A subcommittee for the American Academy of Pediatrics (AAP) has released a statement on identifying and evaluating eating disorders; outpatient, hospital, and day-program treatment options; and prevention and advocacy suggestions. The report was published in the January 2003 issue of Pediatrics.
The increasing incidence and prevalence of eating disorders in children and adolescents have made it increasingly important for physicians to be aware of and be able to treat these problems. Early detection, initial evaluation, and ongoing management can play a significant role in preventing the illness from progressing to a more severe or chronic state.
Identification and Evaluation
Screening for eating disorders should be part of routine annual health care, including ongoing monitoring of weight and height and looking for signs and symptoms of an incipient eating disorder. If eating disorders are detected early, it may prevent any physical or psychologic consequences of malnutrition that could cause the illness to progress. Failure to diagnose an eating disorder early can result in an increase in severity of the illness, which can make the disorder more difficult to treat. Table 1 lists useful questions for gathering a history on eating disorders.
Initial evaluation of a child or adolescent with a suspected eating disorder should include establishing a diagnosis; determining the severity of illness, including an evaluation of medical and nutritional status; and performing a psychosocial evaluation. According to the AAP, more than one half of children and adolescents with eating disorders do not fully meet all Diagnostic and Statistical Manual of Mental Disorders, 4th ed. (DSM-IV) criteria for anorexia or bulimia nervosa, but still experience the same medical and psychologic consequences of these illnesses. These patients require the same attention and care as those who meet all the criteria.
To establish a baseline for severity in a patient with an eating disorder, the physician should determine total weight loss and weight status (i.e., percent below ideal body weight and body mass index) and the types and frequency of purging behaviors (e.g., vomiting, laxatives, starvation). Test results will be normal in most patients with eating disorders, but normal results do not exclude serious illness or medical instability. The psychosocial assessment should include an evaluation of the patient's degree of obsession with food and weight, understanding of the diagnosis, and willingness to receive help; how the patient is functioning at home, in school, and with friends; and if the patient has any other psychiatric diagnoses, such as depression, anxiety, or obsessive compulsive disorder. These diagnoses may be comorbid or a cause or consequence of the eating disorder. History of physical or sexual abuse, or violence and suicidal ideation also should be assessed. The parents' reaction to the illness should be evaluated because denial of the problem or differences in how to approach treatment and recovery may exacerbate the illness.
Treatment should be individualized, and goal weights should be based on age, height, stage of puberty, premorbid weight, and previous growth charts. For a growing child or adolescent, goal weight should be reevaluated at three- to six-month intervals on the basis of changing age and height. In general, medical stabilization and nutritional rehabilitation are the most crucial determinants of short- and intermediate-term outcomes. Individual and family therapy, especially when working with younger patients, are crucial to the long-term prognosis.
Physicians should be aware of several complications that can occur in outpatient settings. Although most patients do not have abnormal electrolyte levels, there is a possibility of hypokalemia, hypochloremic alkalosis resulting from purging behaviors, and hyponatremia or hypernatremia resulting from drinking too much or too little fluid as part of weight manipulation. Endocrine disorders, including hypothyroidism, hypercortisolism, and hypogonadotropic hypogonadism, are common. With amenorrhea, there is a long-term complication of osteopenia and ultimately osteoporosis. Gastrointestinal distress and constipation are common and may require symptomatic relief.
Hospital and Day-Program Treatment
Children and adolescents have the best prognosis if the disease is treated rapidly and aggressively. Hospitalization allows for adequate weight gain, medical stability, and establishment of safe and healthy eating habits, which improves the prognosis. These patients are usually more malnourished than outpatients. Nutrition may need to be provided via nasogastric tube or intravenously, and more severe complications may need to be treated (Table 2). In severely malnourished patients, physicians should avoid replenishing nutrients too quickly, which can cause refeeding syndrome. Slow refeeding, with possible phosphorus supplementation can help prevent this problem.