Identification and management of eating disorders in children and adolescents

Nutritional Strategies for Managing Iron Deficiency in Adolescents: Approaches to a Challenging but Common Problem

Iron deficiency (ID) is a common and challenging problem in adolescence. In order to prevent, recognize, and treat ID in this age range, it is critical to understand the recommended daily intake of iron in relation to an adolescent's activity, dietary habits, and basal iron losses. Adolescents following vegetarian or vegan diets exclusively rely on plant-based, nonheme iron, which has decreased bioavailability compared with heme iron and requires increased total iron intake. Individuals with disordered eating habits, excessive menstrual blood loss, and certain chronic health conditions (including inflammatory bowel disease and heart failure) are at high risk of ID and the development of symptomatic iron deficiency anemia (IDA). Adolescent athletes and those with sleep and movement disorders may also be more sensitive to changes in iron status. Iron deficiency is typically treated with oral iron supplementation. To maximize iron absorption, oral iron should be administered no more than once daily, ideally in the morning, while avoiding foods and drinks that inhibit iron absorption. Oral iron therapy should be provided for ≥3 mo in the setting of ID to reach a ferritin of 20 ng/mL before discontinuation. Intravenous iron is being increasingly used in this population and has demonstrated efficacy and safety in adolescents. It should be considered in those with persistent ID despite a course of oral iron, severe and/or symptomatic IDA, and chronic inflammatory conditions characterized by decreased gastrointestinal iron absorption.

Outcomes of Anorexia Nervosa in a Male Patient Treated With Paroxetine: A Case Report

Eating disorders (EDs) are among the most dangerous mental illnesses, that are characterized by high mortality rates, multisystem comorbidity, and an often chronic and relapsing disease course. EDs occur most commonly in the female gender, with a ratio of 10 females to 1 male for anorexia nervosa (AN). We present the case of a 15-year-old Saudi boy who presented with weight loss (BMI 11.6 kg/m2) and began to have symptoms of obsessive-compulsive disorder (OCD) in prayer and ablution. His first treatment plan was psychoeducation. He then developed a fear of gaining weight and began to count calories; he was diagnosed with AN and started on olanzapine 2.5 mg. The patient had a history of multiple admissions due to electrolyte imbalance, hypokalemia, hypoglycemia, and anal fissure due to constipation, and was prescribed olanzapine 5 mg, fluoxetine 20. His last admission was the worst, as he became semi-comatose with a Glasgow Coma Scale (GCS) of 13, was diffused and disoriented to time and person, unable to walk or sit, and was uncooperative in answering questions. During admission, we changed the fluoxetine to paroxetine 25 mg and increased the olanzapine to 10 mg, and the patient showed a huge improvement physically and mentally. This case emphasizes the significance of including paroxetine in the treatment of diagnoses for AN to prevent unnecessary wasting of time and effort.

Social Media Effects Regarding Eating Disorders and Body Image in Young Adolescents

The following study investigates how eating problems and young people's body image are affected by social media. As social media becomes more pervasive, young teenagers are exposed to many pictures, messages, and influencers encouraging unachievable body and beauty ideals. The study investigates the link between social media usage and the development of binge eating disorder patterns and undesirable body image judgments. It also sheds light on the influence that so-called social media influencers and celebrities have on encouraging disordered eating patterns and forming negative body image perceptions. On websites like Instagram and TikTok, exposure to deliberately selected photographs of "ideal" body types encourages body dissatisfaction and poor self-worth. The research emphasizes social media's possible harm to this vulnerable group's physical and mental health by examining pertinent literature and empirical evidence. It also looks at potential safeguards and methods for fostering good mental and physical health in early adolescents during pervasive social networking site use. Promoting fad diets, weight-loss aids, and the exaltation of extreme thinness aids in the normalization of harmful behaviours. Social media's negative consequences on eating disorders and body image in young teenagers are highlighted by this study in its conclusion. As a critical developmental stage, early adolescence is vulnerable due to the effect of social media, which could normalize unhealthy behaviours and maintain negative body image and insecurities. The findings underscore the need for targeted interventions and educational programs to mitigate the adverse effects of eating problems and young people's body image in light of social media.

The Role of the Dietitian within Family Therapy for Anorexia Nervosa (FT-AN): A Reflexive Thematic Analysis of Child and Adolescent Eating Disorder Clinician Perspectives

BACKGROUND

Despite dietitians being important members of the multidisciplinary team delivering family therapy for anorexia nervosa (FT-AN), their specific responsibilities and roles are unclear and their involvement in the treatment can be a contentious issue.

METHODOLOGY

Clinicians (n = 20) experienced in the delivery of FT-AN who were working at a specialist child and adolescent eating disorder service responded to an online survey about their experience of including a dietitian in FT-AN and how they understand the role. Both categorical and open-ended questions were used. Reflexive thematic analysis was used to analyse the qualitative free-text responses of clinician perspectives on the role of the dietitian in FT-AN.

RESULTS

All clinicians agreed that dietetics had a role within FT-AN and most frequently sought dietetic involvement in the early phases of FT-AN. Reflexive thematic analysis of responses identified three main themes. These were (1) collaboration is key, (2) confidence as a core consideration and (3) case-by-case approach. These themes evidenced the role of the dietitian within FT-AN and highlighted both the benefits and concerns of this involvement.

CONCLUSIONS

This study demonstrated that dietitians can take a core role as collaborators within therapy-led teams that facilitate joint working and sharing of expertise. However, dietetic input should be considered on a case-by-case basis, given its potential for creating an over-focus on nutrition and potentially diminishing parental confidence in feeding. When indicated for selected cases, nutritional counselling should be offered in joint sessions with the therapist rather than separately. The findings of the study were limited by the small sample size of participants recruited from a single centre and heterogeneity in the professional background of respondents. Although the integration of dietetics within the multidisciplinary team and the ability of dietitians to individualise patient care can enhance FT-AN treatment, potential benefits and disbenefits should be considered for each case.

A Retrospective Chart Review Suggests That Coordinated, Multidisciplinary Treatment for Patients with Anorexia Nervosa Improves Odds of Weight Restoration

Purpose

The objective of this study was to conduct a secondary data analysis of clinical information documented in the electronic medical record to assess the clinical outcomes of patients who received three different treatment approaches on clinical outcomes for treatment of patients with anorexia nervosa (AN).

Patients and methods

Historical electronic medical record (EMR) data on patients aged 6 to 80 years diagnosed with AN seen in a healthcare system between 2007 and 2017 were stratified, according to services received, into three groups: Group A (n = 48) received hospital-based services; Group B (n = 290) saw one or two provider types; Group C (n = 26) received outpatient coordinated multidisciplinary care from three provider types. Clinical outcomes [body mass index for adults (BMI), body mass index percentile (BMI%ile) for pediatric patients] defined AN severity and weight restoration. EMR data were analyzed using a generalized mixed-effects model and a Markov Transition model to examine the odds of weight restoration and the change in odds of weight restoration across the number of provider visits, respectively.

Results

Patients receiving coordinated multidisciplinary care had significantly higher odds of weight restoration compared with patients receiving hospital-based services only (OR = 3.76, 95% CI [1.04, 13.54], p = 0.042). In addition, patients receiving care from 1 to 2 providers (OR = 1.006, 95% CI [1.003, 1.010], p = 0.001) or receiving coordinated multidisciplinary care (OR = 1.005, 95% CI [1.001, 1.011], p = 0.021) had significantly higher odds of weight restoration per provider visit day compared with patients receiving hospital-based services only.

Conclusion

This retrospective chart review supports the coordinated, multidisciplinary care model for the weight restoration in patients with AN in an outpatient setting.

Mental Health and Disordered Eating in Athletes

Disordered eating (DE) and eating disorders (EDs) are more prevalent in athletes than non-athletes, and can cause devastating health and performance consequences. Although they can affect any athlete, DE/EDs are more common among women and athletes in lean sports, where there is a perceived competitive advantage to being lean. The sports medicine provider plays a crucial role in screening, diagnosis, and treatment of DE/ED. Treatment should involve a multidisciplinary team with a physician, dietitian, and mental health provider. Preventative efforts should seek to educate athletes and their coaches/support staff and should foster a healthy environment, which deemphasizes weight or body image.

Undetected eating disorders among adolescent psychiatric inpatients

AIM

The aim of this study was to identify the prevalence of undetected eating disorders (EDs) among adolescent psychiatric inpatients and to investigate the association between clinical, psychiatric, and sociocultural factors and EDs.

METHODS

Between January and December 2018, patients aged 12-18 years, hospitalized for inpatient-level treatment were given the self-assessment questionnaires of the Eating Attitudes Test-26 (EAT-26), the Contour Drawing Figure Rating Scale (CDFRS), the Child Behaviour Check List, and Sociocultural Attitudes Toward Appearance Questionnaire-4 after their routine unstructured clinical diagnostic assessment on admission by a psychiatrist. Patients were reassessed after reviewing the psychometric assessment results.

RESULTS

The prevalence of EDs among 117 psychiatric inpatients was 9.4%, all were female and all diagnosed with unspecified feeding and eating disorder. We showed that 63.6% of patients with EDs was diagnosed after the screening and not with the routine clinical interview. EAT-26 scores were weakly correlated with affective (r = 0.314, p = .001), anxious (r = 0.231, p = .012), somatic (r = 0.258, p = .005), and impulsive maladaptive behaviours (r = 0.272, p = .003). A formal ED diagnosis was positively associated with media pressure, (OR:1.660, 95% CI: 1.105-2.495) and oppositional defiance (OR: 1.391, 95% CI: 1.005-1.926), and negatively with conduct problems (OR: 0.695, 95% CI: 0.500-0.964). The CDFRS results were not different between the ED and non-ED groups.

CONCLUSIONS

Our study suggests EDs remain a prevalent yet often overlooked diagnosis in adolescent psychiatric inpatients. Health care providers should screen for EDs in inpatient psychiatric settings as a part of routine assessment to improve the identification of disordered eating behaviours that often begin during adolescence.

Strategies for Creating Multidisciplinary Community Care Teams to Address Barriers to Providing Family Based Treatment of Eating Disorders

Eating disorders, especially anorexia nervosa, are complex and devastating illnesses. Although eating disorders have a high mortality rate and are relatively common, there are many barriers for those seeking treatment. Provider training and education, weight bias among health care providers, geographical and language barriers, and a lack of options because of insurance restrictions prevent many families from receiving appropriate care, especially in smaller or rural communities. In those areas, providers are left to piece together treatment using a small number of other providers from different disciplines who have a willingness to work with this population. Outpatient family based treatment is an evidenced-based treatment of anorexia nervosa and relies on a multidisciplinary approach to care. Community-based care teams can be an effective way to treat those with eating disorders seeking family based treatment. There are several strategies for building collaborative teams that can provide comprehensive and accessible care to those with few options. [Pediatr Ann. 2024;53(1):e22-e27.].

Hypercapnia in hospitalized children and adolescents with anorexia nervosa as a predictive marker for readmission: a prospective study

PURPOSE

To determine whether hypercapnia is associated with risk of hospital readmission related to anorexia nervosa (AN) in children and adolescents.

METHODS

We performed a prospective study of patients ≤ 18 years old admitted due to AN decompensation from November 2018 to October 2019. Both subtypes of AN, restricting subtype (AN-R) and binge-eating/purging subtype (AN-BP), were included. Study participants were evaluated upon admission, at discharge and six months after discharge. T-tests or Mann-Whitney U tests was used to compare means values. Pearson or Spearman correlations were used to measure the association between two variables. Logistic regression models were developed to evaluate the relationship between scoring methods and readmission.

RESULTS

Of the 154 persons admitted during the study period, 131 met the inclusion criteria. Median age was 15.1 years. At admission, 71% of participants were malnourished and 33 (25%) had been previously admitted. We observed a marked decrease in venous pH and stable pCO2 elevation during follow-up period. Hypercapnia at discharge was associated with a twofold increased likelihood of readmission and the odds of readmission increased as discharge pCO2 rose. These findings did not depend on AN subtype or participant sex. Electrolytes persisted within the normal range.

CONCLUSION

Hypercapnia and respiratory acidosis are common alterations in children and adolescents hospitalized due to AN decompensation. Hypercapnia persists for at least 6 months after discharge despite clinical improvement and is associated with higher odds of readmission. This is the first study to identify an abnormal laboratory finding as a potential predictor of readmission in AN.

LEVEL OF EVIDENCE

IV: Multiple time series without intervention.

Family-based treatment takes longer for adolescents with mental health comorbidities: findings from a community mental health service

Children and adolescents diagnosed with an eating disorder often meet the diagnosis of another mental health disorder. In addition to eating disorders, individuals with comorbid disorders have higher suicide rates and more severe and chronic eating disorder symptoms. The present research aimed to investigate the influence of comorbid conditions on the treatment outcomes of children and adolescents that attended a public community mental health service. It was hypothesised that the patients with comorbidities would have a more extended treatment duration, slower rates of weight restoration, more hospital admissions for medical compromise, and poorer functioning than those without comorbidities. Data from 78 past patients at the Eating Disorder Program in Queensland, Australia, were analysed. Patients with comorbidities demonstrated similar recovery rates to those without comorbidities. However, those with comorbid conditions had longer episodes of treatment. The study's results support using Family Based Treatment for patients with and without comorbidities. The implications of the findings for public mental health services and directions for future research are discussed.

The Role of Primary Care in Bridging Adolescents Awaiting Eating Disorder Treatment

The striking rise in adolescent eating disorders since the severe acute respiratory coronavirus syndrome 2 pandemic has amplified demands for specialty eating disorders services and contributed to protracted delays in care. In the context of these delays, patients are at risk for increased weight loss, medical instability, escalating disease progression and poor prognosis. Primary care providers (PCPs) are frequently the first point of contact for young patients with eating disorders and are often left to bridge the gap while families struggle to establish specialty care. Yet, beyond case detection and medical comanagement, there are no evidence-based guidelines that can assist PCPs to prepare families for treatment, halt disease progression, and begin the lengthy process of weight and nutritional restoration in efforts to reduce medical complications and support a favorable prognosis. We present the case of a 13-year-old girl with a restrictive eating disorder to illustrate how PCPs can use intervention principles and strategies derived from evidence-based eating disorder treatment to successfully manage adolescent patients until they can access specialty treatment. We offer concrete guidelines for decision-making, as well as suggested behavioral and medical interventions for the PCP. With evidence-based tools, PCPs are well-positioned to support young patients with restrictive eating disorders and their family members as they begin the process of recovery from an eating disorder.

Fifteen-minute consultation: Recognition and management of eating disorders presenting to the emergency department

Eating disorder presentations in children and young people during the COVID-19 pandemic have increased, and this has become a common presentation to paediatric emergency departments (EDs). We cover a structured approach on identifying and managing these presentations within the ED including history taking, what to look for on examination, what investigations are needed and how to decide who requires admission to hospital.

Electrocardiographic QTc as a Surrogate Measure of Cardiac Risk in Children, Adolescents, and Young Adults With Eating Disorders

The study goal was to investigate electrocardiographic findings, including corrected QT interval (QTc), in patients aged 8 to 23 with eating disorders (EDs) at presentation, compared with an age-and sex-matched control population. We retrospectively reviewed 200 ED patients, and 200 controls. Blinded electrocardiograms (ECGs) were interpreted by an expert reader, and QT intervals corrected using the Bazett formula. Eating disorder patients were 89.5% female, with mean age 16.4 years and median percent median body mass index (BMI)-for-age (%mBMI)a of 91.1%. In ED patients, QTc was significantly shorter than controls (399.6 vs 415.0msec, P < .001). After adjusting for height, %mBMI, sex, magnesium level, and bradycardia, mean QTc duration in patients with anorexia nervosa-restricting subtype (AN-R) was significantly shorter than other ED patients (P = .010). Higher %mBMI was associated with shorter QTc duration (P = .041) after adjusting for height, magnesium, bradycardia, and Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5) diagnosis. Within the ED group, no significant association was identified between QTc and medications, electrolytes, or inpatient status.

Prevalence, predictors, and treatment of eating disorders in children: a national study

BACKGROUND

Although the prevalence rates of preadolescent eating disorders (EDs) are on the rise, considerably less is known about the correlates and treatment of EDs in this age group. Clarifying the epidemiology of EDs in preadolescent children is a necessary first step to understand the nature and scope of this problem in this age group.

METHODS

Analysis of data collected in the ABCD Study release 2.0.1. The ABCD cohort was a population-based sample that consisted of 11 721 children ages 9-10 years. Measures included reports of a lifetime and current mental disorders determined using a diagnostic interview for DSM-5 disorders, sociodemographic factors, and psychiatric treatment utilization.

RESULTS

The lifetime prevalence of EDs was 0.95%. Being Black, multiracial, having unmarried parents, and family economic insecurity were significant predictors for developing an ED. Among psychiatric conditions, the major depressive disorder was most robustly associated with EDs in both cross-sectional and temporal analyses. Only 47.40% of children who had a lifetime ED received some type of psychiatric treatment. EDs were not a significant predictor of psychiatric treatment utilization after accounting for sex, sexual orientation, parent marital status, economic insecurity, and all other psychiatric diagnoses.

CONCLUSIONS

Despite increasing prevalence rates of preadolescent EDs, the current findings suggest that the majority of children with these disorders remain untreated. Devoting increased attention and resources to reaching families of children with EDs with the least means for receiving care, and screening for EDs in children with depression, may be important steps for reducing this unmet need.

Parent, teacher, and nurse concerns and school doctor actions: an observational study of general health checks

OBJECTIVE

To evaluate the association between the concerns of parents, teachers, and nurses regarding each child's well-being and the school doctor actions conducted in routine general health checks.

DESIGN

A blinded, observational study. Prior to the health check parents, teachers, and nurses completed questionnaires assessing their concerns. Doctors, blinded to the responses, routinely examined all children accompanied by parents and reported their actions after each health check. Multilevel logistic regression was used to analyse the association of the concerns with the actions.

SETTING

21 primary schools in four municipalities in Finland.

PARTICIPANTS

Between August 2017 and August 2018, we randomly recruited 1341 children from grades 1 and 5, aged 7 and 11 years, respectively.

OUTCOME MEASURES

Outcome measures were the respondents' concerns and the school doctor actions. The extent of concerns was assessed on a five-point Likert scale. Concern refers to 'Quite a lot or a great deal of concern' by at least one respondent. The school doctor actions included instructions and/or significant discussions, prescriptions, laboratory tests and/or medical imaging, scheduling of follow-up appointments, referrals to other professionals, and referrals to specialised care.

RESULTS

Altogether, respondents were concerned about 47.5% of children. The top three concerns comprised growth/and or physical symptoms (22.7%), emotions (16.2%), and concentration (15.1%). All concerns were associated with some type of school doctor action (ORs: 1.66-4.27, p≤0.05); but only concerns regarding growth and/or physical symptoms were associated with all actions. Almost all concerns were associated with referrals to other professionals (ORs: 1.80-4.52, p≤0.01); emotions had the strongest association OR 4.52 (95% CI 3.00 to 6.80, p&lt;0.0001).

CONCLUSIONS

Health checks by school doctors may lead to referrals of children to other professionals especially for children's psychosocial problems. This should be considered when developing the roles, training, and multiprofessional collaboration of school health care professionals.

TRIAL REGISTRATION

NCT03178331.

Treatment response in children and adolescents with anorexia nervosa: a naturalistic, case-control study

PURPOSE

Although a few recent articles describe adults with treatment-resistant anorexia nervosa (TR-AN), no study addresses the specific features of subjects not responding to treatment in the developmental age. This study reports on the clinical and psychopathological variables that distinguish children and adolescents who did not respond to treatment (here "TR-AN") from good-outcome controls, in a multidisciplinary hospital treatment setting.

METHODS

Naturalistic, case-control study conducted on individuals showing lack of response to treatment and good-outcome controls. TR-AN was defined as two or more incomplete admissions and no complete admissions, consistently with studies in adults. Good-outcome was defined as complete first admission, availability for follow-up visit after 6 months, and maintaining at follow-up a %BMI > 70% in the absence of binging or purging in the preceding 3 months. Psychopathological (Eating Disorders Inventory-3 EDI-3; Beck Depression Inventory-II), clinical, and treatment variables at admission were compared. Significant differences in the univariate analyses were included in an exploratory binary logistic regression.

RESULTS

Seventy-six patients (30 TR-AN, 46 good-outcome AN controls) were enrolled (mean age 14.9 ± 1.9 years, F = 94.7%). TR-AN individuals had a higher age at admission and higher EDI-3 Eating Disorder Risk (EDRC) scores, were treated less frequently with a nasogastric tube (NGT), and achieved a lower BMI improvement at discharge than good-outcome controls. A predictive model for TR-AN status was found (X² = 19.116; Nagelkerke-R² = 0.478, p < 0.001), and age at admission (OR = 0.460, p = 0.019), EDI-3 EDRC (OR = 0.938, p = 0.043), and NGT (OR = 8.003, p = 0.019) were associated with a TR-AN status.

CONCLUSIONS

This is the first report on the psychopathological and clinical characteristics of children and adolescents not responding to treatment. These patients showed higher age and eating disorder scores, and were less frequently fed with NGT than controls. Despite the multiple incomplete admissions of our subjects, the short included follow-up limits the possibility for direct comparisons with adult samples of treatment-resistant patients. Thus, the specific features of children and adolescents with TR-AN should be assessed in longitudinal studies.

LEVEL OF EVIDENCE

III, Observational, case-control study.

Weight Pressures and Eating Disorder Symptoms among Adolescent Female Gymnasts of Different Performance Levels in Greece

This study examined the weight pressures within the gymnastics environment and explored associations between these pressures and eating disorder (ED) symptoms in adolescent female gymnasts. One hundred and forty-seven competitive gymnasts and 122 recreational-level gymnasts (11–17 years old) completed the Eating Attitudes Test (EAT-26), the Weight-Pressures in Sport-Females (WPS-F), the Social Desirability Scale (SDS) and provided information on their training. It was found that 16.3% of competitive gymnasts and 7.4% of non-competitive gymnasts scored ≥20 in EAT-26, indicating disordered eating behavior. Competitive gymnasts scored higher than non-competitive in the total score of EAT-26 (p = 0.027), as well as in the total score of WPS-F, the sport and coaches weight pressures sub-scale and the appearance and performance weight pressures sub-scale (p < 0.001). Multiple regression analyses indicated that sport and coaches weight pressures, appearance and performance weight pressures and body mass index accounted for 30.3% of the variance of EAT-26 in competitive gymnasts, while the appearance and performance weight pressures sub-scale accounted for 16.3% of the variance of EAT-26 in non-competitive gymnasts. Sport and coaches weight pressures are associated with ED in competitive gymnasts, while body appearance and performance demands correlate with ED in female gymnasts irrespective of competitive level.

To Improve the Initial Inpatient Management of Adolescents Admitted with Severe Anorexia Nervosa: A Narrative Review and a Convenient Protocol

Inadequate nutritional rehabilitation of severely malnourished adolescents with Anorexia Nervosa (AN) increases the risk of medical complications. There is no consensus on best practices for inpatient nutritional rehabilitation and medical stabilization for severe AN. This study aimed to elaborate an admission protocol for adolescents with severe AN based on a comprehensive narrative review of current evidence. A Pubmed search was conducted in July 2017 and updated in August 2020, using the keywords severe AN or eating disorders (ED), management guidelines and adolescent. Relevant references cited in these guidelines were retrieved. A secondary search was conducted using AN or ED and refeeding protocol, refeeding syndrome (RS), hypophosphatemia, hypoglycemia, cardiac monitoring or cardiac complications. Evidence obtained was used to develop the admission protocol. Selective blood tests were proposed during the first three days of nutritional rehabilitation. Higher initial caloric intake is supported by evidence. Continuous nasogastric tube feeding was proposed for patients with a BMI < 12 kg/m2. We monitor hypoglycemia for 72 h. Continuous cardiac monitoring for bradycardia <30 BPM and systematic phosphate supplementation should be considered. Developing protocols is necessary to improve standardization of care. We provide an example of an inpatient admission protocol for adolescents with severe AN.

Adolescents With Eating Disorders in Pediatric Practice - The European Academy of Paediatrics Recommendations

In the face of the growing number of adolescents suffering from eating disorders (EDs) and access to psychiatric care limited by the epidemiological and demographic situation, the primary care pediatrician's role in diagnosing and treating EDs is growing. The European Academy of Paediatrics (EAP) decided to summarize knowledge about EDs and formulate recommendations to support European pediatricians and improve care for adolescents with EDs.

Acute Care Visits for Eating Disorders Among Children and Adolescents After the Onset of the COVID-19 Pandemic

PURPOSE

Anecdotal reports suggest a significant increase in acute presentations of eating disorders among children and adolescents. Our objective was to compare the rates of emergency department visits and hospitalizations for pediatric eating disorders before and during the first 10 months of the COVID-19 pandemic.

METHODS

Using linked health administrative databases, we conducted a population-based repeated cross-sectional study of emergency department visits and hospitalizations for eating disorders among all children and adolescents aged 3-17 years, residing in Ontario, Canada. We defined the pre-COVID period from January 1, 2017, to February 29, 2020, and the post-COVID period from March 1, 2020, to December 26, 2020. Poisson generalized estimating equations were used to model 3-year pre-COVID trends to predict expected post-COVID trends and estimate the relative change from expected rates.

RESULTS

In our population of almost 2.5 million children and adolescents, acute care visits for eating disorders increased immediately after the onset of the pandemic, reaching a 4-week peak annualized rate of 34.6 (emergency department visits) and 43.2 per 100,000 population (hospitalizations) in October 2020. Overall, we observed a 66% (adjusted relative rate: 1.66, 95% confidence interval: 1.41-1.96) and 37% (adjusted relative rate: 1.37, 95% confidence interval: 1.25-1.50) increase in risk for emergency department visit and hospitalization, respectively.

CONCLUSIONS

Acute care visits for pediatric eating disorders increased significantly in Ontario after the onset of COVID-19 pandemic and remained well above expected levels during the first 10 months of the pandemic. Further research is needed to understand the social and neurobiological mechanisms underlying the observed changes in health system utilization.

"The role of L. reuteri DSM17938 in nutritional recovery and treatment of constipation in children and adolescents with anorexia nervosa - a randomized, double blind, placebo controlled study"

BACKGROUND

Anorexia nervosa (AN) carries the risk of potentially irreversible medical complications, especially in children and adolescents. Constipation is frequent and difficult to manage. Due to the symptoms it causes, constipation can further compromise nutritional rehabilitation.

OBJECTIVE

To investigate the role of probiotics (Lactobacillus reuteri DSM 17938) in children and adolescent with AN.

DESIGN, SETTING AND PARTICIPANTS

Randomized, double blind, placebo controlled study in 31 female pediatric AN patients with constipation, referred to nutritional therapy in Pediatric Gastroenterology Department, Sestre milosrdnice University Hospital Centre in Zagreb.

METHODS

At hospitalization, patients were randomly assigned into two groups; one taking L. reuteri, and other placebo for 3 months, along with the conventional nutritional rehabilitation. Patients were followed 3 months after stopping the treatment. The primary outcome was relief of constipation, assessed after 3 months, while secondary outcomes were normalization of body weight, stool frequency and consistency, relief of dyspepsia, weight gain and recovery of malnutrition regarding bone density and vitamin D3 levels.

RESULTS

The study showed statistically significant difference between the two groups considering the stool frequency (6.4 vs. 4.2 stools/week; p < 0.05) and normalization of body weight (93 vs. 63%; p = 0.04) after 6 months, but no significant effect on the rate of relief of constipation (87 vs. 64%; p = 0.22) at 3 months. In the L. reuteri group, the normalization of BMD was achieved in 8/15, whereas in the placebo group, in 3/16 patients. However, there was no statistically significant difference compared to the placebo group regarding the BMD recovery as well as the normalization of D3 levels (p = 0.056).

CONCLUSIONS

Probiotics may serve as simple and safe adjuvant therapy of constipation in childhood AN and contribute to faster nutritional recovery. Although a statistically significant difference between the two group in relief of constipation could not be shown after 3 months, a benefit from probiotics could be in increasing stool frequency and nutritional recovery in childhood AN after six months. Registered under ClinicalTrials.gov Identifier no. NCT02004288.

Anorexia nervosa-related cardiopathy in children with physical instability: prevalence, echocardiographic characteristics and reversibility at mid-term follow-up

Prompt detection of cardiovascular abnormalities in children with anorexia nervosa and physical instability requiring hospitalization is essential to identify patients at higher cardiovascular risk. We studied all anorexia nervosa children requiring admission at Paediatric Institute in the period 2015-2019. Anorexia nervosa cardiopathy at admission was defined by the presence of at least two of the following clinical findings: pericardial effusion, mitral regurgitation, bradycardia, mitral billowing, aortic regurgitation, altered LV morphology and ECG abnormalities. Echocardiographic data were compared with those registered at 3-8-month follow-up and with data from a healthy population. Thirty-eight anorexia nervosa children were examined. Prevalence of anorexia nervosa cardiopathy at admission was 63% (24 patients). Pericardial effusion, bradycardia and mitral regurgitation were present together in 26% of patients. Most cardiovascular changes recovered at follow-up. Anorexia nervosa cardiopathy was associated with significantly lower left ventricle end-diastolic diameters and mass, and higher E wave, E/A and E/e' ratios and left ventricle sphericity index values vs healthy population and vs anorexia nervosa children without cardiopathy (p<0.05). Left ventricle global longitudinal strain was significantly reduced only in anorexia nervosa cardiopathy patients but recovered, whereas end-diastolic diameters, E/A ratio and sphericity index values remained impaired.Conclusion: Among anorexia nervosa children requiring hospitalization, those presenting several cardiac findings together express an acute anorexia nervosa cardiopathy which is characterized by worse LV filling, geometry and subclinical myocardial deformation impairment. Despite treatment, in those patients, some alterations persist at mid-term follow-up. What is Known: • Cardiac and electrocardiographic changes are present in anorexia nervosa children at diagnosis or during stable disease, and most recover after body-weight treatment. • It is unknown if anorexia nervosa children with more severe cardiac impairment during hospitalization present higher cardiovascular-risk profile despite treatment. What is New: • In anorexia nervosa children needing hospitalization for physical reasons, prevalence of acute anorexia nervosa cardiopathy at admission is high, around 60%. • By advanced echocardiography, children with anorexia nervosa cardiopathy at admission have a worse cardiac filling, impaired cardiac geometry and systolic deformation that only partially recover at mid-term follow-up.

Prevalence and early risk factors for bulimia nervosa symptoms in inner-city youth: gender and ethnicity perspectives

BACKGROUND

Research on risk factors associated with bulimia nervosa symptoms (BN) in ethnic minorities has been limited. This study adds to the existing literature by providing the ethnicity- and gender-specific prevalence of BN in US inner-city youth and by exploring the longitudinal associations between a clinical level of BN and early risk factors assessed one year previously.

METHODS

The study was conducted on a representative sample of predominantly ethnic minority youth (N = 2794; 54.1% female; age 11-16 years old (M(SD) = 12.77(1.29)); 60.0% African-American, 26.1% Hispanic American, 13.9% White). Self-reported information was obtained on BN and early risk factors (e.g., depressive and anxiety symptoms, posttraumatic stress, somatic complaints). Multivariate analysis of covariance was used to examine the longitudinal associations.

RESULTS

The 3-month BN prevalence was higher in girls (5.1%) than in boys (2.3%) (ratio 2.22:1). Significant differences in BN rates were found between White and African American students (higher in Whites), whereas Hispanic-Americans did not differ significantly from either group. Individuals with BN had significantly higher levels of early risk factors one year prior.

CONCLUSIONS

Timely recognition of BN and associated early risk factors is important for early prevention and intervention strategies.

Associations between study questionnaire-assessed need and school doctor-evaluated benefit of routine health checks: an observational study

Background

In Finland, school doctors examine all children at predetermined ages in addition to annual health checks by school nurses. This study explored the association of study questionnaire-assessed need for and school doctor-evaluated benefit of routine health checks conducted by doctors.

Methods

Between August 2017 and August 2018, we recruited a random sample of 1341 children in grades 1 and 5 (aged seven and eleven years, respectively) from 21 elementary schools in four Finnish municipalities. Children mainly studying in special education groups or whose parents needed an interpreter were excluded. School nurses performed their health check as usual. Parents, nurses, and teachers then completed study questionnaires that assessed the concerns of parents, school nurses, and teachers regarding each child’s physical, mental and social health. Doctors, blinded to the responses, routinely examined all the children. The primary outcome measures were (1) the need for a health check based on the study questionnaires and (2) the benefit/harm of the appointment as estimated by the doctors according to predetermined criteria, and (3) the patient-reported experience measures (PREMs) of benefit/harm of the appointment as estimated by the parents and children. We compared the need for a health check with the doctor-evaluated benefit using multilevel logistic regression.

Results

The participation rate was 75.5 %. According to all questionnaires, 20–25 % of the 1013 children had no need for a health check. The doctors regarded 410 (40.6 %) and the parents 812 (83.4 %) of the appointments as being beneficial. Respondents rarely reported harm. The children who were classified as needing a health check more often benefitted from the health check (assessed by the doctor) than children with no need for one (OR 3.53; 95 % CI 2.41–5.17).

Conclusions

The need for a health check is an important predictor of school-doctor evaluated benefit of the health check. This approach could allow school doctors to allocate time for the children who need them most.

Trial registration

ClinicalTrials.gov, Identifier NCT03178331, registration June 6th 2017.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12887-021-02810-0.

One Year of GH Treatment for Growth Failure in Children With Anorexia Nervosa: A Randomized Placebo-Controlled Trial

CONTEXT

Children with anorexia nervosa (AN) are at risk of adult height deficit due to prolonged low height velocity (HV).

OBJECTIVE

To investigate the effects of human growth hormone (GH) injections on HV in children with AN and severe growth impairment.

DESIGN AND PARTICIPANTS

In this prospective, randomized, double-blind, single-center, proof-of-concept trial, children with AN and low HV (≤2 cm/year) for at least 18 months, and a bone age ≤12 years for girls and ≤14 years for boys, were randomized to receive daily subcutaneous injections of human GH (0.050 mg/kg/day) or placebo for 12 months.

MAIN OUTCOME MEASURES

Change in HV after 12 months.

RESULTS

In total, 8 patients were assigned to the GH group and 6 to the placebo group. Patients had a median (25th-75th percentile) HV of 1.0 (0.5;1.5) cm/year. The effect of GH treatment increased strongly after 6 months, with a height gain after 12 months of 9.65 (8.0;11.6) cm for the GH group vs 3.85 (1.7;7.3) cm for the placebo group, with an absolute median (2.5th-97.5th percentile) difference between the groups of 5.8 (-1.85;9.68) cm after bootstrapping. The percentage of patients with a HV > 5 cm/year during the study period was higher in the GH group than in the placebo group (100% vs 50%, P = 0.05). Adverse events occurred in similar numbers in the 2 groups, were mild or nonfatal, and did not lead to treatment being stopped.

CONCLUSION

GH administration to improve HV is a potentially valid option for increasing HV in children with AN and prolonged severe growth failure.

Eating Disorders in Children and Adolescents: A Practical Review and Update for Pediatric Gynecologists

Eating disorders (EDs) are common among female adolescents and young adults and can have serious and diverse health consequences. Pediatric gynecology providers have the opportunity to play a vital role in the recognition of EDs in this population. Early medical detection and referral for appropriate evidence-based treatment can lead to better health outcomes for youth. In this article we aim to increase the awareness of the pediatric gynecologist of typical and subtle presentations of EDs, provide guidance for screening, discuss common and serious medical complications, and review treatment considerations for gynecologic issues in patients with EDs.

Addressing Disparities in Adolescent Eating Disorders: A Case Report of Family-Based Treatment in Primary Care

Eating disorders typically have a protracted course, marked by significant morbidity. Male adolescents and adolescents of color are at risk of delayed care. Primary care providers are well-positioned to identify eating disorders early and initiate treatment. This case report describes an adaptation of Family-Based Treatment delivered by a primary care provider to an Asian-American male adolescent from an immigrant family with restrictive anorexia nervosa. The adolescent achieved full-weight restoration and remission of his anorexia through treatment in primary care. Embedding eating disorder treatment within primary care could improve detection, engagement, and retention in treatment among young people from diverse backgrounds.

Initial inpatient management of adolescents and young adults admitted with severe malnutrition due to anorexia nervosa: protocol for a systematic review

BACKGROUND

Anorexia Nervosa (AN) is a highly prevalent disease in adolescents and young adults (AYAs). The quality of initial inpatient medical management in a patient with severe malnutrition due to AN is crucial to prevent further medical instability. This review aims to inventory evidence regarding initial refeeding and management of AYAs with AN in an inpatient setting, in order to avoid medical complications.

METHODS

A systematic review will be conducted using PubMed, MEDLINE, All EBM Reviews, Embase, PsycINFO, Cochrane Database and CINAHL. The search strategy consists of terms related to anorexia, hospitalization and Pediatrics. Randomized controlled trials, case-control studies, cross-sectional and cohort studies will be included. Participants will include adolescents and adults 18-24 years old diagnosed with AN and meeting criteria for severe disease. The primary outcome will be any of the following complications: hypophosphatemia, refeeding syndrome, hypoglycemia, cardiac arrythmia, hepatic cytolysis or death. Data will be extracted and the risk of bias will be assessed by one author and reviewed by a second author. Results will be presented in a systematic narrative synthesis format. The quality of evidence for all outcomes will be evaluated using the GRADE methodology.

DISCUSSION

This systematic review will examine current evidence on initial inpatient refeeding and help to document effectiveness of initial inpatient management in AYAs with severe AN in avoiding further medical complications.

TRIAL REGISTRATION

This study is registered on PROSPERO under the reference number CRD42019123608 .

Comparing eating disorder characteristics and treatment in self-identified competitive athletes and non-athletes from the National Eating Disorders Association online screening tool

OBJECTIVE

We compared eating disorder (ED) characteristics and treatment seeking behaviors between self-identified competitive athletes and non-athletes in a large, community-based sample.

METHOD

During the 2018 National Eating Disorders Awareness Week, 23,920 respondents, 14.7% of whom identified as competitive athletes, completed the National Eating Disorders Association online screen. Data were collected on demographics, disordered eating behaviors, probable ED diagnosis/risk, treatment history, and intent to seek treatment.

RESULTS

The sample was predominantly White (81.8%), female (90.3%), and between 13 and 24 years (82.6%). Over 86% met criteria for an ED/subthreshold ED, and of those, only 2.5% were in treatment. Suicidal ideation was reported in over half of the sample. Athletes reported a significantly greater likelihood of engaging in and more frequent excessive exercise episodes than non-athletes. Athletes also reported a significantly lower likelihood of engaging in and less frequent binge-eating episodes compared with non-athletes. Athletes were more likely to screen positive for an ED/subthreshold ED than non-athletes, but percentages across all probable ED diagnoses were similar. No significant differences between athletes and non-athletes emerged on treatment history or intention to seek treatment post-screen (less than 30%).

DISCUSSION

Although the distribution of probable ED diagnoses was similar in athletes and non-athletes, symptom profiles related to disordered eating behavior engagement and frequency may differ. Athletes may be less likely to seek treatment due to stigma, accessibility, and sport-specific barriers. Future work should directly connect survey respondents to tailored treatment tools and increase motivation to seek treatment.

Disordered eating among adolescents with chronic pain: the experience of a pediatric rheumatology subspecialty pain clinic

BACKGROUND

Disordered eating and chronic pain often co-occur in adolescents, but the relationship between these conditions is not well understood. We aimed to determine the prevalence of and to identify the clinical characteristics associated with the presence of disordered eating among adolescents with chronic musculoskeletal pain (CMP) presenting to a pediatric rheumatology subspecialty pain clinic.

METHODS

This was a retrospective cohort study of pediatric patients presenting to a pediatric rheumatology subspecialty pain clinic for an initial consultation from March 2018 to March 2019. We complemented data from an existing patient registry with secondary chart review for patients identified with disordered eating. We compared patient characteristics based on the presence or absence of disordered eating among adolescents with CMP. Logistic regression modeling was used to determine factors associated with disordered eating.

RESULTS

Of the 228 patients who were seen for an initial consultation in the pain clinic in 1 year, 51 (22.4%) had disordered eating. Only eight (15.7%) of the 51 patients identified with disordered eating had a previously documented formal eating disorder diagnosis. Through multivariate logistic regression modeling, we found that disordered eating was associated with older age, higher functional disability, presence of abdominal pain, presence of gastrointestinal comorbidities, and presence of anxiety (all p < 0.05).

CONCLUSIONS

Adolescents with chronic pain, especially those who experience gastrointestinal issues, anxiety, and greater functional disability, should be evaluated for disordered eating by the treating clinician in order to ensure timely and appropriate treatment.

First presentation of restrictive early onset eating disorders in Asian children

OBJECTIVE

This study aims to describe the spectrum of children with restrictive early onset eating disorders (EOEDs), defined as below 13 years of age, presenting to a tertiary institution in Asia and comparing them with older adolescents with eating disorders.

METHODS

This is a retrospective case review of Asian children who were treated in an eating disorder center. Baseline characteristics and inpatient management at first presentation of children younger than 13 years of age (EOED) were compared to those in older adolescents.

RESULTS

A total of 288 patients with restrictive eating disorders were analyzed with 53 (18%) patients having onset younger than age 13 at initial presentation. There were no significant differences in percentage weight loss and hospitalization rates between the two age groups. Patients with EOED presented with significantly shorter duration of symptoms, and lower rates of secondary amenorrhea. More patients with EOED required phosphate supplementation compared to those in older age group.

CONCLUSION

Despite having a shorter duration of illness, Asian children with EOED had similar percentage weight loss and rates of admission due to malnutrition as those in older Asian adolescent patients. This study underlined the severity of EOEDs and the need for early recognition and medical assessment.

Identification and Management of Eating Disorders in Children and Adolescents

Eating disorders are serious, potentially life-threatening illnesses afflicting 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 for the treatment of eating disorders are often limited, pediatricians may be called on to not only provide medical supervision for their patients with diagnosed eating disorders but also coordinate care and advocate for appropriate services. This clinical report includes a review of common eating disorders diagnosed in children and adolescents, outlines the medical evaluation of patients suspected of having an eating disorder, presents an overview of treatment strategies, and highlights opportunities for advocacy.

The Predictive Role of Raw Bioelectrical Impedance Variables in Disordered Eating Attitudes in Female Ballet Dance Students

The present study used receiver operating characteristic (ROC) curve analysis to investigate the accuracy of body composition and raw bioelectrical impedance analysis (BIA) in correctly classifying disordered eating attitudes (DEA) in dance students. Participants were 81 female dancers assigned in two groups: beginner training (BT; age (mean ± SD) = 10.09 ± 1.2 years, n = 32) and advanced training (AT; age = 15.37 ± 2.1 years, n = 49). Fat mass (FM) was estimated by Slaughter's equation and skeletal muscle with Poortman's equation. Impedance (Z), resistance (R), reactance (Xc) and phase angle (PhA) were obtained through multifrequency BIA at a frequency of 50 kHz. Fat-free mass (FFM) was assessed using Sun's equation. For evaluation of DEA, the Eating Attitudes Test-26 (EAT-26) questionnaire was performed. We defined an EAT-26 score ≥ 20 as positive for DEA. Comparisons between groups were performed by a one-way ANOVA test or Kruskall-Wallis test. Spearman's rank correlation coefficients were performed to assess associations between variables. ROC curve analysis was utilized to test the accuracy of body composition and BIA variables in predicting DEA. In the BT group, Xc and PhA demonstrated high accuracy in predicting DEA with an area under the curve (AUC) of 0.976 (95% confidence interval (CI): 0.85-1.00) and 0.957 (95% CI: 0.82-0.99), respectively, (both p < 0.0001). FFM Sun had an AUC of 0.836 (95% CI: 0.66-0.94) (p < 0.0001) in the BT group and FFM Slaughter was 0.797 (95% CI: 0.66-0.90) (p < 0.001) in the AT group. Reactance and Phase angle were excellent and useful predictors of DEA in the BT group.

Change in decision-making skills and risk for eating disorders in adolescence: A population-based study

BACKGROUND

Despite the growing interest in the involvement of decision-making under conditions of risk in the onset of eating disorders in adolescence, no studies have investigated how the development of decision-making across that period may influence such a risk. Using data from the Millennium Cohort Study this study explored whether changes in performance on the Cambridge Gambling Task (CGT) between age 11 and age 14 were associated with presence of eating disorder (ED) symptoms at age 14.

METHODS

Latent class analysis was used to identify groups with distinct profiles based on their responses to questions investigating eating and dieting at age 14. CGT change scores were used as predictors of latent class membership in a logistic regression while accounting for confounders.

RESULTS

In our sample of 11,303 participants, the best class solution was a two-class one reflecting high and low risk for ED symptoms. Higher risk-taking scores and lower quality of decision-making scores at age 11 were associated with increased odds of belonging to the high-risk group at age 14. Risk-taking was reduced from age 11 to age 14, but a smaller reduction was associated with a higher probability of being in the higher risk group at age 14. The change over time in the other CGT measures was not associated with risk for ED symptoms.

CONCLUSIONS

Atypical change in risk-taking from early to middle adolescence may be implicated in the risk of ED symptoms in middle adolescence. These results should be replicated in clinical samples.

Eating disorders, embodiment, and yoga: a conceptual overview

Yoga and its relation to embodiment and disordered eating has only recently received research attention. Nevertheless, early research indicates that yoga is an effective tool in the prevention and treatment of eating disorders. It is assumed that yoga ameliorates eating disorder symptoms and facilitates a shift from negative towards positive body image and well-being by cultivating positive embodiment (i.e., the ability to feel a sense of connection between mind and body). In order to provide the context of the constructs of disordered eating, embodiment, and yoga, this article presents a brief overview and conceptualization of these constructs. The three major eating disorders and current treatment methods are described. Further, the philosophical roots and theoretical models of embodiment are delineated and their communal core features are outlined. Lastly, the origin, basic principles, and modern interpretations of yoga are discussed.

Medical Assessment and Triage of Pediatric Patients with Anorexia Nervosa in Primary Care

OBJECTIVE

To examine the medical assessment and triage of pediatric patients with anorexia nervosa (AN) initially seen in primary care.

METHODS

A retrospective cohort study was conducted for all pediatric patients with AN who had eating/weight concerns and initially identified symptoms in primary care in a single health care system between January 1, 2010, and December 31, 2016. Information on presenting concern, medical assessment/laboratory tests, clinical diagnoses, treatment recommendations, and referrals were abstracted from the medical record.

RESULTS

Forty-one (mean age = 13.7 years; SD = 2.2) pediatric patients with AN had eating/weight concerns and initially identified symptoms in a primary care. Overall, only 5% (n = 2/41) of patients received an AN diagnosis during the index visit; a minority were assessed for electrolyte disturbance (n = 20), electrocardiogram abnormality (n = 18), hypothermia (n = 13), binge/purge behaviors (n = 13), orthostatic hypotension (n = 2), or dehydration (n = 1), and only 56% (n = 23) received triage consistent with practice recommendations. Although 61% (n = 25) met criteria for inpatient admission, inpatient hospitalization was recommended for only 2 patients. Patients who received triage consistent with practice recommendations received AN diagnosis and treatment significantly earlier than those who did not (p < 0.01 and p = 0.001, respectively).

CONCLUSION

Findings suggest that pediatric patients with AN may not be receiving medical assessment and triage per practice recommendations in the primary care setting. Understanding barriers to evidence-based care for pediatric eating disorders may inform provider education and system-wide changes to enhance outcomes in these patients.

Research Review: Effectiveness of universal eating disorder prevention interventions in improving body image among children: a systematic review and meta-analysis

BACKGROUND

Increasingly, children are at risk of developing eating disorders. A systematic review and a meta-analysis were conducted to examine the effectiveness of universal eating disorder prevention interventions in improving body image, internalization of appearance ideals, and self-esteem among children aged 5-17 years old.

METHODS

Nine electronic databases were systematically searched from each database's point of inception to March 2019. The Cochrane Risk of Bias tool assessed each study's risk of bias, while the GRADE approach judged the overall evidence for each review outcome. A meta-analysis was conducted using the random-effect model to obtain standardized mean differences with 95% confidence intervals under the inverse variance method. Heterogeneity was assessed using I² statistic and Cochran's Q chi-squared test. Publication bias was assessed using funnel plots.

RESULTS

A total of 24 studies (22 trials) were included in this review. Universal interventions were found to be effective in improving children's body esteem, self-esteem, and internalization of appearance ideals at postintervention and at follow-up timepoints. Subgroup analyses found that girls benefited more from these interventions than boys. Multisessional interventions with an optimal duration of approximately one month were found to be more effective.

CONCLUSIONS

The findings encourage the incorporation of universal preventive interventions into school curricula to benefit most children. Laypeople such as teachers can deliver these interventions, but content experts should address topics on body dissatisfaction. Due to the low quality of evidence, as accorded by the GRADE approach, current findings should be validated by future research.

What Are the Effects of Restrictive Eating Disorders on Growth and Puberty and Are Effects Permanent? A Systematic Review and Meta-Analysis

PURPOSE

The objective of the study was to examine (1) the effect of restrictive eating disorders (EDs) on growth and pubertal development in children and young people (CYP) and (2) potential reversibility of this with recovery and associated factors. EDs can impact growth and puberty in CYP, but reports have conflicted over effect on height and permanence of growth impairment and pubertal delay.

METHODS

This is a systematic review and meta-analysis, searching PubMed, EMBASE, PsycINFO, and Web of Science from May 31, 2018, to inception. We included observational studies or systematic reviews regarding growth and puberty in EDs in CYP aged <18 years or in studies reporting outcomes in adults known to have had an ED under age 18 years. Cross-sectional studies were pooled for meta-analysis for effects on height.

RESULTS

A total of 27 studies were included. Growth and pubertal delay were commonly reported, but evidence for catch-up growth found in the majority. However, catch-up growth was not seen in all and may be suboptimal. Meta-analysis of 459 subjects (213 with anorexia nervosa and 246 controls) found no significant difference in height at baseline, with weighted mean difference -.13 cm (95% CI -2.64 to 2.38 cm; p = .9; I² = 68.5%). Younger age and longer duration of illness are potential risks for growth delay; weight gain appears protective for catch-up growth. Findings are primarily generalisable to females, given limited data on males.

CONCLUSIONS

CYP with restrictive EDs are at risk of growth impairment and pubertal delay, though potentially reversible. Attention to growth in EDs is important, especially in the young. Weight restoration should be encouraged to avoid adverse effects and allow opportunity for catch-up.

OUTPATIENT ANALYTIC ASSESSMENT OF ANOREXIA NERVOSA - THE IMPORTANCE OF VENOUS BLOOD GASES

OBJECTIVE

To evaluate serum biochemical parameters' evolution, especially venous blood gas (VBG), in anorexia nervosa (AN), correlating with clinical parameters.

METHODS

Retrospective study including out-patient AN adolescents, between January 2014 and May 2017. Three evaluations were compared: t1) first consultation; t2) consultation with the lowest body mass index (BMI) z-score and t3) with the highest BMI z-score.

RESULTS

A total of 24 adolescents (87.5% females) were included, mean age of presentation of 14.9±1.7 years, onset of symptoms 6.4±3.2 months before the first visit. In t1, BMI z-score of -1.91±1.11 kg/m2 and ideal weight % of 84.3±9.2. Amenorrhea was present in 88%. In t2 the analytical alterations were: altered VBG in 100%, altered ferritin (72% elevated), altered thyroid function (53% with thyroxine decrease), dyslipidemia (31% elevation of high density lipoprotein, 25% hypercholesterolemia), elevation of urea (25%), elevation of alanine aminotransferase (14%), hypoglycemia (14%), anemia (9%). Respiratory acidosis was present in 91% in t1, 100% in t2 and 94% in t3. There was a significant decrease between t2 and t3 in mean pCO2 (57.2 versus 53.6 mmHg; p=0.009) and mean HCO3 (30.0 versus 28.8 mEq/L; p=0.023).

CONCLUSIONS

Respiratory acidosis and increased ferritin were common in this group. Respiratory acidosis was the most frequent abnormality with significant pCO2 and HCO3 variation in the recovery phase. VBG should be considered in AN evaluation, once it seems to be important in assessing the severity of the disease and its subsequent follow-up.

Exploring Differences in the Role of Hospitalization on Weight Gain Based on Treatment Type From Randomized Clinical Trials for Adolescent Anorexia Nervosa

Background: This study explores the impact of weight gain during medical stabilization hospitalization on weight outcomes between three outpatient treatments for adolescent anorexia nervosa (AN): Adolescent Focused Therapy (AFT), Systemic Family Therapy (SyFT), and Family Based Treatment (FBT). Methods: A secondary analysis of weight gain data (N = 215) of adolescents (12-18 years) meeting DSM-IV criteria for AN (exclusive of amenorrhea criteria) who participated in two randomized clinical trials (RCTs) was conducted. Main outcomes examined were changes in weight restoration (≥95% expected body weight or EBW) and differences in weight change attributable to hospital weight gain. Results: Weight gain resulting from hospitalizations did not substantially change weight recovery rates. Hospital weight gain contributed most to overall treatment weight gain in AFT compared to FBT and SyFT. Conclusion: Brief medical stabilization weight gain does not contribute substantially to weight recovery in adolescents with AN who participated in RCTs.

A scoping review of the role of primary care providers and primary care-based interventions in the treatment of pediatric eating disorders

Youth with eating disorders are often cared for by specialized interdisciplinary teams in pediatric tertiary care centers. Enhanced involvement of primary care providers may provide added benefits to patients because it offers improved access, better continuity of care, and possibly less financial burden. This paper aims to synthesize and assess the literature on the role of the primary care provider in treating pediatric eating disorders in order to identify an optimal model of shared care. Sources were identified by entering search terms in 10 databases. Eligible sources were English publications focusing on primary care-based interventions for eating disorders in youth (=<24 years). The search yielded 5,516 unique citations. Of these, 61 were ultimately included. Sources fell into two categories: (1) primary research (n = 3) and (2) reviews with recommendations for primary care providers (n = 58). The primary studies considered the primary care provider conducting behavioral therapy and guided self-help. Review articles suggested providing education, assessing for hospitalization, aiding in weight restoration, managing complications, referring, and coordinating care. Limited evidence exists that can guide effective primary care-based interventions for the treatment of pediatric eating disorders. Further research is needed to develop and evaluate interventions for the treatment of pediatric eating disorders in primary care settings so that best practices can be identified.

Feeding and eating disorders

Eating disorders (EDs) are a group of prevalent psychiatric illnesses with an onset in early to late adolescence-a time of significant neural development, physical and psychologic growth, and self-exploration. The etiology and neurobiology of EDs are not well understood, but EDs are recognized as brain-based illnesses with serious acute and long-term consequences if undertreated or ignored. Two EDs, anorexia nervosa (AN) and bulimia nervosa (BN), have historically been the primary EDs of focus. The DSM-5 updated diagnostic criteria for these disorders added two more: binge-eating disorder (BED) and avoidant/restrictive food intake disorder (ARFID). EDs severely impact males as well as females across the weight spectrum. Comorbidity is high; mortality rates for AN and BN are the highest in psychiatric conditions and higher than many medical conditions. Several treatment options are available to treat an ED ranging from inpatient hospitalization to outpatient services and different psychotherapy options. This chapter reviews the diagnostic criteria, clinical presentation, and treatment for these disorders. Where available, sex differences and developmental considerations will be noted. For all EDs, early recognition and swift treatment are necessary to avoid a chronic course.

Effects of vitamin D and estrogen receptor polymorphisms on bone mineral density in adolescents with anorexia nervosa

Background Anorexia nervosa (AN) is a serious eating disorder that is associated with decreased bone mineral density (BMD) and greater lifetime risk for fractures. The aim of this study was to determine the correlation between BMD and genetic polymorphisms in AN. Methods This case-control study analyzed vitamin D receptor (VDR) (VDRBsml, VDRFokl) and estrogen receptor (ESR) (ESR1Xbal, ESR1Pvull) polymorphisms in 45 adolescents diagnosed with AN and 46 age-matched healthy controls. BMD values of the AN group were classified as low or normal, and polymorphisms were compared between cases and controls. The effects of body mass index (BMI), duration of disease and amenorrhea on BMD were also evaluated. Results In girls with AN, a positive effect of the bb genotype of VDRBsmI polymorphism on femur Z-scores (p = 0.103) and of the Ff genotype of VDRFokI polymorphism on vertebra Z-scores (p = 0.097) was observed. In boys with AN, a positive effect of the Ff genotype of VDRFokI polymorphism on vertebra BMD (g/cm2) was detected (p = 0.061). No association was detected between ESR polymorphisms. An inverse relationship was observed between BMD and duration of illness and amenorrhea. A direct relationship was detected between BMD and BMI. Conclusions Specific VDR gene polymorphism genotypes may have positive effects on BMD in patients with AN. Additionally, the lack of association between ESR gene polymorphisms on BMD could be attributed to the low estrogen status of the patient.

Feasibility of Implementing a Family-Based Inpatient Program for Adolescents With Anorexia Nervosa: A Retrospective Cohort Study

Background: Manualized Family Based Therapy (FBT) is the treatment of choice for adolescent anorexia nervosa, but it is an outpatient treatment. Very little research has examined whether or how the principles of FBT might be successfully adapted to an inpatient setting, and there is little other evidence in the literature to guide us on how to best treat children and adolescents with eating disorders (EDs) while in hospital. This paper describes and provides treatment outcomes for an intensive inpatient program that was designed for the treatment of adolescents less than 18 years of age with severe anorexia nervosa, based on the principles of FBT. Each patient's family was provided with FBT adapted for an inpatient setting for the duration of the admission. Parents were encouraged to provide support for all meals in hospital and to plan meal passes out of hospital. Methods: A retrospective cohort study was conducted that examined the outcomes of 153 female patients admitted over a 5-year period. Outcome data focused primarily on weight change as well as psychological indicators of health (i.e., depression, anxiety, ED psychopathology). Results: Paired t-tests with Bonferroni corrections showed significant weight gain associated with a large effect size. In addition, patients showed improvements in scores of mood, anxiety, and ED psychopathology (associated with small to medium effect sizes), though they continued to display high rates of body dissatisfaction and some ongoing suicidality at the time of discharge. Conclusion: This study shows that a specialized inpatient program for adolescents with severe EDs that was created using the principles of FBT results in positive short-term medical and psychological improvements as evidenced by improved weight gain and decreased markers of psychological distress.

Unique Needs of the Adolescent

Adolescence is the transitional bridge between childhood and adulthood; it encompasses developmental milestones that are unique to this age group. Healthy cognitive, physical, sexual, and psychosocial development is both a right and a responsibility that must be guaranteed for all adolescents to successfully enter adulthood. There is consensus among national and international organizations that the unique needs of adolescents must be addressed and promoted to ensure the health of all adolescents. This policy statement outlines the special health challenges that adolescents face on their journey and transition to adulthood and provides recommendations for those who care for adolescents, their families, and the communities in which they live.

Development of the Ottawa Disordered Eating Screen for Youth: The ODES-Y

OBJECTIVE

To develop a concise screening tool that allows for early identification of disordered eating in youth.

STUDY DESIGN

In this 2-step classification accuracy study, questions for the Ottawa Disordered Eating Screen-Youth, a 2-question screening tool (index test), were conceptualized by clinician-scientists from tertiary care pediatric eating disorder and weight-related clinics, and was validated using retrospective data (2004-2010) from a community-based study, the Research on Eating and Adolescent Lifestyles (REAL) study.

RESULTS

Analyses of contrast between the index test and the reference standard using data from 2892 (1714 females) students between grade 7 and grade 12 revealed classification statistics of 67.1% for sensitivity, 85.9% for specificity, 4.7 for positive likelihood ratio, 0.38 for negative likelihood ratio, 50.6% for positive predictive value, and 92.4% for negative predictive value for females and 61.1% for sensitivity, 93.9% for specificity, and 9.9 for positive likelihood ratio, 0.41 for negative likelihood ratio, 32.3% for positive predictive value, and 98.0% for negative predictive value for males.

CONCLUSIONS

Our findings suggest that the index test has utility as a short and accurate screening tool for earlier detection of disordered eating thoughts and behaviors in youth. Additional research is needed to best determine how the index test can be administered to youth across various health care, school, public health, and surveillance settings in clinically sensitive pragmatic ways.

Adolescent males with atypical anorexia nervosa and premorbid obesity: three case reports

PURPOSE

Premorbid obesity is an identified risk factor for eating disorder (ED) development among adolescent males. However, pervasive gender- and weight-related biases about ED inhibit timely diagnosis and treatment among this demographic. This study examined the psychological and medical characteristics of three adolescent males with premorbid obesity who were not diagnosed with atypical anorexia nervosa (AAN) until medical sequelae of malnutrition warranted emergent hospitalization. Factors associated with diagnostic delays among these cases were identified to facilitate increased awareness of this at-risk demographic.

METHODS

Retrospective chart review was conducted on three adolescent males (aged 12-17) with AAN and premorbid obesity who were medically hospitalized for 13-24 days (M = 20.3, SD = 9.7). Demographic variables, psychological characteristics, and physical data were extracted.

RESULTS

Each case presented at normal or overweight BMI status (M = 22.7 kg/m², SD = 3.2) following a significant loss of weight ranging from 19 to 42% of total body mass (M = 31.7%, SD = 9.5) over 5-12 months (M = 8.3, SD = 2.9). Plausible factors associated with diagnostic delays included initial weight loss recommendations by a medical provider, with little support or oversight; limited insight that symptoms were problematic; social reinforcement of dieting behaviors; low prevalence of psychiatric comorbidity; parental obesity; and parental history of bariatric surgery.

CONCLUSIONS

These cases elucidate the importance of close follow-up of youth with obesity who are encouraged to lose weight. Further education about AAN among males with premorbid obesity is crucial for timely diagnosis and intervention.

Increased odds of disordered eating in polycystic ovary syndrome: a systematic review and meta-analysis

PURPOSE

We aimed to identify the risk of eating disorders (ED) in women with polycystic ovary syndrome (PCOS) compared to controls.

METHODS

We performed a systematic review and meta-analysis of studies that included women with well-defined PCOS and controls and used validated ED screening/diagnostic tools to measure mean ED score, prevalence of abnormal ED scores, and/or prevalence of specific ED diagnoses such as bulimia nervosa and binge eating disorder.

RESULTS

Eight studies, including 470 women with PCOS and 390 controls, met inclusion criteria for the systematic review. Meta-analysis of seven of those studies found that the odds of an abnormal ED score (OR 3.05; 95% CI 1.33, 6.99; four studies) and the odds of any ED diagnosis (OR 3.87; 95% CI 1.43, 10.49; four studies) were higher in women with PCOS compared to controls.

CONCLUSIONS

Our study suggests that women with PCOS are at increased odds of having abnormal ED scores and specific ED diagnoses. Given the potential implications of an ED on weight management strategies, our findings support routine screening for ED in this population.

LEVEL OF EVIDENCE

Level I, systematic review and meta-analysis.

The Role of Higher Levels of Care for Eating Disorders in Youth

Many eating disorder patients are successfully treated in outpatient settings. Family-based treatment allows youth to recover at home. Higher levels of care may be necessary for medical or psychiatric stabilization, or to provide added structure. Historically, hospital lengths of stay were long. Currently, insurance limitations encourage intermediate care levels to support patients not requiring inpatient treatment but not ready for outpatient care. Options include inpatient medical stabilization, locked units for individuals with suicidal ideation, and outpatient programs offering daily meal support and group therapy. Outpatient teams and families collaborate to determine the appropriate level of care.