Eating Disorders

Pediatric eating disorders should be considered in the differential diagnosis for a patient of any weight who presents with weight loss, growth stunting, pubertal delay, recurrent vomiting, excessive exercise, restrictive or abnormal eating behaviors, or body image concerns.  

The epidemiology of eating disorders is changing, with increasing rates in boys, younger children, and minority groups.  Pediatric hospitals saw a marked increase in admissions for eating disorders during the COVID-19 pandemic.  

The etiology of eating disorders is unknown, but likely includes genetic and biological predispositions interacting with psychological traits and social, cultural, and environmental factors.  Older conceptualizations of eating disorders as arising from the pernicious effects of overcontrolling parents have been abandoned and families are considered key participants in assessment and treatment.

Early recognition of eating disorders is key to early treatment.  Early treatment reduces risk of mortality and long-term morbidity including reduced bone density and cardiovascular, renal, gastrointestinal and neurological damage (Campbell & Peebles 2015).


The Disorders

Anorexia nervosa (AN)

Pediatric patients with AN often begin weight loss-motivated behaviors 6-12 months before a clinical diagnosis.  They may report a desire for thinness, but may also report that they are trying to eat less or exercise more for health reasons.  They may deny body image or weight concerns and insist that they are just not hungry.  These assertions may conflict with observed weight-obsessed behaviors such as repeatedly weighing, pinching skin, calorie counting, and increasingly restrictive eating patterns, often avoiding fats, sweets and protein.  

DSM-5 Criteria for Anorexia Nervosa

Restriction of energy intake relative to requirements, leading to a significantly low body weight in the context of age, sex, developmental trajectory, and physical health. Sig­nificantly low weight is defined as a weight that is less than minimally normal or, for children and adolescents, less than that minimally expected.

Intense fear of gaining weight or of becoming fat, or persistent behavior that interferes with weight gain, even though at a significantly low weight.

Disturbance in the way in which one’s body weight or shape is experienced, undue in­fluence of body weight or shape on self-evaluation, or persistent lack of recognition of the seriousness of the current low body weight.

American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.). Washington, DC

Bulimia nervosa (BN)

BN is characterized by recurrent binge-eating episodes with a sense of loss of control over eating during the episode followed by recurrent compensatory behavior such as vomiting, fasting, exercise, or use of laxatives, diuretics or diet pills, together with preoccupation with weight and body shape.  

Patients with BN are often of normal or high normal body mass index.  BN may be accompanied by secrecy, shame, and guilt.  Adolescent males with BN may increased in those who participate in sports where weight and appearance affect performance.  The course of BN may be prolonged with cycles of exacerbation and partial remission.

DSM-5 Criteria for Bulimia Nervosa

Recurrent episodes of binge eating. An episode of binge eating is characterized by both of the following:

1. Eating, in a discrete period of time (e.g., within any 2-hour period), an amount of food that is definitely larger than what most individuals would eat in a similar period of time under similar circumstances.

2. A sense of lack of control over eating during the episode (e.g., a feeling that one cannot stop eating or control what or how much one is eating).

Recurrent inappropriate compensatory behaviors in order to prevent weight gain, such as self-induced vomiting; misuse of laxatives, diuretics, or other medications; fasting; or excessive exercise.

The binge eating and inappropriate compensatory behaviors both occur, on average, at least once a week for 3 months.

Self-evaluation is unduly influenced by body shape and weight.

The disturbance does not occur exclusively during episodes of anorexia nervosa.

American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.). Washington, DC

Binge-eating disorder (BED)

BED is distinguished from BN by the lack of compensatory behaviors.  The binge-eating episodes are accompanied by a sense of loss of control over eating, eating rapidly, eating when not hungry, eating alone out of embarrassment, and feelings of disgust, depression or guilt.

DSM-5 Criteria for Binge-eating disorder

Recurrent episodes of binge eating. An episode of binge eating is characterized by both of the following:

1. Eating, in a discrete period of time (e.g., within any 2-hour period), an amount of food that is definitely larger than what most people would eat in a similar period of time under similar circumstances.

2. A sense of lack of control over eating during the episode (e.g., a feeling that one cannot stop eating or control what or how much one is eating).

The binge-eating episodes are associated with three (or more) of the following:

  1. Eating much more rapidly than normal.
  2. Eating until feeling uncomfortably full.
  3. Eating large amounts of food when not feeling physically hungry.
  4. Eating alone because of feeling embarrassed by how much one is eating.
  5. Feeling disgusted with oneself, depressed, or very guilty afterward.

Marked distress regarding binge eating is present.

The binge eating occurs, on average, at least once a week for 3 months.

The binge eating is not associated with the recurrent use of inappropriate compensa­tory behavior as in bulimia nervosa and does not occur exclusively during the course of bulimia nervosa or anorexia nervosa.

American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.). Washington, DC

Avoidant restrictive food intake disorder (ARFID)

ARFID is distinguished from AN in that in ARFID, there is no fear of weight gain, no shape or weight concerns, and no specific focus on weight loss.  The patient with ARFID engages in food restriction or avoidance that results in significant weight and nutritional deficiencies.  They may restrict intake or eat selectively based on fear of certain foods, fear of swallowing, choking or vomiting, or simply lack of interest in food.  

DSM-5 Criteria for Avoidant restrictive food intake disorder

An eating or feeding disturbance (e.g., apparent lack of interest in eating or food; avoid­ance based on the sensory characteristics of food; concern about aversive conse­quences of eating) as manifested by persistent failure to meet appropriate nutritional and/or energy needs associated with one (or more) of the following: 

  1. Significant weight loss (or failure to achieve expected weight gain or faltering growth in children).
  2. Significant nutritional deficiency.
  3. Dependence on enteral feeding or oral nutritional supplements.
  4. Marked interference with psychosocial functioning.

The disturbance is not better explained by lack of available food or by an associated culturally sanctioned practice.

The eating disturbance does not occur exclusively during the course of anorexia ner­vosa or bulimia nervosa, and there is no evidence of a disturbance in the way in which one’s body weight or shape is experienced.

The eating disturbance is not attributable to a concurrent medical condition or not bet­ter explained by another mental disorder. When 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 and warrants additional clinical attention.

American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.). Washington, DC


Treatment

Treatment begins with triaging the patient to outpatient, inpatient, partial hospitalization, or residential treatment based on the severity and duration of illness and family preferences. 

The AAP guidelines for inpatient hospitalization are shown below.

Anorexia Nervosa Bulimia Nervosa
Heart rate < 50 bpm daytime; < 45 bpm nighttime Syncope
Systolic BP < 90 mm Hg Serum potassium <3.2 mmol/L or serum chloride <88 mmol/L
Orthostatic changes in pulse (>20 bpm) or BP (>10 mm Hg) Cardiac arrhythmias including prolonged QTc
Arrhythmiatemperature < 96oF Esophageal tears
<75% ideal body weight or ongoing weight loss despite intensive management Hematemesis or intractable vomiting
Body fat < 10% Hypothermia
Refusal to eat Suicide risk
Failure to respond to outpatient treatment Failure to respond to outpatient treatment

Psychotherapeutic Treatments

Evidence for effective treatments in pediatric anorexia nervosa increasingly supports family-based treatment (FBT). FBT involves 3 phases. Phase 1 focuses on coaching caregivers to refeed their child through specific interventions including food exposures.  Phase 2 begins when the patient has regained adequate weight and focuses on gradually transferring appropriate control of eating back to the child or adolescent. Phase 3 works on relapse prevention. Recent trials have shown that, with training, primary care pediatricians can deliver FBT for eating disorders in their outpatient practice.  

Calculation of adequate or goal weight in pediatric patients with eating disorders is complex and must consider previous weight and growth trajectories, genetic potential, and caloric needs. Consulting a registered dietician with eating disorder experience is recommended. 

Cognitive behavioral therapy and FBT have been shown to be effective in the treatment of bulimia nervosa.

Pharmacologic Treatments

No medications have been found effective in treating the core symptoms of anorexia nervosa in adult or pediatric studies. SSRIs and atypical antipsychotics may be appropriate in patients with premorbid psychiatric conditions. 

Randomized controlled trials have shown efficacy of SSRIs in the treatment of bulimia nervosa in adults, and fluoxetine has an FDA approved indication for this.  There is clinical support for SSRIs in the treatment of bulimia nervosa in children and adolescents.

The extended-release dexamphetamine-based stimulant Vyvanse has an FDA indication for the treatment of binge eating disorder in adults.  Clinical evidence suggests it may be effective in children and adolescents.


References

Practice Parameter for the Assessment and Treatment of Children and Adolescents With Eating Disorders  AACAP 2015 (pdf)

Beccia, A. L., Baek, J., Jesdale, W. M., Austin, S. B., Forrester, S., Curtin, C., & Lapane, K. L. (2019). Risk of disordered eating at the intersection of gender and racial/ethnic identity among U.S. high school students. Eating Behaviors, 34, 101299. https://doi.org/10.1016/j.eatbeh.2019.05.002

Campbell, K., & Peebles, R. (2014). Eating Disorders in Children and Adolescents: State of the Art Review. Pediatrics, 134(3), 582–592. https://doi.org/10.1542/peds.2014-0194

DerMarderosian, D., Chapman, H. A., Tortolani, C., & Willis, M. D. (2018). Medical Considerations in Children and Adolescents with Eating Disorders. Child and Adolescent Psychiatric Clinics of North America, 27(1), 1–14. https://doi.org/10.1016/j.chc.2017.08.002

Lebow, J., Mattke, A., Narr, C., Partain, P., Breland, R., Gewirtz O’Brien, J. R., Geske, J., Billings, M., Clark, M. M., Jacobson, R. M., Phelan, S., Harbeck-Weber, C., Le Grange, D., & Sim, L. (2021). Can adolescents with eating disorders be treated in primary care? A retrospective clinical cohort study. Journal of Eating Disorders, 9, 55. https://doi.org/10.1186/s40337-021-00413-9

Otto, A. K., Jary, J. M., Sturza, J., Miller, C. A., Prohaska, N., Bravender, T., & Van Huysse, J. (2021). Medical Admissions Among Adolescents With Eating Disorders During the COVID-19 Pandemic. Pediatrics, 148(4), e2021052201. https://doi.org/10.1542/peds.2021-052201

Rienecke, R.D. (2017) Family-based treatment of eating disorders in adolescents: current insights. Adolescent Health Medicine Theraputics, 8, 69-79. doi: 10.2147/AHMT.S115775.