CLINICAL REPORT Guidance for the Clinician in Rendering Pediatric Care

Identification and Management of Eating Disorders in Children and Adolescents Laurie L. Hornberger, MD, MPH, FAAP,a Margo A. Lane, MD, FRCPC, FAAP,b THE COMMITTEE ON ADOLESCENCE

Eating disorders are serious, potentially life-threatening illnesses afflicting abstract individuals through the life span, with a particular impact on both the physical and psychological development of children and adolescents. Because care for children and adolescents with eating disorders can be complex and resources aDivision of Adolescent Medicine, Children’s Mercy Kansas City and School of Medicine, University of Missouri–Kansas City, Kansas City, for the treatment of eating disorders are often limited, pediatricians may be Missouri; and bDepartment of Pediatrics and Child Health, Max Rady called on to not only provide medical supervision for their patients with College of Medicine, Rady Faculty of Health Sciences, University of diagnosed eating disorders but also coordinate care and advocate for Manitoba, Winnipeg, Manitoba appropriate services. This clinical report includes a review of common eating Clinical reports from the American Academy of Pediatrics benefit from expertise and resources of liaisons and internal (AAP) and external disorders diagnosed in children and adolescents, outlines the medical reviewers. However, clinical reports from the American Academy of evaluation of patients suspected of having an eating disorder, presents an Pediatrics may not reflect the views of the liaisons or the organizations or government agencies that they represent. overview of treatment strategies, and highlights opportunities for advocacy. Drs Hornberger and Lane were equally responsible for conceptualizing, writing, and revising the manuscript and considering input from all reviewers and the board of directors; and all authors approve the final manuscript as submitted. INTRODUCTION The guidance in this report does not indicate an exclusive course of treatment or serve as a standard of medical care. Variations, taking Definitions into account individual circumstances, may be appropriate. All clinical reports from the American Academy of Pediatrics Although the earliest medical account of an adolescent patient with an automatically expire 5 years after publication unless reaffirmed, eating disorder was more than 300 years ago,1 a thorough understanding revised, or retired at or before that time. of the pathophysiology and psychobiology of eating disorders remains This document is copyrighted and is property of the American elusive today. The Diagnostic and Statistical Manual of Mental Disorders, Academy of Pediatrics and its Board of Directors. All authors have filed conflict of interest statements with the American Academy of Fifth Edition (DSM-5) includes the latest effort to describe and categorize Pediatrics. Any conflicts have been resolved through a process eating disorders,2 placing greater emphasis on behavioral rather than approved by the Board of Directors. The American Academy of Pediatrics has neither solicited nor accepted any commercial physical and cognitive criteria, thereby clarifying these conditions in those involvement in the development of the content of this publication. children who do not express body or weight distortion. DSM-5 diagnostic DOI: https://doi.org/10.1542/peds.2020-040279 criteria for several of the eating disorders commonly seen in children and Address correspondence to Laurie L. Hornberger, MD. Email: adolescents are presented in Table 1. [email protected] Notable changes in DSM-5 since the previous edition include the elimination of amenorrhea and specific weight percentiles in the diagnosis To cite: Hornberger LL, Lane MA, AAP THE COMMITTEE ON of anorexia nervosa (AN) and a reduction in the frequency of binge eating ADOLESCENCE. Identification and Management of Eating and compensatory behaviors required for the diagnosis of bulimia nervosa Disorders in Children and Adolescents. Pediatrics. 2021; 147(1):e2020040279 (BN). The diagnosis “eating disorder not otherwise specified” has been

Downloaded from www.aappublications.org/news by guest on September 27, 2021 PEDIATRICS Volume 147, number 1, January 2021:e2020040279 FROM THE AMERICAN ACADEMY OF PEDIATRICS TABLE 1 Diagnostic Features of Eating Disorders Commonly Seen in Children and Adolescents DSM-5 Eating Disorder Diagnosis Diagnostic Features Anorexia nervosa (AN) A. Restricted caloric intake relative to energy requirements, leading to significantly low body weight for age, sex, projected growth, and physical health B. Intense fear of gaining weight or behaviors that consistently interfere with weight gain, despite being at a significantly low weight C. Altered perception of one’s body weight or shape, excessive influence of body weight or shape on self-value, or persistent lack of acknowledgment of the seriousness of one’s low body weight Subtypes: restricting type (weight loss is achieved primarily through dieting, fasting, and/or excessive exercise. In the previous 3 mo, there have been no repeated episodes of binge eating or purging); binge-eating/purging type (in the previous 3 mo, there have been repeated episodes of binge eating or purging; ie, self-induced vomiting or misuse of laxatives, diuretics, or enemas) Bulimia nervosa (BN) Repeated episodes of binge eating. Binge eating is characterized by both of the following: within a distinct period of time (eg, 2 h), eating an amount of food that is clearly larger than what most individuals would eat during a similar period of time under similar circumstances and a sense that one cannot limit or control their overeating during the episode Repeated use of inappropriate compensatory behaviors for the prevention of weight gain, such as self-induced vomiting; misuse of laxatives, diuretics, or other medications; fasting; or excessive exercise On average, the binge eating and compensatory behaviors both occur at least once a week for 3 mo Self-value is overly influenced by body shape and weight The binge eating and compensatory behaviors do not occur exclusively during episodes of AN Binge-eating disorder (BED) Recurrent episodes of binge eating. An episode of binge eating is characterized by both of the following: within a distinct period of time (eg, 2 h), eating an amount of food that is clearly larger than what most individuals would eat during a similar period of time under similar circumstances and sense that one cannot limit or control their overeating during the episode The binge-eating episodes include 3 or more of the following: eating much more quickly than normal, eating until uncomfortably full, eating large amounts of food when not feeling hungry, eating alone because of embarrassment at how much one is eating, and feeling guilty, disgusted, or depressed afterward Marked anguish is experienced regarding binge eating On average, the binge eating occurs at least once a week for 3 mo The binge eating is not associated with the use of inappropriate compensatory behavior as in BN and does not occur only in the context of BN or AN Avoidant/restrictive food intake disorder (ARFID) A disrupted eating pattern (eg, seeming lack of interest in eating or food; avoidance based on the sensory qualities of food; concern about unpleasant consequences of eating) as evidenced by persistent failure to meet appropriate nutritional and/or energy needs associated with 1 (or more) of the following: significant weight loss or, in children, failure to achieve expected growth and/or weight gain, marked nutritional deficiency, reliance on enteral feeding or oral nutritional supplements, significant interference with psychosocial functioning The disturbance cannot be better explained by lack of available food or by an associated culturally sanctioned practice The eating disturbance cannot be attributed to a coexisting medical condition nor better explained by another mental disorder. If the eating disturbance occurs in the context of another condition or disorder, the severity of the eating disturbance exceeds that routinely associated with the condition or disorder Other specified feeding or eating disorders, examples Atypical AN: all of the criteria for AN are met yet the individual’s weight is within or above the normal range despite significant weight loss BN (of low frequency and/or limited duration): All of the criteria for BN are met, but, on average, the binge eating and compensatory behaviors occur less than once a week and/or for ,3mo BED (of low frequency and/or limited duration): All of the criteria for BED are met, but, on average, the binge eating occurs less than once a week and/or for ,3mo Purging disorder: recurrent purging behavior (eg, self-induced vomiting; misuse of laxatives, diuretics, or other medications) in the absence of binge eating with the intent to influence weight or body shape Adapted from the DSM-5, American Psychiatric Association, 2013.2 eliminated, and several diagnoses restrictive food intake disorder previously categorized in the fourth have been added, including binge- (ARFID).3–5 The diagnosis of ARFID edition (DSM-IV)as“feeding disorder eating disorder (BED) and avoidant/ encompasses feeding behaviors of infancy and early childhood” and

Downloaded from www.aappublications.org/news by guest on September 27, 2021 2 FROM THE AMERICAN ACADEMY OF PEDIATRICS expands these into adolescence and BED prevalence rates of 2 to 4, with Eating disorders can occur in adulthood. Individuals with ARFID a more equal distribution between individuals with various body intentionally limit intake for reasons girls and boys, making it perhaps the habitus, and their presence in those of other than for concern for body most common eating disorder among larger body habitus is increasingly weight, such as the sensory adolescents.14 In contrast, the apparent.31–34 Weight stigma (the properties of food, a lack of interest in diagnoses seen in treatment may undervaluation or negative eating, or a fear of adverse belie the relative prevalence of these stereotyping of individuals because consequences with eating (eg, disorders. In a review of 6 US they have overweight or obesity) choking or vomiting). As a result, they adolescent eating disorder treatment seems to play a role. Adolescents with may experience weight loss or failure programs, the distribution of larger body habitus are exposed to to achieve expected weight gain, diagnoses was 32 AN, 30 atypical AN, weight stigma through the media, malnutrition, dependence on 9 BN, 19 ARFID, 6 purging disorder, their families, peers, and teachers, nutritional supplementation, and/or and 4 others. 15 This may reflect the and health care professionals, interference with psychosocial underrecognition and/or resulting in depression, anxiety, poor – functioning.6 9 The category “other undertreatment of disorders such as body image, social isolation, specified feeding and/or eating BED. unhealthy eating behaviors, and disorder” is now applied to patients worsening obesity.35 When whose symptoms do not meet the full Although previously mischaracterized presenting with significant weight criteria for an eating disorder despite as diseases of non-Hispanic white, loss but a BMI still classified in the fl causing significant distress or af uent adolescent girls, eating “healthy,” overweight, or obese impairment. Among these disorders disorder behaviors are increasingly ranges, patients with eating disorders is atypical AN in which diminished recognized across all racial and ethnic such as atypical AN may be groups16–20 and in lower self-worth, nutritional restriction, and 21 overlooked by health care socioeconomic classes, 36,37 weight loss mirrors that seen with 22 providers but may experience the AN, although body weight at preadolescent children, males, and same severe medical complications as presentation is in the normal or children and adolescents perceived as those who are severely above-normal range. Efforts are having an average or increased body underweight.38–40 ongoing to further categorize size. Increased rates of disordered eating abnormal eating behaviors and refine 10 Preteens with eating disorders are may be found in sexual minority diagnoses. – more likely than older adolescents to youth.41 43 Analysis of Youth Risk Epidemiology have premorbid psychopathology Behavior Survey data reveals lesbian, (depression, obsessive-compulsive gay, and bisexual high school students Prevalence data for eating disorders disorder, or other anxiety disorders) have significantly higher rates of vary according to study populations and less likely to have binge and unhealthy and disordered weight- and the criteria used to define an purge behaviors. There is a more control behaviors than their eating disorder.11 A systematic review equal distribution of illness by sex heterosexual peers.44,45 Transgender of prevalence studies published among younger patients and, youth may be at particular risk.46,47 between 1994 and 2013 found widely frequently, more rapid weight loss, In a survey of nearly 300 000 college varied estimates in the lifetime leading to earlier presentation to students, transgender students had prevalence of eating disorders, with 23 health care providers. the highest rates of self-reported a range from 1.0 to 22.7 for female eating disorder diagnoses and individuals and 0.3 to 0.6 for male Although diagnosis in males may compensatory behaviors (ie, use of indnividuals.12 A 2011 cross-sectional increase with the more inclusive diet pills or laxatives or vomiting) survey of more than 10 000 DSM-5 criteria,24,25 it is often delayed compared with all cisgender groups. nationally representative US because of the misperception of Nearly 16 of transgender respondents adolescents 13 to 18 years of age health care providers that eating reported having been diagnosed with estimated prevalence rates of AN, BN, disorders are female disorders.26 In an eating disorder, as compared with and BED at 0.3, 0.9, and 1.6, addition, disordered eating attitudes 1.85 of cisgender heterosexual respectively. Behaviors suggestive of may differ in male individuals,27 women.48 AN and BED but not meeting focusing on leanness, weight control, diagnostic thresholds were identified and muscularity. Purging, use of Adolescents with chronic health in another 0.8 and 2.5, respectively. muscle-building supplements, conditions requiring dietary control The mean age of onset for each of substance abuse, and comorbid (eg, diabetes, cystic fibrosis, these disorders was 12.5 years.13 depression are common in inflammatory bowel disease, and Several studies have suggested higher males.28–30 celiac disease) may also be at

Downloaded from www.aappublications.org/news by guest on September 27, 2021 PEDIATRICS Volume 147, number 1, January 2021 3 TABLE 2 Example Questions to Ask Adolescents With a Possible Eating Disorder History/Information Example Questions Weight history What was your highest weight? How tall were you? How old were you? What was your lowest weight? How tall were you? How old were you? Body image What do you think your weight should be? What feels too high? What feels too low? Are there body areas that cause you stress? Which areas? Do you do any body checking (ie, weighing, body pinching or checking, mirror checking)? How much of your day is spent thinking about food or your body? Diet history 24-h diet history Do you count calories, fat, carbohydrates? How much do you allow? What foods do you avoid? Do you ever feel guilty about eating? How do you deal with that guilt (ie, exercising, purging, eating less)? Do you feel out of control when eating? Exercise history Do you exercise? What activities? How often? How intense is your workout? How stressed do you feel when you are unable to exercise? Binge eating and purging Do you ever binge? On what foods? How much? How often? Any triggers? Do you vomit? How often? How soon after eating? Do you use laxatives, diuretics, diet pills, caffeine? What types? How many? How often? Family history Does anyone in your family have a history of dieting or an eating disorder? Anyone on special diets (eg, vegetarian, gluten-free)? Anyone with obesity? Does anyone in your family have a history of depression, anxiety, bipolar disorder, obsessive-compulsive disorder, substance abuse, or other psychiatric illness? Does anyone in your family take psychiatric medication? Review of systems Dizziness, syncope, weakness or fatigue? Pallor, easy bruising or bleeding, cold intolerance? Hair loss, lanugo, dry skin? Constipation, diarrhea, early fullness, bloating, abdominal pain, heartburn? Palpitations, chest pain? Muscle cramps, joint pains? Excessive thirst and voiding? For girls: Age at menarche? Frequency of menses? LMP? Weight at time of LMP? Psychosocial history (HEADSS) Home Who lives in the home? How well do the family members get along with each other? Is the family experiencing any stressors? Education Where do you attend school? What grade? Regular classroom? Is school challenging for you? What grades do you receive? Has there been a change in your grades? Activities What activities are you involved in outside of the classroom? Do you have friends you can trust? Have you experienced any bullying? What Web sites do you most often visit when you go online? How much time is spent each day online? Drug use Have you ever used tobacco, e-cigarettes, alcohol, or drugs? Which ones? How much? How often? Have you ever used anabolic steroids or stimulants? Caffeine consumption? Other substances? Depression/suicide How is your mood? Increased irritability? Feelings of depression or hopelessness? Any anxiety or obsessive-compulsive thoughts or behaviors? Any history of cutting or self-injury? Have you ever wished you were dead? How often do you have these thoughts? When was the last time? Any thoughts of suicide? What methods have you imagined? Any attempts? History of physical, sexual or emotional abuse? Any previous mental health care? Sexual history

Downloaded from www.aappublications.org/news by guest on September 27, 2021 4 FROM THE AMERICAN ACADEMY OF PEDIATRICS TABLE 2 Continued History/Information Example Questions Do you feel that the gender you feel inside matches your body on the outside? Are you romantically or sexually attracted to guys, girls, or both? Not sure? Have you had any sexual contact with another person? If yes, was it with guys, girls or both? Use of condoms? Use of contraceptives? History of pregnancy or sexually transmitted infection? Has anyone touched you sexually when you didn’t want to be touched? Adapted from Rome and Strandjord.89 LMP, last menstrual period. increased risk of disordered young women acknowledged that requirements, or idealized body eating.49–51 Among teenagers with their decision to become vegetarian shapes may be at particular risk of type 1 diabetes mellitus, at least one- was primarily motivated by their relative energy deficiency in sport. third may engage in binge eating, self- desire for weight loss, and most Signs and symptoms of relative induced vomiting, insulin omission reported that they had done so at energy deficiency, such as for weight loss, and excessive least a year after first developing amenorrhea, bradycardia, or stress exercise,52,53 resulting in poorer eating disorder symptoms.60 fractures, may alert pediatricians to glycemic control.54 this condition. In an attempt to improve Many adolescents engage in dietary performance or achieve a desired practices that may overlap with or physique, adolescent athletes may SCREENING FOR EATING DISORDERS disguise eating disorders. The lay engage in unhealthy weight-control 61 “ Pediatricians are in a unique position term "orthorexia" describes the behaviors. The term female athlete ” to detect eating disorders early and behavior of individuals who become triad has historically referred to (1) low energy availability that may or interrupt their progression. Annual increasingly restrictive in their food health supervision visits and consumption, not based on concerns may not be related to disordered eating; (2) menstrual dysfunction; preparticipation sports examinations for quantity of food but the quality of offer opportunities to screen for food (eg, specific nutritional content and (3) low bone mineral density (BMD) in physically active eating disorders. Bright Futures: or organically produced). The desire 62–65 Guidelines for Health Supervision of to improve one’s health through females. Inadequate caloric intake in comparison to energy Infants, Children, and Adolescents, optimal nutrition and food quality is expenditure is the catalyst for fourth edition, offers sample the initial focus of the patient, and endocrine changes and leads to screening questions about eating weight loss and/or malnutrition may 69 decreased bone density and patterns and body image. Reported ensue as various foods are eliminated menstrual irregularities. Body weight dieting, body image dissatisfaction, from the diet. Individuals with may be stable. This energy imbalance experiences of weight-based stigma, orthorexia may spend excessive may result from a lack of knowledge or changes in eating or exercise amounts of time in meal planning and regarding nutritional needs in the patterns invite further exploration. experience extreme guilt or athlete or from intentional intake Positive responses on a standard frustration when their food-related restriction associated with disordered review of symptoms may need practices are interrupted.55,56 eating. further probing. For example, Psychologically, this behavior appears oligomenorrhea or amenorrhea to be related to AN and obsessive- Hormonal disruption and low BMD (either primary or secondary) may 57 compulsive disorder and is can occur in undernourished male indicate energy deficiency.70 Serial considered by some to be a subset athletes as well.66 Increased weight and height measurements within the restrictive eating recognition of the role of energy plotted on growth charts are disorders. Vegetarianism is a lifestyle deficiency in disrupting overall invaluable. Weight loss or the failure choice adopted by many adolescents physiologic function in both male and to make expected weight gain may be and young adults that may sometimes female individuals led a 2014 more obvious when documented on signal underlying eating International Olympic Committee a graph. Similarly, weight fluctuations pathology.58,59 In a comparison of consensus group to recommend or rapid weight gain may cue a health adolescent and young adult females replacing the term female athlete care provider to question binge eating with and without a history of eating triad to the more inclusive term, or BN symptoms. Recognizing that disorders, those with eating disorders “relative energy deficiency in many patients who present to eating were more likely to report ever sport.”67,68 Athletes participating in disorder treatment programs have or having been vegetarian. Many of these sports involving endurance, weight previously had elevated weight

Downloaded from www.aappublications.org/news by guest on September 27, 2021 PEDIATRICS Volume 147, number 1, January 2021 5 TABLE 3 Notable Physical Examination Features in Children and Adolescents With Eating Disorders may have been unrecognized Features related to inadequate energy intake or malnutrition: previously. Deviation from previous growth trajectory when plotted on height, weight, and BMI graphs Abnormal vital signs: A comprehensive physical Low resting HR or BP examination, including close attention Orthostatic increase in HR (.20 beats per min) or decrease in BP (.10 mm Hg) to growth parameters and vital signs, Hypothermia allows the pediatrician to assess for Flat or anxious affect signs of medical compromise and for Pallor, dry sallow skin; carotenemia (particularly palms and soles) Cachexia: facial wasting, decreased subcutaneous fat, decreased muscle mass signs and symptoms of eating Dull, thin scalp hair or lanugo disorder behaviors; findings may be Cardiac murmur (one-third with mitral valve prolapse), cool extremities; acrocyanosis; poor subtle and, thus, overlooked without perfusion careful notice. For accuracy, weights Stool mass left lower quadrant are best obtained after the patient has Delayed or interrupted pubertal development Small breasts; vaginal dryness voided and in an examination gown Small testes without shoes. Weight, height, and Features related to purging: BMI can be evaluated by using Abnormal vital signs: appropriate growth charts. Low body . . Orthostatic increase in HR ( 20 beats per min) or decrease in BP ( 10 mm Hg) temperature, resting blood pressure Angular stomatitis; palatal scratches; dental enamel erosions Russell’s sign (abrasion or callous on knuckles from self-induced emesis) (BP), or resting heart rate (HR) for Salivary gland enlargement (parotid and submandibular) age may suggest energy restriction. Epigastric tenderness Because a HR of 50 beats per minute Bruising or abrasions over the spine (related to excessive exercise or sit ups) or less is unusual even in college- Features related to excess energy intake: aged athletes,76 the finding of a low Deviation from previous growth trajectory when plotted on height, weight, and BMI curves Obesity HR may be a sign of restrictive eating. Elevated BP or hypertension Orthostatic vital signs (HR and BP, Acanthosis nigricans, acne, hirsutism obtained after 5 minutes of supine Hepatomegaly rest and repeated after 3 minutes of Premature puberty standing)77,78 revealing a systolic BP Musculoskeletal pain drop greater than 20 mm Hg, 208 Adapted from Rosen; American Academy of Pediatrics. a diastolic BP drop greater than 10 mm Hg, or tachycardia may suggest according to criteria from the Centers the Academy for Eating Disorders.72 volume depletion from restricted fl for Disease Control and Prevention,71 Relevant interview questions are uid intake or purging or it is worthwhile to carefully inquire listed in Table 2. A collateral history a compromised cardiovascular about eating and exercise patterns from a parent may reveal abnormal system. when weight loss is noted in any child eating-related behaviors that were Pertinent physical findings in children or adolescent. Screening for denied or minimized by the child or and adolescents with eating disorders unhealthy and extreme weight- adolescent. are summarized in Table 3. A control measures before praising differential diagnosis for the signs desirable weight loss can avoid A full psychosocial assessment, and symptoms of an eating disorder inadvertently reinforcing these including a home, education, is found in Table 4, and selected practices. activities, drugs/diet, sexuality, medical complications of eating suicidality/depression (HEADSS) disorders are provided in Table 5. assessment is vital. This evaluation ASSESSMENT OF CHILDREN AND includes screening for physical or ADOLESCENTS WITH SUSPECTED sexual abuse by using the principles LABORATORY EVALUATION EATING DISORDERS of trauma-informed care and Initial laboratory evaluation is A comprehensive assessment of responding according to American performed to screen for medical a child or adolescent suspected of Academy of Pediatrics guidance on complications of eating disorders or having an eating disorder includes suspected physical or sexual abuse or to rule out alternate diagnoses – a thorough medical, nutritional, and sexual assault73 75 as well as state (Tables 4 and 5). Typical initial psychiatric history, followed by laws. Vital to the HEADSS assessment laboratory testing includes a detailed physical examination. A is an evaluation for symptoms of a complete blood cell count; serum useful web resource for assessment is other potential psychiatric diagnoses, electrolytes, calcium, magnesium, published in multiple languages by including suicidal thinking, which phosphorus, and glucose; liver

Downloaded from www.aappublications.org/news by guest on September 27, 2021 6 FROM THE AMERICAN ACADEMY OF PEDIATRICS TABLE 4 Selected Differential Diagnosis for Eating Disorders According to Presentation Clinical Presentations Differential Diagnosis Weight loss Gastrointestinal Inflammatory bowel disease; celiac disease Endocrine Hyperthyroidism; diabetes mellitus; adrenal insufficiency Infectious Chronic infections, such as tuberculosis or HIV; intestinal parasite Psychiatric Depression; psychosis; anxiety or obsessive-compulsive disorder; substance use Other Neoplasm; superior mesenteric artery syndrome Vomiting Gastroesophageal reflux disease Gastrointestinal disease Gastroesophageal reflux disease Eosinophilic esophagitis Pancreatitis Cyclic vomiting Neurologic Increased intercranial pressure Migraine Other Food allergy Binge eating or unexplained weight gain Endocrine Hypothyroidism; hypercortisolism Psychiatric Depression Iatrogenic Medication side effect Genetic Prader Willi syndrome; Kleine-Levin syndrome Adapted from Rome and Strandjord89 and Rosen; American Academy of Pediatrics.208 transaminases; urinalysis; and eating disorders; normal results do abnormality. A urine pregnancy test thyroid-stimulating hormone not exclude the presence of serious and serum gonadotropin and concentration.72 Screening for illness with an eating disorder or the prolactin levels may be indicated for specific vitamin and mineral need for hospitalization for medical girls with amenorrhea; a serum deficiencies (eg, vitamin B12, vitamin stabilization. An electrocardiogram is estradiol concentration may serve as D, iron, and zinc) may be indicated on important for those with significant a baseline for reassessment during the basis of the nutritional history of weight loss, abnormal cardiovascular recovery.79 Similarly, serum the patient. Laboratory investigations signs (such as orthostasis or gonadotropin and testosterone levels are often normal in patients with bradycardia), or an electrolyte can be useful to assess and monitor

TABLE 5 Selected Medical Complications Resulting From Eating Disorders Eating Disorder Behaviors Medical Complications Related to dietary restriction or weight loss Fluids and electrolytes Dehydration; electrolyte abnormalities: hypokalemia, hyponatremia Psychiatric Depressed mood or mood dysregulation; obsessive-compulsive symptoms; anxiety Neurologic Cerebral cortical atrophy; cognitive deficits; seizures Cardiac Decreased cardiac muscle mass, right axis deviation, low cardiac voltage; cardiac dysrhythmias, cardiac conduction delays; mitral valve prolapse; pericardial effusion; congestive heart failure; edema Gastrointestinal Delayed gastric emptying, slowed gastrointestinal motility, constipation; superior mesenteric artery syndrome; pancreatitis; elevated transaminases; hypercholesterolemia Endocrinologic Growth retardation; hypogonadotropic hypogonadism: amenorrhea, testicular atrophy, decreased libido; sick euthyroid syndrome; hypoglycemia/hyperglycemia, impaired glucose tolerance; hypercholesterolemia; decreased BMD Hematologic Leukopenia, anemia, thrombocytopenia, elevated ferritin; depressed erythrocyte sedimentation rate Related to vomiting Fluid and electrolytes Electrolyte disturbance: hypokalemia, hypochloremia, metabolic alkalosis Dental Dental erosions Gastrointestinal Gastroesophageal reflux, esophagitis; Mallory-Weiss tears; esophageal or gastric rupture Related to laxative use Fluids and electrolytes Hyperchloremic metabolic acidosis; hypocalcemia Gastrointestinal Laxative dependence Related to binge eating Obesity with accompanying complications Related to refeeding Night sweats; polyuria, nocturia; refeeding syndrome: electrolyte abnormalities, edema, seizures, congestive heart failure (rare) Seen among all eating disorder Suicide behaviors Adapted from Rosen; American Academy of Pediatrics.208

Downloaded from www.aappublications.org/news by guest on September 27, 2021 PEDIATRICS Volume 147, number 1, January 2021 7 for central hypogonadism in boys participants had deficits in executive increased growth of cariogenic oral with restrictive eating. Bone functioning, including global bacteria.98,100 densitometry, by using dual processing and cognitive flexibility radiograph absorptiometry analyzed but performed better than control Cardiovascular Effects with age-appropriate software, may participants on measures of visual Reports of cardiac complications in 94 be considered for those with attention and vigilance. eating disorders are focused amenorrhea for more than 6 to 12 predominantly on restrictive eating 80,81 Structural brain imaging studies to months. If there is uncertainty disorders. Common cardiovascular date have yielded inconsistent results, about the diagnosis, other studies signs include low HR, orthostasis, and fl likely explained, at least in part, by including in ammatory markers, poor peripheral perfusion. methodologic differences and the serological testing for celiac disease, Orthostatic intolerance symptoms need to control for many variables, serum cortisol concentrations, testing (eg, lightheadedness) and vital sign including nutritional state, hydration, stool for parasites, or radiographic findings may resemble those of medication use, and comorbid imaging of the brain or postural orthostatic tachycardia illness.95 A longitudinal study gastrointestinal tract may be syndrome101,102 and may contribute revealed that global cortical thinning considered. In the occasional patient, to a delay in referral to appropriate in acutely ill adolescents and young both an eating disorder and an care if eating disorder behaviors are adults with AN normalized with organic illness, such as celiac disease, not disclosed or appreciated. may be discovered.82 weight restoration over a period of approximately 3 months.96 Cardiac structural changes include decreased left ventricular (LV) mass, MEDICAL COMPLICATIONS IN PATIENTS Dermatologic Effects LV end diastolic and LV end systolic WITH EATING DISORDERS volumes, functional mitral valve Common skin changes in Eating disorders can affect every prolapse, pericardial effusion, and underweight patients include lanugo, organ system83,84 with potentially myocardial fibrosis (noted in hair thinning, dry scaly skin, and 103–105 serious medical complications that adults). Electrocardiographic yellow discoloration related to develop as a consequence of abnormalities, including sinus carotenemia. Brittle nails and angular malnutrition, weight changes, or bradycardia, and lower amplitude LV cheilitis may also be observed. purging. Details of complications are forces are more common in AN than – Acrocyanosis can be observed in 106 described in reviews85 89 and are in nonrestrictive eating disorders. underweight patients and may be summarized in Table 5. Most medical One study reported a nearly 10 a protective mechanism against heat complications resolve with weight prevalence of prolonged (.440 loss. Abrasions and calluses over the normalization and/or resolution of milliseconds) QTc interval in knuckles can occur from cutting the purging. Complications of BED can hospitalized adolescents and young skin on incisors while self-inducing include those of obesity; these are 97 adults with a restrictive eating emesis. 107 summarized in other reports and not disorder. Repolarization reiterated here.84,90 abnormalities, a potential precipitant Dental and/or Oral Effects to lethal arrhythmia,108 may prompt Psychological and Neurologic Effects Patients with eating disorders clinicians to also consider other Psychological symptoms can be experience higher rates of dental factors, such as medication use or primary to the eating disorder, erosion and caries. This occurs more electrolyte abnormalities, that may 107,109 a feature of a comorbid psychiatric frequently in those who self-induce affect cardiac conduction. disorder, or secondary to starvation. emesis but can also be observed in Initial symptoms of depression and those who do not.98 Normal dental Gastrointestinal Tract Effects anxiety may abate with refeeding.91 findings do not preclude the Gastrointestinal complaints are Rumination about body weight and possibility that purging is common and sometimes precede the size is a core feature of AN, whereas occurring.99 Hypertrophy of the diagnosis of the eating disorder. rumination about food decreases as parotid and other salivary glands, Delayed gastric emptying and slow starvation reverses.92 Difficulty in accompanied by elevations in serum intestinal transit time often emotion regulation occurs across the amylase concentrations with normal contribute to reported sensations of spectrum of eating disorders but is lipase concentrations, may be a clue nausea, bloating, and postprandial more severe in those who binge eat to vomiting.99 Xerostomia, from fullness110 and may be a presenting or purge.93 Cognitive function studies either salivary gland dysfunction or feature of restrictive eating. in a large population-based sample of psychiatric medication side effect, can Constipation is a frequent experience adolescents revealed eating disorder reduce the oral pH, which can lead to for patients and multifactorial in

Downloaded from www.aappublications.org/news by guest on September 27, 2021 8 FROM THE AMERICAN ACADEMY OF PEDIATRICS etiology.111 Esophageal mucosal supplemental thyroid hormone is not a healthy sense of self. Independent of damage from self-induced vomiting, indicated when this pattern is a specific DSM diagnosis, treatment is including scratches, and bleeding noted.116 Hypercortisolemia may be focused on nutritional repletion and secondary to Mallory-Weiss tears can seen in AN.81,116 Hypothalamic- psychological therapy. Psychotropic occur.99 Superior mesenteric artery pituitary-gonadal axis suppression medication can be a useful adjunct in syndrome may develop in the setting may be attributable to weight loss, select circumstances. of severe weight loss.111 Hepatic physical overactivity, or stress. transaminase concentrations and Female individuals with AN may have The Pediatrician’s Role in Care coagulation times can be elevated as amenorrhea, and male individuals can After diagnosing an eating disorder, a consequence of malnutrition and, have small testicular volumes117 and the pediatrician arranges appropriate typically, normalize with appropriate low testosterone concentrations.118 care. Patients who are medically nutrition.110 Growth retardation, short stature, and unstable may require urgent referral Renal and Electrolyte Effects pubertal delay may all be observed in to a hospital (Table 6). Patients with prepubertal and peripubertal mild nutritional, medical, and Fluid and electrolyte abnormalities children and adolescents with eating psychological dysfunction may be may occur as a result of purging or disorders.115 AN is associated with managed in the pediatrician’soffice in cachexia.99,112 Dehydration can be low levels of insulin-like growth collaboration with outpatient present in any patient with an eating factor-1 and growth hormone nutrition and mental health disorder. Disordered osmotic resistance.119 Catch-up growth has professionals with specific expertise regulation can present in many been inconsistently reported in the in eating disorders. Because an early patterns (central and renal diabetes literature; younger patients may have response to treatment may be insipidus, syndrome of inappropriate 112 greater and more permanent effects associated with better antidiuretic hormone). Patients 125,126 on growth.120,121 Adolescent boys outcomes, timely referral to who vomit may have a hypokalemic, may be at an even greater risk for a specialized multidisciplinary team hypochloremic metabolic alkalosis height deficits than girls; because is preferred, when available. If resulting from loss of gastric boys typically enter puberty later resources do not exist locally, hydrochloric acid, chronic than girls and experience their peak pediatricians may need to partner dehydration, and the subsequent growth at a later sexual maturity with health experts who are farther increase in aldosterone that promotes stage, they are less likely to have away for care. For patients who do sodium reabsorption in exchange for completed their growth if an eating not improve promptly with potassium and acid at the distal disorder develops in the middle outpatient care, more intensive tubule level.113 Patients who abuse teenage years.119 programming (eg, day-treatment laxatives may experience a variety of programs or residential settings) may electrolyte and acid-base Low BMD is a frequent complication be indicated. derangements.113 Dilutional of eating disorders in both male and hyponatremia can be observed in female patients117 and is a risk in Often, an early task of the pediatrician patients who intentionally water load both AN and BN.122 Low BMD is is to identify a treatment goal weight. to induce satiety or to misrepresent worrisome not only because of the This goal weight may be determined their weight at clinic visits. Abrupt increased risk of fractures in the in collaboration with a registered cessation of laxative use may be short-term123 but, also, because of the dietitian. Pediatricians who are associated with peripheral edema potential to irreversibly compromise planning to refer the patient to and, therefore, motivate further skeletal health in adulthood.124 a specialized treatment team may opt laxative114 or diuretic misuse. to defer the task to the team. Acknowledging that body weights Endocrine Effects TREATMENT PRINCIPLES ACROSS THE naturally fluctuate, the treatment goal Restrictive eating disorders EATING DISORDER SPECTRUM weight is often expressed as a goal commonly cause endocrine The ultimate goals of care in eating range. Individualized treatment goal dysfunction.80,115 Euthyroid sick disorders are that children and weights are formulated on the basis syndrome (low triiodothyronine, adolescents are nourished back to of age, height, premorbid growth elevated reverse triiodothyronine, or their full healthy weight and growth trajectory, pubertal stage, and normal or low thyroxine and thyroid- trajectory, that their eating patterns menstrual history.87,127 In a study of stimulating hormone) is the most and behaviors are normalized, and adolescent girls with AN, of those common thyroid abnormality.116 that they establish a healthy who resumed menses during Functioning as an adaptive relationship with food and their body treatment, this occurred, on average, mechanism to starvation, weight, shape, and size as well as at 95 of the treatment goal weight.128

Downloaded from www.aappublications.org/news by guest on September 27, 2021 PEDIATRICS Volume 147, number 1, January 2021 9 TABLE 6 Indications Supporting Hospitalization in an Adolescent With an Eating Disorder One or More of the Following Justify Hospitalization 1. #75 median BMI for age and sex (percent median BMI calculated as patient BMI/50th percentile BMI for age and sex in reference population 3 100) 2. Dehydration 3. Electrolyte disturbance (hypokalemia, hyponatremia, hypophosphatemia) 4. ECG abnormalities (eg, prolonged QTc or severe bradycardia) 5. Physiologic instability: a. Severe bradycardia (HR ,50 beats per min daytime; ,45 beats per min at night); b. Hypotension (90/45 mm Hg); c. Hypothermia (body temperature ,96°F, 35.6°C); d. Orthostatic increase in pulse (.20 beats per min) or decrease in BP (.20 mm Hg systolic or .10 mm Hg diastolic) 6. Arrested growth and development 7. Failure of outpatient treatment 8. Acute food refusal 9. Uncontrollable binge eating and purging 10. Acute medical complications of malnutrition (eg, syncope, seizures, cardiac failure, pancreatitis and so forth) 11. Comorbid psychiatric or medical condition that prohibits or limits appropriate outpatient treatment (eg, severe depression, suicidal ideation, obsessive- compulsive disorder, type 1 diabetes mellitus) Reprinted with permission from the Society for Adolescent Health and Medicine.85 ECG, electrocardiogram.

Health care providers may be help ensure that deficits in recommendations for patients who pressured by patients, their patients’ micronutrients are addressed. vomit include the use of topical parents, or other health care To optimize bone health, calcium fluoride, applied in the dental office providers to target a treatment goal and vitamin D supplements can be or home, or use of a prescription weight that is lower than the previous dosed to target recommended fluoride (5000 ppm) toothpaste. growth trajectory or other clinical daily amounts (elemental calcium: Because brushing teeth immediately indicators would suggest is 1000 mg for patients 4–8 years of after vomiting may accelerate enamel appropriate. If a treatment goal age, or 1300 mg for patients 9–18 erosion, patients can be advised to weight is inappropriately low, there is years of age; vitamin D: 600 IU for instead rinse with water, followed by an inherent risk of offering only patients 4–18 years of age).87,131 using a sodium fluoride rinse partial weight restoration and Patients can be reassured that whenever possible.132 insufficient treatment.129 The the bloating discomfort caused treatment goal weight is reassessed at by slow gastric emptying improves AN regular intervals (eg, every 3–6 with regular eating. When Collaborative Outpatient Care months) to account for changes in constipation is troubling, nutritional physical growth and development (in strategies, including weight Most patients with AN are treated in particular, age, height, and sexual restoration, are the treatments of outpatient settings.85,133 maturity).87,127 choice.111 When these interventions Pediatricians play an important role are inadequate to alleviate in the medical management and An important role for the pediatrician constipation, osmotic (eg, coordination of the treatment of these is to offer guidance regarding polyethylene glycol 3350) or bulk- patients. The pediatrician plays eating and to manage the physical forming laxatives are preferred over a primary role in assessing for and aspects of the illnesses. For all stimulant laxatives. The use of managing acute and long-term classifications of eating disorders, nonstimulant laxatives decreases the medical complications, monitoring reestablishing regular eating patterns risks of electrolyte derangement and treatment progress, and coordinating is a fundamental early step. Meals avoids the potential hazard of care with nutritional and mental and snacks are reintroduced or “cathartic colon syndrome” that may health colleagues.85,130,134 Although improved in a stepwise manner, be associated with abuse of stimulant some primary care pediatricians with 3 meals and frequent snacks cathartics (senna, cascara, bisacodyl, feel comfortable coordinating care, per day. Giving the message that phenolphthalein, others choose to refer patients “food is the medicine that is required anthraquinones).99,114 to providers with expertise in for recovery” and promoting pediatric eating disorders. Ideally, adherence to taking that medicine To optimize dental outcomes, all members of the treatment team at scheduled intervals often helps patients can be encouraged to are sensitive to the unique patients and families get on track.130 disclose their illness to their developmental needs of children A multivitamin with minerals can dentist. Current dental hygiene and adolescents.133

Downloaded from www.aappublications.org/news by guest on September 27, 2021 10 FROM THE AMERICAN ACADEMY OF PEDIATRICS Educating young people and their restoration is the primary goal. pediatrician directs the care only parents about the physiologic Parents, supported by the therapist, when there are immediate medical and psychological effects of food take responsibility to ensure that safety concerns. If the pediatrician restriction is an early component their child eats sufficiently and limit identifies an urgent medical issue of care. Parents are empowered pathologic weight-control behaviors. that requires intervention or to feed their children regularly Parents are encouraged to take hospitalization, he or she is obligated (typically 3 meals and 2–3 snacks responsibility for meal planning and to provide recommendations to per day) and adjust portion size preparation. Pediatricians can be the patient, the parents, and the and energy richness based on helpful by reminding parents of the primary therapist. For the medically weight progress. Many parents are importance of fighting the disease stable patient, the pediatrician acts amazed to discover the amount of effectively in the early stages, with as a consultant to the parents and energy (3500 kcal or more) that the goals of reaching a truly healthy primary therapist. When a parent may be required to restore weight weight, resuming pubertal asks a question related to treatment, for their children. Detailed tracking development, reversing medical instead of directly advising the of caloric intake is not necessary. complications, and restoring normal parents what to do, the pediatrician, Serving foods with high caloric cognitions. Early weight gain (4–5 ideally, redirects that treatment density and ensuring that beverages pounds by session 4, typically decision back to the parent: “You are energy rich (eg, choosing correlating with 4 weeks of know your child the best. What fruit juice or milk instead of water) treatment) is predictive of better do you think will best help in your are effective strategies to maximize outcomes in adolescents.126,137,138 child’s recovery?” In this way, the energy intake without requiring By phase 2, substantial weight physician empowers parents to large increases in volume. Parents recovery has occurred, and the make their own decisions, enhancing can relieve adolescents of having adolescent gradually resumes their confidence to care for their ill to decide on appropriate serving responsibility for his or her own child. sizes by plating meals for them. eating. By phase 3, weight has been Accommodating special diets, restored, and the therapy shifts to Day-Treatment Programs such as vegetarian or vegan, can address general issues of adolescent Day-treatment programs (day make meeting nutritional goals psychosocial development.136 This hospitalization and partial especially challenging. Reintroducing therapy is detailed in manuals for hospitalization) provide an foods that have been avoided or providers137 and families.139 FBT intermediate level of care for patients that induce fear of weight gain with experienced providers is not with eating disorders who are are essential steps on the path to available in all communities. medically stable and do not require recovery. Nevertheless, community providers 24-hour supervision but need more may integrate the essential principles than outpatient care.133,141 These Family-Based Treatment and Parent- of FBT in their work with patients programs may prevent the need for Focused Therapy and families.130 higher levels of care or may be Over the past 2 decades, a specialized a “step-down” from inpatient or Parent-focused therapy is an eating disorder–focused, family-based residential to outpatient care. Day adaptation of FBT wherein the intervention, commonly referred to as treatment typically involves 8 to 10 therapist supports the parents to family-based treatment (FBT), has hours per day of care (including renourish the patient and limit emerged as the leading first-line meals, therapy, groups, and other weight-control behaviors but, after treatment approach for pediatric activities) by a multidisciplinary staff the initial appointment, meets only eating disorders.135 Effectiveness is 5 days per week. Reported with the parents.140 The patient has well established for AN.133,136 Rather evaluations of child and adolescent brief visits with a nurse or physician than dwelling on possible causes of day-treatment programs are few and for the assessment of weight and – the eating disorder, FBT is focused on observational in design.142 145 acute mental health issues but is not recovery from the disease. FBT Despite the absence of systematic directly involved with a therapist. consists of 3 phases and contends data supporting their usefulness, that parents are not to blame for their The role pediatricians serve in the these programs are generally believed child’s illness, eating disorders are care of an adolescent in FBT differs to have an important role in the not caused by dysfunctional families, from the customary role of continuum of care. and parents play an essential role in a physician with patients.134 In the recovery.136 During appointments, FBT setting, the pediatrician does not Residential Treatment the entire family unit meets with the weigh the patient because that task is Residential treatment may be therapist. In phase 1, weight performed by the therapist. The necessary for a minority of medically

Downloaded from www.aappublications.org/news by guest on September 27, 2021 PEDIATRICS Volume 147, number 1, January 2021 11 stable patients with eating disorders. remains to be seen how many severely malnourished (,70 median Indications for residential treatment programs will pursue this BMI) children until further studies include a poor motivation for accreditation. are reported.87,154 recovery, need for structure and The National Eating Disorders Nasogastric tube (NGT) feeding may supervision to prevent unhealthy Association Web site offers be necessary for some hospitalized behaviors (eg, food restriction, useful suggestions for evaluating adolescents, but opinions vary compulsive exercise), lack of treatment programs (www. regarding when they should be a supportive family environment, nationaleatingdisorders.org). initiated.161 Most North American absence of outpatient treatment in programs reserve NGT feeds for when the patient’s locale,146 or outpatient Hospital-Based Stabilization patients are not able to complete interventions having been Suggested indications for the meals; however, internationally, some unsuccessful.133 Residential hospitalization of children and centers report the routine use of NGT treatment typically includes 24 hour adolescents with eating disorders feeding, either exclusively at first or per day supervision, medical published by the Society for in combination with meals.162,163 oversight, group-based Adolescent Health and Medicine are Potential benefits of NGT feeding psychoeducational therapy, listed in Table 6. include faster weight gain and nutritional counseling, individual medical stabilization, with therapy, and family therapy. The The most common goal for hospital- a possibility for a reduced hospital length of stay can be weeks to based stabilization is nutritional length of stay.162,163 Although viewed months, depending on the severity of restoration. Variation occurs with by some health care providers as illness and financial resources. regard to how quickly hospitalized invasive or punitive, others view Outcome studies reported by patients with AN are refed.153,154 It is NGT feeding as empathic, by reducing residential programs, generally, important to balance 2 competing both physical and psychological pain reveal improved symptomatology at goals: achieve weight gain swiftly and in the early treatment stages.161 discharge,147 but the results at long- avoid refeeding syndrome.155 There is insufficient evidence to term follow-up are mixed.148,149 Refeeding syndrome refers to the recommend one approach over However, few outcome studies are metabolic and clinical changes that another.154 Independent of whether focused on adolescents, compare the occasionally occur when NGT feeds are used routinely, efficacy of residential to outpatient a malnourished patient is physicians involved in the treatment treatment, or make comparisons aggressively nutritionally of hospitalized medically unstable across programs or treatment rehabilitated; the hallmarks are patients may be called on to provide modalities. hypophosphatemia and multiorgan – nutrition via an NGT when nutritional dysfunction.155 157 A systematic needs are not being met. The use of Although some adolescents review of hospitalized adolescents total parenteral nutrition carries require this higher level of care, with AN reported an average higher risks of medical complications, health care providers and families incidence of refeeding is costly, and is not recommended are encouraged to exercise caution hypophosphatemia (without unless other forms of refeeding are when selecting a residential necessarily organ dysfunction) of not possible.154 treatment program. The number of 14.158 Over the past decade, a long residential programs has more than followed maxim, “start low and go High-quality studies in which tripled in the last decade, with many slow,” has been challenged.87,155 researchers examine the impact of operated by for-profit companies. Several centers have described inpatient care are limited, and the Marketing practices by some are starting calories at 1400 kcal or more best end point for hospital treatment 150 questionable. Outcome studies per day,154 including recent reports of children and adolescents is unclear. demonstrating program efficacy may demonstrating safe treatment of A US multicenter research be misleading because of a lack of mildly and moderately malnourished collaborative showed that, in 151 rigorous design or peer review. adolescents by using initial caloric a national cohort of low-weight 9- to Until recently, there was no prescriptions of 2200 to 2600 kcal 21-year-olds with restrictive eating certification process to ensure per day, while achieving a weight gain disorders, those who were program quality and safety. In 2016, of approximately 3 to 4.5 pounds per hospitalized had a greater odds The Joint Commission implemented week.159,160 Because the risk of of being at 90 of the median BMI new accreditation standards for refeeding hypophosphatemia may at 1-year follow-up.164 However, behavioral health care organizations correlate with the degree of a randomized controlled trial that provide outpatient or residential starvation, pediatricians may opt to (RCT) of treatment of adolescent 152 eating disorder treatment. It take a more cautious approach in AN in the United Kingdom revealed

Downloaded from www.aappublications.org/news by guest on September 27, 2021 12 FROM THE AMERICAN ACADEMY OF PEDIATRICS no benefits of inpatient over weight restoration with physiologic frequency may decrease guilt and outpatient care165; this study was resumption of menses and shame and the ensuing negative limited by poor adherence to the supplementation with calcium and self-assessment. During CBT, patients allocated treatment. An RCT in vitamin D.79,81,87,115 Bisphosphonate are taught to question their distorted Germany in 2014 revealed that treatment is not recommended.79,87,115 thoughts and remodel their eating inpatient adolescents discharged Estrogen supplementation in the behaviors.182 earlier to outpatient treatment fared form of combined estrogen- as well as those discharged later.141 progesterone oral contraceptive FBT Similarly, an RCT conducted in pills is not effective in enhancing Although there is a manual to Australia in 2015 revealed that BMD in adolescents with AN.81 guide FBT for patients with BN,183 adolescents who were discharged to Small trials with transdermal it is based on more limited evidence FBT as soon as they were medically estrogen180 or with low-dose than FBT for AN.182 An RCT stable fared at least as well as combined oral contraceptive pills comparing FBT with CBT revealed adolescents who remained inpatients plus dehydroepiandrosterone181 patients in the FBT group were until achieving 90 of their treatment have shown a positive effect on more likely to abstain from binge goal weight.166 The recently reported BMD compared with controls, eating and purging at the end of average length of stay in the United but further studies are needed the 18-week treatment (39 vs 20) States for patients admitted for before these are considered with no statistical difference (49 medical stabilization by using higher standard care. Although cyclic vs 32) at 1-year follow-up.184 caloric prescriptions was 3 to 12 vaginal bleeding may be induced There are no published studies in days.159,167,168 with the use of exogenous which researchers examine FBT for hormones, this may reinforce BED. Pharmacotherapy for AN a patient’s denial of the medical consequences of her disease and Pharmacotherapy for BN A variety of medications have been masks the spontaneous return of As with other pharmacotherapy studied for the treatment of AN, menses. research, studies of treatment of primarily in adults, but none have BN have primarily been in adult been approved for this indication by BN and BED subjects. Several pharmacologic the US Food and Drug Administration agents, including SSRIs, have been (FDA).169 Despite their demonstrated Collaborative Outpatient Care demonstrated to be effective for ineffectiveness,170 more than one-half Most patients with BN and BED are the treatment of adult BN, although of adolescents with restrictive eating managed in outpatient settings with only fluoxetine has FDA approval. disorders are prescribed the collaboration of a medical and Although not approved for pediatric psychotropic medications, most likely mental health care providers as well BN, fluoxetine is FDA approved for in attempts to treat comorbid as a dietitian, as needed. child and adolescent depression conditions, such as depression and Psychological treatment studies are and obsessive-compulsive disorder, anxiety.171 Selective serotonin- more limited in BN compared with so it is a reasonable option if reuptake inhibitors (SSRIs) have been AN and are especially lacking in pharmacologic treatment of BN is tried but are not effective in acutely BED.133 Cognitive behavioral therapy considered.169 The antiepileptic ill, malnourished patients and have (CBT) has a modest evidence-base for topiramate has been shown to not been shown to prevent disease BN and BED.133,182 CBT explicitly significantly decrease binge eating relapse in those who are weight – recognizes the interrelationships in adults who do not respond to restored.172 174 A number of atypical among an individual’s thoughts, or are not able to tolerate SSRIs. antipsychotic medications have also feelings, and actions, and its However, cases of topiramate been studied, including quetiapine, principles can be used by all triggering eating disorder symptoms risperidone, and olanzapine. Results disciplines. Reestablishing regular in adolescents have been reported.185 have generally revealed little benefit eating patterns is a central goal, and Other drugs, including naltrexone in weight gain or improvement in – educating patients about the and ondansetron, are being used with eating-disorder thinking.169,175 178 perpetuating nature of the some success in adult BN, although Initial studies of augmentation of restriction-binge-purge cycle is an data are lacking to recommend SSRIs with atypical antipsychotics in early focus. Patients with BN and BED their use more broadly.169 adult patients have been can minimize the urge to binge that is promising.179 typically experienced late in the day, Pharmacotherapy for BED The current recommendations if they eat regularly throughout the Research on the treatment of binge to optimize bone health are full day. Decreasing the binge amount and eating lags behind that for other

Downloaded from www.aappublications.org/news by guest on September 27, 2021 PEDIATRICS Volume 147, number 1, January 2021 13 eating disorders and has been FINANCIAL CONSIDERATIONS methodology, definitions of focused on adult subjects. SSRIs The treatment of eating disorders is recovery, and duration of follow-up. have rarely differed from placebo multidisciplinary, often long-term, Generally, adolescents have greater in their effect on BED and show no and may require expensive, high-level success in recovery from eating better outcome than behavioral disorders than their adult care, such as inpatient stabilization or 193 therapy alone. Although the use residential or partial hospitalization counterparts, with overall of topiramate has been shown to recovery rates of approximately programs. The costs associated with 194 reduce binge eating and help with treatment can create substantial 70. weight loss, the rates of adverse financial burdens for families.191 186 In a review of 11 adolescent eating effects are relatively high. Having medical insurance, public or Lisdexamfetamine, a central nervous disorder treatment programs, 54 private, is no guarantee that these of patients treated for restrictive system stimulant approved for 192 costs will be covered. Insurance disorders had restored to at least treatment of attention-deficit/ fi carriers are able to de ne their 90 of their median body weight hyperactivity disorder, was approved own criteria for eating disorder by the FDA in 2015 for the treatment (MBW) for age and height at 1-year treatment, leading to wide variations follow-up. This is essential for of moderate to severe BED in in coverage from state to state. adults. Although it has been catch-up growth and resumption of Some states do not identify eating menses in girls. Two significant demonstrated to reduce the disorders as life-threatening frequency of binge-eating episodes, predictors of weight recovery conditions, thereby limiting treatment were a higher percentage of lisdexamfetamine is not indicated coverage. State-sponsored public for weight loss. As with the use MBW at initial presentation and insurance plans may not cover shorter duration of symptoms, of other central nervous system out-of-state treatment programs, stimulants, there is a potential highlighting the importance of even when no comparable treatment fi for abuse and dependence as early identi cation of these programs exist within that state. disorders. Outcomes did not vary well as serious cardiovascular Outpatient mental health providers reactions.187 meaningfully across programs, who are willing to accept the lower suggesting that all treatment payments from public insurance models were helpful.195 ARFID may have no expertise in treating eating disorders. Those who do In a more-recent study, researchers ARFID is a relatively new diagnosis, and will see publicly insured patients examined the weight restoration and, consequently, there is limited or those in managed care plans of patients from 14 adolescent 188,189 literature describing treatment. typically limit the number of these treatment programs with a diagnosis Because patients with ARFID vary in patients in their panels. Private of a restrictive eating disorder by terms of underlying psychological insurance may increase access to DSM-5 criteria. At 1-year follow-up, motivations for restrictive eating, treatment but dictate lower levels those with ARFID were the least individualized behavioral treatment and shorter periods of care than is likely (43) to have regained $90 182,190 strategies are needed. indicated by a patient’s clinical MBW and were also more likely Despite varying characteristics status and health care provider to be younger, have had a longer of the disorder, the dual goals of recommendation. Families of duration of symptoms, and refeeding and normalization of patients with eating disorders have left treatment prematurely. eating align with the goals of treating typically will need assistance Eighty-two percent of those other eating disorders. A study of navigating the financial aspects with atypical AN and 64 of those pediatric and young adult patients of treatment. The National Eating with AN had regained $90 MBW. admitted with ARFID at a single Disorders Association offers Having received a higher level of academic medical center reported general information online for care (eg, partial hospitalization that ARFID patients were more families regarding financial and/or residential care) did likely to require enteral nutrition coverage for treatment (www. not increase the likelihood of and stayed in the hospital longer nationaleatingdisorders.org). weight recovery. Again, there 9 than patients with AN. were no significant differences in outcomes between programs, No medication is specifically despite various treatment indicated for use in ARFID; PROGNOSIS modalities.196 pharmacotherapy is directed at The prognoses reported for treating underlying comorbid illness adolescents with eating disorders Information on the long-term (eg, anxiety) as necessary. vary widely, depending on research prognosis of adolescents with AN

Downloaded from www.aappublications.org/news by guest on September 27, 2021 14 FROM THE AMERICAN ACADEMY OF PEDIATRICS – is limited. In a study of adolescents with BN.200 203 Suicide rates are Pediatricians can join others who completed a 12-month increased among patients with in advocating for improved outpatient AN treatment study eating disorders204 and, in one access to quality eating disorder (either FBT or adolescent-focused study, accounted for 30 deaths.203 treatment services. The limited therapy), approximately one-third In a national survey of adolescents, availability of developmentally of patients were in full remission 35 of those meeting criteria for appropriate mental health 1 year after completion, with better BN, 15 of those meeting criteria services, lack of mental health rates in the FBT group (49) than in for BED, and 8 of those meeting parity, and service “carve-outs” the adolescent-focused therapy criteria for AN reported having all have been barriers group (23).197 Follow-up in made a suicide attempt.205 The to patients and families who seek a convenience sample of the risk of suicide among patients necessary treatment and seem original study 2 to 4 years after with eating disorders appears to be disproportionately treatment revealed less than 10 to be declining and has been problematic for patients with of patients relapsed, with no attributed to an increased recognition eating disorders. Despite evidence difference between the 2 groups.198 of eating disorders and effective of its effectiveness, FBT is not An RCT comparing parent-focused treatment.206 available in many communities. therapy with FBT demonstrated Through advocacy, pediatricians equivalent outcomes between the can help support health care ’ groups at 12-month follow-up PEDIATRICIAN S ROLE IN PREVENTION reform efforts that will enable (37 vs 29).140 AND ADVOCACY children and adolescents Efforts to prevent eating disorders with eating disorders to access Information about recovery from may occur in clinical practice and necessary care. BN, BED, and purging disorder community settings. By using in adolescents is less available sensitive, nonstigmatizing language but suggests higher rates of GUIDANCE FOR PEDIATRICIANS and demonstrating supportive relapse and the development of attitudes toward children and 1. Pediatricians should be comorbidities. Outcome studies adolescents of all body shapes knowledgeable about the variety on BN in adults reveal variable and sizes, pediatricians create of risk factors and early signs recovery rates, ranging from a welcoming clinical setting for and symptoms of eating approximately 50 to 70 at 4- to discussions about weight and disorders in both male and 6-year follow-up, with relapse weight-related behaviors. The female children and adolescents. rates of 30 and about 25 having American Academy of Pediatrics Pediatricians should screen chronic disease.194 A longitudinal clinical report “Preventing Obesity patients for disordered eating study of adolescent girls with and Eating Disorders in Adolescents” and unhealthy weight-control BED and purging disorders into highlights steps that pediatricians can behaviors at annual health early adulthood revealed that one- take to prevent both conditions.207 supervision visits. Pediatricians quarter of these girls started to These steps include focusing on should evaluate weight, height, use drugs other than marijuana, healthy habits with patients and and BMI by using age- and more than one-third began to families rather than weight and sex-appropriate charts, binge drink frequently, and 27 dieting, encouraging more frequent assess menstrual status in demonstrated high levels of family meals, discouraging “weight girls, and recognize the changes depressive symptoms.199 talk” and “weight teasing” in the in vital signs that may signal Not surprisingly, misuse of home, closely monitoring weight the presence of an eating drugs and alcohol among loss in patients advised to lose disorder. patients with eating disorders is weight, and promoting a healthy 2. When an eating disorder is associated with a poorer outcome body image in all children and suspected, pediatricians, in or death.193 adolescents.207 Pediatricians conjunction with appropriate Mortality rates among individuals may also advise teachers, consultants, should initiate with eating disorders are coaches, and athletic trainers a comprehensive evaluation of substantially elevated in comparison about healthy approaches to the patient that includes both with those of the general population, nutrition and exercise, raise medical and psychological with death typically occurring in awareness of the detrimental assessments as well as suicide adulthood. Premature death is 4 to 5 effects of weight stigmatization, risk appraisal. Once diagnosed, times higher for patients with AN and alert them to the warning signs patients should be monitored and 2 to 3 times as high for those of eating disorders. for medical and nutritional

Downloaded from www.aappublications.org/news by guest on September 27, 2021 PEDIATRICS Volume 147, number 1, January 2021 15 complications by their pediatrician Margo A. Lane, MD, FRCPC ABBREVIATIONS or referred to other qualified practitioners for medical AN: anorexia nervosa oversight. COMMITTEE ON ADOLESCENCE, 2018–2019 ARFID: avoidant/restrictive 3. To facilitate multidisciplinary care, Cora C. Breuner, MD, MPH, Chairperson food intake disorder pediatricians should refer their Elizabeth M. Alderman, MD, FSAHM BED: binge-eating disorder patients with eating disorders to Laura K. Grubb, MD, MPH BMD: bone mineral density Makia Powers, MD, MPH treatment resources in their region BN: bulimia nervosa Krishna Kumari Upadhya, MD BP: blood pressure when available. Ideally, these Stephenie B. Wallace, MD treatment program providers CBT: cognitive behavioral should have expertise in the therapy DSM-5: Diagnostic and Statistical unique developmental needs of LIAISONS this age group. Manual of Mental Laurie L. Hornberger, MD, MPH – Section on Disorders Fifth Edition 4. Pediatricians are encouraged to Adolescent Health FBT: family-based treatment advocate for legislation and policy Margo A. Lane, MD FRCPC – Canadian FDA: Food and Drug changes that ensure appropriate Pediatric Society Meredith Loveless, MD – American College of Administration services for patients with eating Obstetricians and Gynecologists HEADSS: home, activities, drugs/ disorders, including medical care, Seema Menon, MD – North American Society diet, sexuality, nutritional intervention, mental of Pediatric and Adolescent Gynecology suicidality/depression health treatment, and care Lauren Zapata, PhD, MSPH – Centers for HR: heart rate coordination, in settings that are Disease Control and Prevention Liwei Hua, MD, PhD – American Academy of LV: left ventricular appropriate for the developmental Child and Adolescent Psychiatry MBW: median body weight level of the patient and severity of NGT: nasogastric tube the illness. RCT: randomized controlled trial STAFF SSRI: selective serotonin- LEAD AUTHORS Karen Smith reuptake inhibitor Laurie L. Hornberger, MD, MPH James Baumberger, MPP

PEDIATRICS (ISSN Numbers: Print, 0031-4005; Online, 1098-4275). Copyright © 2021 by the American Academy of Pediatrics FINANCIAL DISCLOSURE: The authors have indicated they have no financial relationships relevant to this article to disclose. FUNDING: No external funding. POTENTIAL CONFLICT OF INTEREST: The authors have indicated they have no potential conflicts of interest to disclose.

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Downloaded from www.aappublications.org/news by guest on September 27, 2021 Identification and Management of Eating Disorders in Children and Adolescents Laurie L. Hornberger, Margo A. Lane and THE COMMITTEE ON ADOLESCENCE Pediatrics originally published online December 21, 2020;

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