Assessing Pediatric Patients for Eating Disorders

Since the start of the COVID-19 pandemic, eating disorders have increased dramatically across the United States. Throughout 2020 and into 2021, eating disorder treatment center patient admissions more than doubled. Eating disorder treatment centers were so full in 2021 that many people had to wait months before they could get admitted for care. Despite these grave facts, many doctors who treat young people are still not routinely screening for eating disorders even though they play a valuable role as front line physicians in the fight against eating disorders.

Pediatric Eating Disorder Screening

About half a million teens suffer from an eating disorder or disordered eating and nearly 90% of patients with eating disorders have disease onset in adolescence. With 12-14 being the mean age of onset of anorexia nervosa and bulimia nervosa often presents in late teens, pediatricians are in a prime position to diagnose and address eating disorder concerns in young patients, both screening and referring out for treatment. This will help to save lives and reduce the amount of suffering that eating disorders cause for individuals and their families.

A number of evidence-based tools are available for pediatricians to use to screen for eating disorders. But these tools rely on young patients providing honest answers. Unfortunately, individuals with eating disorders are often adept at denying or masking that they even have a problem at all. So, in addition to evidence-based questionnaires and screeners, clinicians should hold meaningful conversations with their patients as they review key data points during appointments. These conversations work best when brought up using supportive, non-stigmatizing language. Asking questions regarding:

• Patient’s height, weight and body mass index (BMI) including any recent abnormal (rapid or excessive) weight loss or gain
• Menstruation status in females (amenorrhea can be a sign of an eating disorder)
• Food preferences and unusual eating habits (including restriction of food intake, dieting or fasting, self-induced vomiting, eating large amounts of food in one setting or disinterest in food)
• Use of diuretics, laxatives or enemas
• Excessive exercise
• Body image or body dissatisfaction issues, including fear of becoming fat, paying excessive attention to or over-valuing oneself based on weight or appearance

It is important to note that eating disorders affect people of all races, ethnicities, socioeconomic statuses, gender identities and body types. Eating disorders disproportionately affect the lesbian, gay, bisexual, transgender, questioning or queer, intersex, and asexual (LGBTQIA) community. Males represent at least 10% of patients with eating disorders and are easy to slip through the cracks. Further, patients with atypical anorexia or binge eating disorder may exhibit disordered eating yet present at normal body weights, which is why it’s important to delve further into eating and exercise habits rather than assume a patient is fine because their weight is within normal range. No patient is immune to eating disorders and doctors must assess all patients, particularly those with a family history of eating disorders.

Along with the rise in eating disorders, suicidality has also increased since 2020, particularly in adolescent females. Therefore, an evidence-based suicide risk assessment is highly recommended for young patients as well.

How to Proceed if You Suspect an Eating Disorder

Eating disorders can wreak havoc on the body and mind, affecting every organ system. Pediatricians must be aware of these high stakes, including a 2 to 5 times higher premature death rate. Consider proceeding with some or all of the following evaluations if you see markers of an existing eating disorder or suspect that a patient is at risk.

• Review the patient’s medical history and nutritional history
• Perform a physical exam. There are several changes to look for in patients with eating disorders including:
  • Skin and hair changes such as acrocyanosis, dry or pale skin, thin hair/lanugo
  • Russell’s sign — abrasion or callouses on the fingers/knuckles caused by purging — is pathognomonic of AN-BP and BN (though if absent does not mean an eating disorder is not present)  
  • Salivary gland enlargement, enamel erosion or dental caries resulting from purging if present
  • Vital sign abnormalities including low body temperature, low resting blood pressure and low resting heart rate
• Obtain a family psychiatric history and screen for symptoms of depression and anxiety as well as preoccupation with food, weight or body shape
• Screen for physical or sexual abuse or trauma following a trauma-informed approach
• Conduct laboratory testing including complete blood cell count, electrolyte panel, liver function tests, urinalysis and thyroid-stimulating hormone test
  • Patients with malnutrition may have normal labs, but also may have low white and red blood cell count, elevated liver enzymes due to starvation, abnormal thyroid tests or hypoglycemia
  • Patients who are purging or using laxatives will often have electrolyte and kidney abnormalities and metabolic alkalosis
• Observe cardiovascular, gastrointestinal and endocrine health or refer out if needed for further testing; Electrocardiogram may be indicated for abnormal cardiac results
• Consider bone mineral density screening

Severe and extreme eating disorders can be fatal without urgent specialized medical treatment. Sadly, very few medical providers in local emergency rooms and hospitals are trained to identify and safely treat the medical issues caused by malnutrition and purging behaviors. Instead of heading to the nearest emergency room or residential eating disorder treatment center, an individual who is medically unstable due to an extreme eating disorder must be referred to a higher level of care.

When Severe Eating Disorders Are Present, Seek the Highest Level of Care

If a patient is unstable and in need of immediate medical assistance, urgent referral is recommended. Air ambulance transport is available for patients in immediate need of medical stabilization. As hard as it is to send your child on a plane for treatment, you want them to be in the best and most capable hands.

Should a young patient need emergency care for an eating disorder, ACUTE Center for Eating Disorders & Severe Malnutrition offers a better trajectory for recovery and refeeding. Led by Dr. Philip S. Mehler, MD, FACP, FAED, CEDS, the level of care and service that young patients receive at ACUTE is unmatched, providing them the life-saving option they need. With a passion for supporting teens and families, ACUTE offers:

• Specialized medical care from the world’s leading experts in the medical treatment of eating disorders in adolescents
• Behavioral health support from psychologists specializing in adolescent eating disorders
• 24/7 1:1 support from a Certified Nursing Assistant (CNA) or Behavioral Health Technician (BHT)
• Additional medical support and consultation from an adolescent medicine physician specializing in eating disorders, and collaboration with any needed Denver Health medical specialists
• Seamless collaboration with Denver Health’s Pediatric ICU (when necessary)
• A dedicated Child Life Specialist to help adolescents cope with the stress and uncertainty of illness, injury, disability and hospitalization
• Extended visiting hours for families and caregivers
• Family psychoeducation
• Pet therapy
• Discharge support, including transition to an adolescent residential eating disorder program or appropriate next level of care to continue recovery
• Air ambulance transport to help the sickest patients travel for care

Accepting male and female patients starting at age 15 — regardless of how low their BMI is — the private, 30-bed medical telemetry unit at Denver Health Medical Center provides inpatient medical treatment for life-threatening eating disorder complications, as well as behavioral support tailored to the needs of adolescents. Patients receive around-the-clock care from expert doctors and nurses, as well as a multidisciplinary team including occupational therapy, physical therapy, psychology, psychiatry and dietary services. This comprehensive approach addresses the individual’s physical and behavioral recovery needs and prepares the individual to seek further treatment at a residential eating disorder treatment program after they medically stabilize.

Families need not worry about the process of admissions or transferring in and out of care. ACUTE’s team works to make this process seamless, all working with the same goal: to save lives and help individuals find their path to a long-term and full eating disorder recovery.

Conclusion

Eating disorders can be severe, extreme and life-threatening, with psychiatric and medical complications requiring immediate attention. Even in young people who are relatively new to their eating disorder, getting help can be a matter of life or death.

Pediatricians have a responsibility to stay up to date regarding the signs, symptoms, risk factors and treatment options for eating disorders. Along with evaluation and assessment, pediatricians can help young patients and their families find the resources they need to manage medical complications stemming from eating disorders.  

Related Articles: 

• Helping Adolescents with Severe and Extreme Eating Disorders 

• Medical Stabilization for Severe and Extreme Eating Disorders at ACUTE 

• ACUTE’s Expertise in Refeeding Underweight Patients 

Resources: 

• Hornberger, L. L., Lane, M. A., Hornberger, L. L., Lane, M., Breuner, C. C., Alderman, E. M., Grubb, L. K., Powers, M., Upadhya, K. K., Wallace, S. B., Hornberger, L. L., Lane, M., FRCPC, M., Loveless, M., Menon, S., Zapata, L., Hua, L., Smith, K., & Baumberger, J. (2021). Identification and Management of Eating Disorders in Children and Adolescents. Pediatrics, 147(1).  

• Sulaski Wychoff, A. (2020, December 21). With eating disorders easy to miss, report urges screening of all youths. American Academy of Pediatrics. Retrieved December 24, 2021.