Post-Graduate Residency Program Teaching Day
Department of Family Medicine – University of Calgary
January 28, 2016
New Insights into the Field of Eating
Disorders in Children and Adolescents
Jorge L. Pinzon, M.D., FRCPC, FAAP, FSAHM
Calgary Eating Disorders Program
Clinical Associate Professor of Pediatrics & Psychiatry
University of Calgary
Objectives
Identify flags that may indicate eating
disorders and initial work-up
 Describe the care related to medical
complications for patients with eating
disorders
 Learn approaches to help patients
struggling with eating disorders

Eating Disorders in Children
and Adolescents Epidemiology

Increase recognition of problem 8-14 year olds with
anorexia nervosa (Lask & Bryant-Waugh, 1993)

Male children form a larger proportion 19-30%

Incidence rates steadily increasing

Prevalence of anorexia nervosa in 15-19 year olds =
0.48%, and overall 1%

Prevalence of bulimia nervosa = 1- 3%

Mortality rate in excess of 10% (Litt)
ICD – 10 (WHO)
2000
 Pica (F98.3)
 Rumination Disorder (F98.21)
 Avoidant/Restrictive Food Intake Disorder (F50.8)
 Anorexia nervosa (F50.01 or F50.02)
 Atypical anorexia nervosa (F50.8)
 Bulimia nervosa (F50.2)
 Atypical bulimia nervosa (F50.8)
 Binge eating Disorders (F50.8)
 Purging Disorder (F50.8)
 Other specific feeding or eating disorders (F50.8)
DSM – 5 (APA)
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Pica (307.52)
Rumination Disorders (307.53)
Avoidant/Restrictive Food Intake Disorder (307.59)
Anorexia nervosa (307.1)
o
o
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
2013
Restrictive type
Binge eating / purging type
Bulimia nervosa (307.51)
Binge Eating Disorder (307.51)
Other Specific Feeding or eating Disorders (307.59)

Atypical AN; BN low frequency, lim duration ; BED; Purging Disorder
Avoidant/Restrictive Food Intake Disorder
(AFRID)

New diagnostic category in the DSM-V

Problem around eating  inadequate intake of
calories  weight loss/FTT

Ex: difficulty digesting certain foods, avoiding
certain colours or textures of food, no appetite, fear of
eating after a frightening episode of choking or
vomiting
Puberty & Menstruation Facts
 Menarche (median age): 12.43 years
 Mean cycle interval: 32.2 days in first gynecological
year
 Menstrual cycle interval: typically 21 – 45 days
 Menstrual flow length: < 7 days
 Menstrual product use: 3 – 6 pads/tampons per day
American Academy of Pediatrics - Committee on Adolescent Health. American College of Obstetrics and Gynecology –
Committee on Adolescent Health Care. Menstruation in girls and adolescents: Using the menstrual cycle as a vital sign.
Pediatrics 2006;118(5):2245-2250. http://dx.doi.org/ 10.1542/peds.2006-2481
Sequence of Pubertal Events in Females
Pubic Hair 5
Menarche
Breast5
Breast 4
Pubic Hair 4
Pubic Hair 3
Breast 3
PHV
Pubic Hair 2
Breast 2
11.5
12
13
14
Adopted from: Adolescent Health Care: A Practical Guide. L. S. Neinstein, 4rd ed., 2002
15 Years old
Pubertal Events in Males
10
11
12
13
14
15
16
17
18
APEX STRENGTH SPURT
HEIGHT SPURT
13-17 1/2
10 1/2 - 16
PENIS
11-14 1/2
13 1/2- 17
TESTIS
10-13 1/2
PUBIC
HAIR
10
2
3
14 1/2 - 18
5
4
10-15
11
12
14-18
13
14
15
16
17
18
AGE, YEARS
Figure 16-18. Diagram of the sequence of events at puberty in males. An average is represented in relation to the scale in ages.
The range of ages within which some of the changes occur is indicated by the figures below. These data are for British Children
But boys in the United States would normally enter puberty between 9 years and 14 years. (From Marshall WA, Tanner JM:
Variation in the pattern of pubertal changes in boys. Arc Dis Child 45:13, 1970.

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SMR1
SMR2
SMR3
SMR4
15.7%
18.9%
21.6%
26.7%



SMR1
SMR2
14.3%
11.3%
CASE
 Mary is a 16 year old female who has lost 25% of her





body weight over the past 8 months.
Complains of cold hands and feet, fatigue,
constipation and having lost her periods.
In the past she has been diagnosed with food allergies
and exercise induced asthma.
O/E emaciated, acrocyanotic, BMI of 14.
Evidence of orthostatic changes on BP and HR.
Lanugo hair and scaphoid abdomen. The rest of
examination is negative.
Blood Test
CBC#1
Hgb/Hct: 114/35.6
WBC:
1.7
PMN: 1.1
MCV:
99.3
MCH: 33.7
Platelets: 136
LFTs
TP: 63
Alb: 39
AST: 58
ALT: 48
ALP: 90
TB: 7
DB: 0
#2
86/29.3
3.5
2.8
71.2
24.6
245
Hormones
TSH:
1.2
LH:
<1
FSH:
3.5
Estradiol: 96
Cortisol: 562
Biochemistry
Na:
143
K:
3.5
CL:
97
Gluc:
3.2
Ca:
2.1
Mg:
0.7
Phos:
0.9
BUN:
7.2
Cr:
87
Amylase:115
Urianalysis
Vol: 10ml
SG: 1.030
Ph: 7.5
Gluc: (-)
Ket: (++)
Prot: (+)
Blood: (-)
WBC: (-)
Differential Diagnosis
Neurological
Gastrointestinal
CNS lesion or tumor

Inflammatory Bowel Disease
Seizure disorder

Neoplastic bowel disease
Kluver-Bucy syndrome

Pancreatitis
Kleine-Levine syndrome

Malabsortive syndrome

Achalasia




Malnutrition
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
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Multisystem
Disorder

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Fluids & Electrolytes
Metabolic
Cardiovascular
Pulmonary
Gastrointestinal
Renal
Endocrine
Hematologic
Immunologic
Neurologic
Dermatologic
Fluids & Electrolytes
Anorexia Nervosa
Usually
normal
Dehydration
Hyponatremia
Hypophosphatemia
Edema
Bulimia Nervosa
Hypochloremia
Hypokalemia
Metabolic Alkalosis
Dehydration
Hyponatremia
Hypokalemic Complications
• Cardiovascular
• Renal
Arrhythmias
Polyuria, polydipsia
Rx: K-Dur 20 mmol/TID
Kaliopenic nephropathy
Edema & sodium retention
• Neuromuscular
Ileus
Weakness
Autonomic insufficiency
Tetany
Rabdomyolysis
Encephalopathy
• Metabolic
Abnormal carbohydrate
metabolism
Negative nitrogen balance
Decrease insulin release
Cardiovascular Complications
Anorexia Nervosa
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Bradycardia
Hypotension
Orthostatic Changes
EKG abnormalities
Mitral valve prolapse
Pericardial effusion
Congestive cardiomyopathy
Bulimia Nervosa
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Same as AN
Ipecac cardiomyopathy
Peripheral edema
Arrhythmias
Gastrointestinal Complications
Bulimia Nervosa
Anorexia Nervosa
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Constipation
Delayed gastric emptying
Transaminitis
Fatty degeneration of the
liver
Superior Mesenteric artery
syndrome
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Mouth changes
GER
Esophagitis
Mallory-Weiss
Esophageal rupture
Cathartic colon
Gallbladder stones
Pancreatitis
The Abnormal CBC
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Normal CBC
Elevated MCV / MCH
Normal B12 / Folate
Leukopenia with Neutropenia
Thrombocytopenia
Microcytic – Hypochromic Anemia
Bone marrow gelatinous changes
Reversible with nutritional restoration
Refeeding Syndrome
Hypophosphatemia
Abrupt
shift from catabolism to anabolism
Glucose
Rapid
predominant cellular fuel
release of insulin
Glucose,
water, phosphorus, potassium into cells
with decrease in serum levels
Vulnerable
tissue:
Neurons
Cardiac
RBCs
Rx: PO4 500mg / BID
Bone Accretion
Variables that affect bone accretion
 Bone health evaluation


(DEXA, BUA, CT, MRI)
50% of bone mass is attained in adolescence
 calcium accretion

Kreipe RE. Assessment of
Weight Loss in the
Adolescent. Ross Labs.
Columbus, OH 1988
Drawing by C. Lyons, MD
Family-Based Therapy
 I – Initial evaluation and setting up therapy
 II – Helping the adolescent eat on her own
 III – Adolescent issues
Lock J., LeGrange D., Agras WS & Dare C. Treatment manual for anorexia nervosa: A family-based approach.
New York: Guilford Press; 2001. ISBN: 1-57230-836-2
Hospitalization Criteria
Vital Signs
 pulse less than 40-45 (dependent upon age)
 orthostatic BP changes systolic>20
 orthostatic HR changes >35
 Temperature <35.5
Electrolyte Imbalances (if intractable despite outpatient treatment)
 Hypokalemia
 Hyponatremia
 Hypophosphatemia
 Hypernatremia (dehydration)
HOSPITAL MANAGEMENT
Medical Complications
 Refeeding Syndrome
 Cardiac Concerns/Complications
 Gastrointestinal: dysmotility
Psychosocial Issues
 Adjustment to hospitalization
 Food refusal
 Co-morbidities
Admission Orders
Nutrition
 Consult Dietician
 If severely emaciated start with 20kcal/kg
 Increase by 200 cal/day based on weight changes and
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fluid balance. (+&-)
Fluid mins/max
Daily weights, Ins/Outs
Increase caloric intake if weight gain <200gms/day
>500gms monitor for heart failure or intentional water
loading
Intake may need to be increased as high as 60-70
kcal/kg/day
Commonly Cited Approaches to EDs
 ID problem behavior
 Socratic/Columbo approach
 Address “denial”
 Eclectic approach
 Address medical factors
 Psycho-Ed techniques
 Use MIT*
 How to do it?
 Revisit readiness
 Can we sit with helplessness
 Talk about nutrition
 Psycho-Ed techniques
 Review-review-review
MIT - How to do it?
 Directive, client-centered counseling style for
eliciting behavior change by helping patients to
explore and resolve ambivalence
 Central purpose is the examination and resolution of
ambivalence, and the counselor is intentionally
directive in pursuing this goal.
Annabelle Blanchet M.D.
Erickson SJ., Gerstle M., & Feldstein SW. Brief interventions and motivational interviewing with children, adolescents, and their
parents in pediatric health care settings. Achieves of Pediatric and Adolescent Medicine 2005;159:1173-1180.
MIT & Youth
 High ambivalence
 Developmentally - questioning authority
 Cohersive approach likely unsuccessful
 The invulnerable teen
 The maturing brain and lack or experiences
Annabelle Blanchet M.D.
In Summary
What Have I Learned?
 Time
 Engaging with boundaries
 Adolescent focus in a family center context
 Blame and its sticky properties
 Transference & countertransference
 Positive Youth development
Summary
 Presentation of children and adolescents with EDs is
different from adults
 There still remain major challenges in diagnosis and
classification
 Eating disorders present in childhood with a wider
array of symptomatology
 To date family-based treatment appears to be the
choice for adolescent AN
Overas M., Winje E., & Lask B. Eating disorders in children and adolescents. In Annual Review of Eating Disorders, ed: Wonderlich S.,
Mitchell JE., deZwaan M., & Steiger H. part 2 – 2008; Chapter 8: 110-124. Radclife Publisging, Oxford.
Comments & Questions