Materials for this week:
- Case discussion
- Pediatrics in Review article co-authored by our own resident, Dr. Sarah Strandjord MD MS, (who has published many articles in this field)!
- National Eating Disorders Association (NEDA) website includes an online screening for ages 13 and above
- Check out a number of great resources from SCH
Take home points to review about Eating Disorders:
- Epidemiology: Once thought of as primarily a problem for white upper middle class females, unfortunately, the number of males and minority tweens/teens of both genders with disordered eating has increased in recent years, with up to 14% meeting criteria for disordered eating NOS. About 0.5% of female adolescents are diagnosed with anorexia and 1.5% with bulimia. Teens are particularly high risk during times of transition, and also in highly competitive athletics.
- Clinical definition: Eating disorders involve dysfunctional eating habits (may include restrictive eating and binge/purging), weight changes, and body image distortion with intense fear of gaining wt. Suspect in patients who fail to maintain weight in adolescence (especially concerning if <85% of ideal body wt, IBW), or who have amenorrhea, cold intolerance, constipation, headaches, fainting or dizziness. Ask about satisfaction with weight, efforts to control weight, exercise, and changes in diet. The female athlete triad is defined by low energy with or without eating disorder, hypothalamic amenorrhea, and osteoporosis. (DSM-5 criteria are in Tables 1 & 6 in the Peds in Review article).
- Physical exam: Some patients have normal exams, and patients with bulimia may have normal weight. Vital sign changes are important including bradycardia, hypothermia, and orthostatic changes. Skin findings may include acrocyanosis, lanugo, peripheral edema, and muscle atrophy. “Russell sign” is callus/abrasion over the MCP/PIP joints from tooth scraping while inducing vomiting. Also look for worn tooth enamel and salivary gland enlargement from purging.
- Work-up: Review wt trajectories/changes, and compare weight to median BMI (50th percentile BMI for age on growth chart, which is the ideal body wt). The current weight is divided by the IBW. In primary care it is more important to diagnose medical complications of eating disorders and refer for psychological management. Labs to consider initially are BMP (electrolyte, BUN, glucose abnormalities), ESR (to rule out systemic inflammation), and CBC (assess for malignancy/anemia).
- Management: Eating disorders represent complex physical and mental health disorders with high mortality rates. Refer to adolescent medicine for multidisciplinary care. If acutely ill/worsening, determine if patient meets criteria for inpatient admission in consultation with adolescent specialists (see AAP guidelines for hospitalization in Table 4 of this review). Provide regular follow-up as PCP for overall health/support and encouragement to engage in treatment. SSRIs may be considered for concurrent depression/anxiety, especially with bulimia.