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Eating Disorders Update

Megen Vo, MD and Lisa Patel, MD
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Lisa and Megen Vo, Clinical Assistant Professor at Stanford Children’s Health, discuss the recent AAP clinical report on the identification and management of eating disorders in children and adolescents.

  • In January 2021, the American Academy of Pediatrics released a new clinical report on identifying and managing eating disorders in children and adolescents.

  • When presenting with significant weight loss but a BMI still classified in the “healthy,” overweight, or obese ranges, patients with eating disorders may be overlooked by health care providers.

  • Heart rates of 50 bpm or less are unusual even in college-aged athletes, thus the finding of a low HR may be a sign of restrictive eating and requires further investigation.

  • Eating disorders can affect every organ system with potentially serious medical complications that develop as a consequence of malnutrition.

    • Cardiovascular Effects:

      • Patients with restrictive eating disorders are at risk for arrhythmias. One study reported a near 10% prevalence of prolonged QTc interval in hospitalized adolescents and young adults with a restrictive eating disorder.

      • Cardiac structural changes may include: 

        • decreased left ventricular  mass

        • decreased LV end diastolic and LV end systolic volumes 

        • functional mitral valve prolapse 

        • pericardial effusion

        • myocardial fibrosis. 

    • Gastrointestinal Tract Effects:

      • GI complaints are common and sometimes precede the diagnosis of the eating disorder. Delayed gastric emptying and slow intestinal transit time often contribute to reported sensations of nausea, bloating, and postprandial fullness.

    • Endocrine Effects:

      • Low bone mineral density is a frequent complication of eating disorders and leads not only to increased risk of fractures in the short-term but also irreversibly compromises skeletal health in adulthood.

  • Refeeding syndrome refers to the metabolic and clinical changes that can occur when a malnourished patient is aggressively nutritionally rehabilitated; the hallmarks are hypophosphatemia and multiorgan dysfunction.

    • The risk of refeeding is thought to correlate with the degree of starvation, so pediatricians should consider taking a more cautious approach in severely malnourished (<70% median BMI) patients. 

  • A variety of medications have been studied for the treatment of eating disorders but few have demonstrated to be effective. Of note SSRIs, such as fluoxetine, have been shown to work as treatment for bulimia nervosa in adults. 

  • Family-Based Treatment (FBT) consists of 3 phases and contends that parents are not to blame for their child’s illness. In phase 1, weight restoration is the primary goal. By phase 2, substantial weight recovery has occurred, and the adolescent gradually resumes responsibility for his or her own eating. By phase 3, weight has been restored, and the therapy shifts to address general issues of psychosocial development as well as relapse prevention.

  • Day-treatment programs provide an intermediate level of care for patients with eating disorders who are medically stable. Day treatment typically involves 8 to 10 hours per day of care by a multidisciplinary staff 5 days per week.

  • Additionally resources: National Eating Disorders Association and Wendy Sterling (Certified Eating Disorder Registered Dietitian).

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Hippo Peds RAP September 2021 Written Summary 240 KB - PDF

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