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Copyright © 2007 Saunders, An Imprint of Elsevier << Previous | Next >> EATING PROBLEMSEATING PROBLEMS KEY POINTS When entertaining a diagnosis of feeding disorder, consultation with a physician familiar with growth problems in children should be considered because the differential diagnosis is extensive and includes many metabolic syndromes, child abuse, and neglect. The long-term mortality rate for anorexia nervosa is 6% to 20%, the highest rate for any psychiatric disorder. The most useful measure to assess for extreme weight loss in adolescents is a body mass index (BMI) adjusted for age that is less than the fifth percentile. For anorexia nervosa, vomiting is a poor prognostic feature; for bulimia nervosa, the use of purgatives is a poor prognostic feature. Patients with eating disorders should be managed by a multidisciplinary team that includes a primary physician, a mental health professional, and a nutritionist.
Background The eating disorders are included last because the most common and serious ones, anorexia nervosa and bulimia nervosa, typically have their onset in adolescence. However, several eating problems are associated with infants and children. Feeding and Eating Disorders of Infancy and Early Childhood Feeding difficulties are common in infants and young children. Most are minor and selflimited and can be addressed through education and reassurance of caregivers. However, physicians must be alert for specific feeding and eating disorders that can lead to malnutrition or chronic toxicity from ingested substances. The most important of these is listed in DSM-IV-TR as ³Feeding Disorder of Infancy or Early Childhood.´ The diagnosis has previously been described as psychosocial failure to thrive and as psychosocial dwarfism. The key feature of the diagnosis is that the child fails to gain weight appropriately over a prolonged period of time, not fully explained by a gastrointestinal, endocrinologic, or neurologic condition. Of children admitted to the hospital for failure to thrive, as many as half have a psychosocial etiology. The other important consideration in this category is pica, the persistent eating of nonnutritive substances, such as hair, soil, paint, animal droppings, or sand. Pica can lead to vitamin deficiencies, lead or other heavy metal intoxication, phytobezoar, and other
Assessment and Management The most important aspect in assessing feeding difficulties in infants and children is tracking height and weight with each office visit. In contrast. The number of young people with eating disorders (anorexia nervosa or bulimia nervosa) and eating disturbances (some but not all criteria for diagnosis of a disorder) is increasing. misuse of laxatives or diuretics. or excessive exercise. If she is postmenarcheal. eating disorders are the third leading chronic illness. and exhibits a distorted self body image. behind obesity and asthma. the evaluation and treatment depend on the specific substance ingested and symptoms the child exhibits. is very fearful of gaining weight. the highest rate for any psychiatric disorder ( Roerig et al. The prevalence of bulimia nervosa is 1% to 3% in adolescents and young women. The prevalence of pica is not certain but it is probably fairly common in preschool children and especially so in mentally retarded persons. The diagnosis of feeding disorder is suggested by improvement in feeding and weight gain following a change in caregivers. The long-term mortality rate for anorexia nervosa is 6% to 20%. and the prevalence of eating disorders has been directly correlated to the rates of dieting behavior. This is due to a combination of improved recognition and reporting as well as an apparent true increased incidence. This is because the differential diagnosis for growth problems is extensive and the implications for a diagnosis of feeding disorder include child abuse and neglect. The important aspect in assessing for pica is to ask about it. Then. fasting. 2000 ). seeing it as something to be proud of. Children who are not maintaining expected gains should be observed more closely. Anorexia Nervosa and Bulimia Nervosa In adolescent girls. such as self-induced vomiting. High-risk groups include female athletes and diabetic adolescents.complications. Bulimia nervosa is characterized by binge eating and inappropriate compensation attempts to avoid weight gain. 2002 ). When a diagnosis of feeding disorder is entertained. consultation with a physician familiar with growth problems in children should be considered. patients with eating disorders are usually reluctant to discuss their diets even when it is obvious to those around them that they are restricting . Normal dieters typically tell those around them that they are dieting. keeping in mind that feeding problems in a significant percentage of these children have a psychosocial basis. Assessment A prime objective in assessment is to distinguish normal dieters from persons with eating disorders. A person with anorexia nervosa refuses to maintain a minimally normal body weight. she is amenorrheic. About 95% of patients are female. It is more common but less often fatal than anorexia nervosa ( APA. if any.
and a nutritionist. the use of purgatives indicates a poor prognosis ( Wilhelm and Clarke. cardiac disturbances. magnesium. often hiding it with baggy clothing.their intake. Indications for immediate referral include any patient with abnormal findings on physical exam or lab studies because these indicate severe and entrenched eating disorders. often depressed or irritable. 1998 ). or other acute medical disorders. A reading less than the fifth percentile is considered extreme ( Selzer et al. glucose. Laboratory studies should include a complete blood count. 1996 ). Patients with eating disorders should be managed by a multidisciplinary team that includes a primary physician. The usual criteria of less than 85% of average body weight (ABW) or a body mass index (BMI) of less than 17. The most clinically useful measure is the BMI percentile adjusted for age ( Hebebrand et al. severe electrolyte imbalances. Normal dieters exhibit a feeling of accomplishment and a rise in self esteem when they achieve their planned weight loss. 1995 ). and Addison's disease. a new swimsuit or sunbathing). a mental health professional. like eating less than the person at the table who eats the least. chronic infections. often in new and more revealing clothes or situations (e. ³What would it be like to find you weighed one pound more next week when you get on the scales?´ This can provoke an overly emotional response in a person with an eating disorder ( Selzer et al. they want to show off their new body. It is important to assess the acuteness and severity of malnutrition or fluid and electrolyte abnormalities. the presence of vomiting is a poor prognostic feature and for bulimia nervosa. Normal dieters regulate their intake by internal cues and the rules of their diet plan. When normal dieters achieve their weight loss goal. Those with eating disorders tend to become self-critical. 1995 ). phosphorus. To explore this possibility.5 kg/m2 used in adults to diagnose anorexia nervosa can be misleading. 1999 ). 1995 ). Those with eating disorders may use external cues. Included are such diverse problems as inflammatory bowel disease. severe or intractable purging.. and avoid social occasions. creatinine. Extreme weight loss is difficult to define in growing adolescents. no matter how much weight they lose.g. The erythrocyte sedimentation rate (ESR) and serum albumin tend to remain normal in eating disorders. Another important aspect to evaluation is to exclude certain medical conditions in the differential diagnosis as the primary cause of the symptoms. diabetes mellitus. Management Indications for inpatient management include ³extremely low weight (<75% of expected body weight) or rapid weight loss. and electrocardiogram ( Walsh et al. hyperthyroidism. a useful question to ask is. so an elevated ESR or a reduced albumin point to an organic cause for weight loss ( Selzer et al. For anorexia nervosa. psychosis or a high risk of suicide. urea nitrogen. 2000 ). albumin. Patients with eating disorders have a pathological reaction to weight gain. Family physicians should be aware of the resources available in their area and be prepared to refer any . calcium. girls with eating disorders avoid exposing their bodies. to avoid feeling selfish or gluttonous. electrolytes. and symptoms refractory to outpatient treatment´ ( Becker et al. or they regard their physical dimensions with disgust. Usually.
adolescent whom they suspect of an eating disorder or any adolescent with abnormal eating behavior who does not respond to initial efforts at diet education. For now. . exercise. sexual activity. and family relationships. body image. Cognitive-behavioral therapy has been shown to be the most effective psychological approach to bulimia nervosa ( RCT. These include eating habits. diet. Various antidepressants are effective for treating bulimia nervosa but they have not shown definite benefit for anorexia nervosa ( Roerig et al. 2002 ). menstruation. Little is known of the effectiveness of primary prevention of eating disorders. physicians should include questions about risk factors for eating disorders as a standard part of their evaluation of adolescents. 2000 ). drug use. Walsh et al.
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