AAP Updates Guidance on Pediatric Eating Disorders

AUTHOR:
Brittany Perry, DO
Nemours/Alfred I. duPont Hospital for Children

CITATION:
Perry B. AAP updates guidance on pediatric eating disorders. Published online January 25, 2021. Consultant360.

Hornberger LL, Lane MA, Committee on Adolescence. Identification and management of eating disorders in children and adolescents. Pediatrics. 2021;147(1):e2020040279. https://doi.org/10.1542/peds.2020-040279

Eating disorders are common in youth. They occur among all races, ethnicities, socioeconomic statuses, gender identities, and body types. Pediatricians and other primary care providers play an important role in early identification of eating disorders that can lead to appropriate treatment. A clinical report published by the American Academy of Pediatrics (AAP) this month guides clinicians on this topic. 

The authors provided guidance on how to gather patient information about weight, body image, diet, exercise, binging and purging, and family history, as well as administered a HEADSS assessment and detailed review of systems. Significant changes noted on the growth chart and abnormal vital signs, including low heart rate or blood pressure, hypothermia, and orthostatic hypotension, may raise suspicion for an eating disorder. Clinical signs of malnutrition on physical examination include pallor, dry skin, cachexia, thinning hair or lanugo, murmur, poor perfusion, or delayed pubertal development. Clinical signs of purging include dental changes, abrasion or callous of the knuckles (Russel’s sign), salivary gland enlargement, and epigastric tenderness. 

A laboratory evaluation can screen for medical complications of eating disorders or alternative diagnoses. The authors suggest performing a complete blood cell count test, electrolyte panel, liver function tests, urinalysis, and thyroid-stimulating hormone test. Additionally, checking vitamin levels, testing for pregnancy, or evaluating hormone levels are recommended in some cases. An electrocardiogram should be obtained to further evaluate abnormal cardiac findings.

Medical complications in individuals with eating disorders may include gastrointestinal problems, dermatologic changes, dental erosion and caries, endocrine dysfunction, cardiac complications, dehydration, and electrolyte abnormalities. Psychiatric comorbidities are common. 

When an eating disorder is identified, the primary care provider should arrange appropriate care. This may include referral for admission to the hospital, to a specialized multidisciplinary team, or to coordinating care with nutrition and outpatient mental health providers with expertise in caring for patients with eating disorders. For pediatricians taking a primary role in management, the AAP advises to set goal weight and establish regular eating patterns, vitamin supplementation, and dental care. 

Outpatient therapy is an important part of treating eating disorders. Family based treatment is first-line therapy for anorexia nervosa, with parent-focused therapy as an alternative option. Cognitive behavioral therapy is recommended for treating bulimia nervosa. Patients requiring more support may participate in day-treatment programs or may require closer supervision in a residential treatment program. Hospitalization may be indicated for treatment of dehydration and malnutrition with close monitoring for refeeding syndrome. 

In summary, pediatricians and primary care providers should screen patients for disordered eating during well visits and be able to recognize the signs and symptoms of eating disorders. When identified, patients should be directed to the appropriate level of care depending on the severity of their condition. Pediatricians may oversee medical and nutritional care or may opt to refer the patient to a treatment center that specializes in treating eating disorders. This clinical report from the AAP provides an excellent reference with useful clinical information for providers caring for youth with eating disorders.