Current Problems in Pediatric and Adolescent Health Care
Eating Disorders in Children and Adolescents
Section snippets
The Classification of Eating Disorders: What Is on the Horizon
The DSM-IV categories for eating disorders included anorexia nervosa, bulimia nervosa, and eating disorder not otherwise specified. Anorexia nervosa has traditionally been defined as an intense fear of gaining weight or becoming fat; refusal to maintain body weight at or above a minimally normal weight for age and height, or failure to grow/gain weight during a period of expected growth, leading to a body weight of <85% of expected weight; a distorted body image with undue influence of weight
The Changing Face of the Epidemiology of Eating Disorders
Estimated overall prevalence for anorexia nervosa remains at 1%, with bulimia nervosa currently at 4%22, 23, 24, 25; an increasing number of boys and young men have also been found in several studies, especially at earlier ages.26, 27, 28 ED-NOS, estimated at 10% prevalence currently,29, 30, 31 has a broader spectrum of illness represented within it, with studies using DSM-IV, including diverse populations and including binge eating disorder, night eating syndrome, and other subcategories of
The Female Athlete Triad: Recent Dilemmas
Adolescents and young adults in aesthetic sports, such as ballet, gymnastics, and figure skating, were considered at higher risk for the triad, especially during physical shifts of early puberty (11-14 years) or during the transition to college (17-19 years). In college populations, the prevalence of female college athletes with disordered eating has ranged from 15% to 62%, distinctly higher than the 5%-10% prevalence of disordered eating in the general adult population.41, 42, 43 In a study of
Predictive Factors
In an Australian population-based sample, being perceived as overweight by one's parent and being female were both factors strongly predictive of the development of eating disorders.45 Other predictive factors included having an overweight mother (measured by elevated body mass index), social problems and/or neurocognitive difficulties in the child, and low social-related self-efficacy. Other potential risk factors for eating disorders can be found in Table 1. Neumark-Sztainer and others have
Taking a History in the Child or Adolescent with an Eating Disorder
The keynote to diagnosis of an eating disorder in a child or adolescent remains a careful history and physical examination. Most clinicians start with parent(s) and child together, asking the child/adolescent why he or she thinks he/she is there today. Much can be learned from their initial response. Does the child or teen defer to the parent and ask them to answer? Is there an immediate response, “I'm fine!” Is there an open tone between the two, or frank hostility? Take note of eye contact
The Physical Examination
The physical examination should include height, weight obtained in a hospital gown (after voiding), and calculation of BMI. Many centers opt for “blinded weights,” where the individual is weighed facing backwards on the scale, so they cannot read the numbers. Some children and adolescents become overly focused on the numbers to the point of sabotaging themselves; others handle that knowledge well. This discrepancy can be a point of clinical judgment left to the clinician, care team, family, and
Medical Complications of Eating Disorders
The Academy for Eating Disorders Medical Task Force Committee recently created a brochure to help educate primary care and emergency room physicians to better recognize the acute medical complications of eating disorders (Academy for Eating Disorders web site, http://www.aedweb.org/Medical_Care_Standards.htm). Medical complications can be divided into those resulting from binges, those from purging, and those from restricting. These behaviors can result in significant pathology in almost every
Medical Complications of Binges
Acute binges involving a high volume may cause acute esophageal rupture or acute gastric dilatation and rupture.54 Bingeing on sugary food may increase dental caries. Binge—purge cycles have also been associated with secondary amenorrhea, with an odds ratio of 4.17.55 Individuals who binge may have low self-esteem, as well as feelings of shame or guilt, which may interfere with day-to-day life. Binges can also take a financial toll and may have legal ramifications if the binges occur after
Medical Complications of Purging
Chronic, self-induced vomiting can lead to volume depletion and secondary hyperaldosteronism, which along with loss of gastric fluid hydrogen ion, chloride, and potassium result in a hypokalemic, hypochloremic metabolic alkalosis.53, 56 As long as relative volume depletion continues, high levels of aldosterone promote renal tubular sodium reabsorption and potassium and hydrogen ion excretion, thus maintaining the alkalosis and hypokalemia. Serum sodium levels are either normal or low. In the
Medical Complications of Caloric Restriction
Starvation has major effects on brain, bone, heart, and all other organ systems. The cardiac effects are among the most life-threatening, but cognitive challenges may be more noticeable to the teen, including loss of memory, difficulty encoding from short-term to long-term memory, or other problems. Specific cardiac effects include risk of prolonged QTc syndrome, myocardial wasting with sinus bradycardia, and other arrhythmias, all of which can be life threatening. Patients with anorexia
Treatment for Children and Adolescents with Eating Disorders
Pediatricians play an essential role not just in the recognition of eating disorders, but also in their treatment. Serving as the medical home, the pediatrician can be the daily, weekly, monthly, or quarterly monitor of weight, orthostatic vital signs, and growth pattern. For those pediatricians comfortable serving as medical subspecialist, he/she can function as the quarterback coordinating care with the therapeutic team, often necessitating use of an adolescent medicine specialist, therapist,
How Do We Prevent Both Eating Disorders and Obesity?
The pediatrician can serve as tracker of health and growth charts, evaluator when risk factors surface, communicator and educator of children, parents, and families. Promoting media literacy is an important area of focus in parent and child education, including avoidance of so-called “pro-ana” and “pro-mia” sites that glorify eating disorders as a lifestyle, not a disease. A study in Belgium of 711 students in 7th, 9th, and 11th grades found that 12.6% of the girls and 5.9% of the boys had
Future Challenges
Unanswered questions remain with respect to children and adolescents with eating disorders. For those with amenorrhea, how often should bone density be tested, and with which technology? Vitamin D has received much recent attention; what dose should we recommend daily? Currently many practices recommend providing calcium 1200-1500 mg a day and 800-1000 IU of vitamin D, with screening for low vitamin D levels at time of diagnosis in patients with eating disorders. How best can care proceed in
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