esophageal cancer
Children’s Healthcare of Atlanta | Emory University
Goals of Medical Admission
•
Manage
medical
complications
–Correct metabolic disturbances
–Prevent refeeding syndrome
•
Evaluate
psychiatric
comorbidities
–Some patients may benefit from medication
–Some patients may have co‐morbid conditions that may also need
treatment
•
Initiate
correction
of
malnourished
state
–Start evaluation and treatment – promote healthy eating and weight gain
–Important to have a multidisciplinary team approach
•
Develop
plan
of
care
for
after
hospital
discharge
–Assess and refer to adequate level of psychiatric care – residential, PHP,
IOP, outpatient
–Eating disorders are a psychiatric illness and need treatment from a multidisciplinary team with extensive eating disorder experience
Children’s Healthcare of Atlanta | Emory University
What happens after medical
admission?
• The patient that improves with admission or does not require admission – Remain an active member of the team when the patient goes home
•Monitor weight, vital signs, menses
•Remember that restoration of health can take 2‐3 years – Expect set‐backs, especially with new stressors – Encourage and require ongoing follow‐up
•Nutritionist, therapist and psychiatrist
•May need formal programming for enough support (PHP, IOP) • The patient that does not improve sufficiently with medical admission
– Remain an active member of the team when the patient goes to residential treatment •Ask for updates from the residential facility
•Support the family during the admission and on return home – Expect set‐backs, especially with returning home
– Encourage and require ongoing follow‐up •Nutritionist, therapist and psychiatrist
•Most will need formal programming for enough support (PHP, IOP) initially
Children’s Healthcare of Atlanta | Emory University
Remember
• Medically unstable patients must be hospitalized
• Refeeding syndrome can be deadly
• Most medical complications, except osteoporosis, resolve with weight
restoration
• Patients with eating disorders can, and do, get better
• Thank you!
Local Resources
• Outpatient Facilities
–Atlanta Center for Eating Disorders (ACE) (males and females, age 10+)
–Ridgeview Institute (females only, age 13+)
–Renfrew Treatment Center (females only, age 15+)
• Acute Psychiatric Inpatient Facilities
–Ridgeview Institute (females only, age 13+)
• Long‐Term Residential Facilities: No facilities in Atlanta
–Veritas Collaborative (Durham, NC) (ages 10+)
Children’s Healthcare of Atlanta | Emory University
National Resources
•
Academy
for
Eating
Disorders
(AED)
–
www.aedweb.org
•
National
Eating
Disorder
Association
(NEDA)
–
www.nationaleatingdisorders.org
•
National
Association
of
Anorexia
Nervosa
and
Associated
Disorders
(ANAD)
–
www.anad.org
•
Eating
Disorder
Information
Network
(EDIN)
