Summary

Given the current health focus on childhood obesity, it is important to keep in mind that young patients, often with the family’s involvement, may take weight loss efforts to the extreme, resulting in the development of an eating disorder. Anorexia nervosa is an eating disorder characterized by a patient’s overwhelming desire for thinness, which usually leads to extreme weight loss. Age of onset ranges from preteen to adulthood and peaks bi-modally at ages 13 to 14 and 17 to 18 years. Although over 90% of patients with the disorder are females, males can suffer from anorexia. This disorder can affect patients of any ethnicity and socioeconomic status. Although anorexia is rare, patients usually require considerable attention from their pediatrician. It is particularly important for pediatricians to recognize precursor signs of anorexia and intervene, since early detection has been linked with better recovery.

Educational objectives

At the conclusion of this activity, participants will be able to:

• Recognize the physical and emotional symptoms of anorexia nervosa
• Identify patients at higher risk for developing anorexia and screen for precursor signs
• Refer to appropriate resources to address nutritional and behavioral aspects of the disorder

CME credit

This is an article from The Child's Doctor, Spring 2007 issue. You may take the quiz for learning purposes, but credits are no longer valid.

Author disclosures

Dr. Kamran has no industry relationships to disclose and does not refer to products that are still investigational or not labeled for the use in discussion.

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Definition

Anorexia nervosa as defined in the DSM-IV-TR includes a patient's refusal to reach or maintain at least 85% of expected body mass index (BMI) for age. The DSM-IV-TR uses 2 types of anorexia to describe the nature of the patient's weight loss behaviors – restricting type and binge-eating/purging type. The patient with the binge-eating/purging type regularly engages in binge-eating followed by purging behaviors, such as self-induced vomiting or laxative abuse. The patient with the restricting type of anorexia does not regularly engage in these behaviors, and primarily induces weight loss by restricting oral intake and by excessive exercise.

Physical symptoms and complications

The physical manifestations are multiple and increase with disease severity. Physical examination findings can include cachexia, appearance much younger than chronological age, dry skin, dental erosion, dorsal surface hand lesions (Russell's sign), bradycardia, hypotension, lanugo, alopecia, and edema.

The medical complications of anorexia are primarily related to starvation, and are usually treated with restoration of a healthier nutritional state, as well as specifically targeted therapies as needed. A hallmark complication of the disorder is amenorrhea. The pediatrician should specifically question regarding menstrual periods if anorexia is suspected. Other complications can include cardiac arrhythmias, hematological changes, gastrointestinal problems, renal abnormalities, skeletal issues such as bone density loss, and endocrine disorders.

Emotional manifestations

Patients with anorexia often have very distorted thinking related to their weight, nutritional needs, and body image. Weight loss is accompanied by fear of weight gain. This can be worsened by their physiological semi-starvation-state. The patients' distorted thinking may manifest in resistance to the pediatrician's efforts to help. They resist reasoning regarding the need for weight gain and other treatments. During these times, involvement of the patient's entire family system to aid in restoring a healthier nutritional state is critical. Some patients may require hospitalization when their cognitive impairments are severely interfering with their evaluation and treatment, or if their vital signs become unstable (eg, bradycardia, hypotension).

Anorexia also has high levels of psychiatric co-morbidity that should not be ignored during the evaluation and/or treatment of the illness. Major depression has been reported in 50% to 70% of patients. Anxiety disorders, including obsessive compulsive disorder, have been found in 50% of patients. Patients with anorexia also may have a history of sexual abuse. Older patients are more likely to suffer from substance abuse disorders as well.

Risk factors

Patients involved in sports and activities with more focus on weight and/or appearance, such as ballet, gymnastics, and modeling, may be at higher risk for developing anorexia. Also at high risk are patients with chronic medical conditions, such as diabetes and cystic fibrosis.

Screening

Pre-screening physicals for sports activities may be a critical contact with a patient who has anorexia or who is developing the disorder. Even in routine office contacts, pediatricians should be aware whether a patient is "dieting" and understand what that self-labeled dieting entails, such as:

• Is the patient restricting food intake severely? Ask the patient what she/he ate during a 3-day period, as opposed to asking only about the last meal, since the patient may have eaten then, but not for a longer period prior to that last meal.
• Is the patient using/abusing laxatives, diet pills, diuretics?
• Is the patient using/abusing caffeine, nicotine, alcohol, or illicit drugs to eat less?
• Is the patient purging after eating?
• Is the patient's BMI less than 85% of what is expected for her/his age?

Pediatricians should also ask about the patient's level of exercise, including the types of activities the patient is doing, for how long, and how often. Many patients with eating disorders will tell clinicians that they "don't exercise," but actually have rituals that they use to stay active and "burn calories." Examples include not sitting for periods longer than 10 minutes, flexing their buttock muscles while sitting, and movements while they are lying in bed at night.

Upon learning that a patient has lost weight recently, pediatricians should refrain from automatically congratulating the patient. Attitudes toward current and ideal weight, body image, eating and exercise behaviors should be explored in order to rule out the presence or the early development of anorexia.

If anorexia is suspected, it is critical to determine whether the patient has suicidal thoughts or plans, or has engaged in recent acts related to harming self or others. If there are any concerns about acute safety, this must be addressed immediately with measures such as psychiatric hospitalization.

Evaluation and treatment

Complete evaluation of a patient with a suspected eating disorder usually requires a team of professionals, as does the treatment. The physical, psychological, and nutritional aspects of the illness all must be addressed, and the pediatrician may by choice or by default serve as the coordinator of these efforts. The pediatrician is usually responsible for identifying the need for these services and helping the family to gain access to them. Frequently, an important initial care decision is whether the patient needs to be hospitalized, either medically or psychiatrically. Sometimes the financial realities of limited insurance coverage for the medical and psychiatric treatment of anorexia can be daunting. The pediatrician and the family should be aware of these constraints and strongly advocate for adequate treatment despite this barrier.

The treatment setting is usually determined by the severity of the patient's physical and emotional state. Even when some type of medical or psychiatric hospitalization is needed, this stay will usually be of short duration. Acute stabilization allows the patient to participate in specialized day treatment or outpatient treatment.

The Internet can serve as a helpful tool in research to find specialized treatment service providers, both individual and programmatic. It may be useful to enlist the patient's family to find these resources. Usually when the patient is less than 18 years old, the specialized treatment programs require significant family involvement. These programs typically will not accept patients automatically. They look for evidence of strong family commitment upfront as a sign that treatment can be successful. A phone contact from a concerned parent strongly advocating for his/her child demonstrates to the specialist provider that the family is willing to commit to this frequently intense treatment process.

Research on eating disorders is progressing, but at this point, there are modest data regarding use of psychotherapy treatments and virtually none regarding pharmacological treatments for children and adolescents with eating disorders. Pharmacological treatment alone is not appropriate for anorexia, but can be helpful when used in conjunction with psychotherapeutic treatments, especially when there is psychiatric co-morbidity such as depression. Different types of individual therapy as well as group therapy are used to treat anorexia. Family therapy, such as the model developed at London's Maudsley Hospital, has been shown to be successful in treating anorexia by using the patient's family as a resource toward recovery.

Any type of therapy provided should be coordinated with the monitoring and maintenance of nutrition, weight, and physical stability. Some therapists take this role in the treatment, and some pediatricians serve this role. It requires weight goals and weight monitoring, as well as monitoring of other physical parameters as needed, such as pulse and blood pressure. Nutritionists also are very helpful with these issues.

Prognosis

Early identification of anorexia, or recognition of the physical and behavioral signs leading to the full blown development of the disorder, improves the chances of successful recovery. If a patient's weight is very low at diagnosis, this may predict a more difficult recovery. Although overall, the mortality rates for anorexia nervosa are among the highest of the mental disorders, treatment outcomes for adolescents with anorexia are not disheartening – 50% to 70% recover with treatment; 20% are improved with treatment, but have residual symptoms; and 10% to 20% develop chronic forms of the disorder.

Special issue

Bulimia nervosa is another eating disorder with similar features to anorexia nervosa, but it usually affects patients of normal weight or who are slightly overweight. It is characterized by recurrent binge-eating and various compensatory behaviors such as purging to prevent excessive weight gain. Research has shown that up to 50% of patients with anorexia may develop symptoms typical of bulimia during the course of their illness, but anorexia and bulimia are considered distinct disorders.

Advice to families from pediatrician

Pediatricians may be approached by parents who are concerned that their child or adolescent may have an eating disorder or has been diagnosed with an eating disorder. The following advice to parents and caretakers may help:

• To help screen for anorexia, pay attention to your child's eating habits and exercise routines. If you think they are abnormal, alert me immediately.
• Kids can hide their behaviors from families for long periods of time. If you did not know in the past that your child was practicing unhealthy eating and/or exercise habits, do not use your parental energy worrying about "what you missed." What is important is that you are seeking help for your child now and can use that energy to help her/him now.
• Watch your own attitudes about "thinness and fatness" as well as your dieting and fitness activities. You are not to blame for your child's eating disorder, but your child may use your activities to rationalize her/his own abnormal activities.
• Your child or teenager may have severe distortions about her/his weight. For example, your extremely thin teenager may continue to complain of "feeling fat." Do not criticize your teenager for these distorted body image beliefs. Acknowledge the concern, but understand that these beliefs are a part of the illness and will not change quickly or easily.
• Advocate for your child! Parents' energies, time, and resources will be critical in finding and using the best care for their child.
• Do not get discouraged. Anorexia nervosa is treatable, but the treatment process can be long. Your child also may experience setbacks, but these do not always signal a complete return of the illness.

Conclusion

Eating disorders are rare, but frequently are significant to pediatricians when they occur due to the amount of care patients with anorexia nervosa require from their doctor. Pediatricians can be very effective in both screening and treating this serious disorder through their long-term, strong relationship with their patient and his/her family. Involvement of nutritionists, psychiatrists, and therapists, as part of a treatment team for the patient with anorexia is very useful. Research has shown that family involvement also is critically important to the patient's recovery. Specialized treatment settings may be needed as well.

FOR FURTHER READING

[1.] American Academy of Pediatrics Committee on Adolescence. Identifying and treating eating disorders. Pediatrics 2003;111:204-211.

[2.] Fisher M, et al. Eating disorders in adolescents: A background paper. Journal of Adolescent Health 1995;16:420-437.

[3.] Kreipe RE, Dukarm CP. Eating disorders in adolescents and older children. Pediatrics in Review 1999 Dec;20(12):410-421.

[4.] Herzog DB, Eddy KT, Beresin EV. Anorexia nervosa and bulimia nervosa. In: Dulcan MK, Wiener JM, eds. Essentials of Child and Adolescent Psychiatry. Washington, DC: American Psychiatric Pub; 2006:527-558.

[5.] Lock J, et al. Treatment Manual for Anorexia Nervosa: A Family-Based Approach. New York, London: Guilford Press; 2001. (Model developed at Maudsley Hospital, London)

[6.] Lock J, Le Grange D, Forsberg S, Hewell K. Is family therapy useful for treating children with anorexia nervosa? Results of a case series. J. Am. Acad. Child Adolesc. Psychiatry 2006 Nov;45(11):1323-1328. (Model developed at Maudsley Hospital, London)