OCCASIONAL REVIEW
Anorexia nervosa in
adolescence
Damian Wood
Claire Knight
Abstract
Eating disorders are complex mental health conditions. Anorexia Nerv-
osa (AN) represents a particular subtype of eating disorder that is
significantly more common in young women than in young men and
is the second most common mental health disorder in adolescent
girls. It is a serious condition with the highest standardized mortality
of any psychiatric condition. Optimal care of requires input from a
multi-disciplinary team (MDT) providing collaborative medical, nutri-
tional and psychological interventions, which includes the family, die-
ticians, consultant psychiatrists, therapists, nurses, paediatricians and
general practitioners. AN is associated with a range of physical com-
plications and symptoms including acute complications such as
refeeding syndrome, electrolyte disturbance and cardiovascular ef-
fects. Outpatient family based treatment is the first line psychological
intervention for children and adolescents with AN. Nutritional rehabili-
tation including weight stabilization and restoration are to essential el-
ements of treatment and early dietician involvement is crucial. Current
outcomes for AN are variable and a firm evidence base for many areas
of treatment has yet to be established.
Keywords adolescent; anorexia nervosa; eating disorder; refeeding
syndrome; underweight
Classification and epidemiology
Eating disorders affect 1.6 million people in the UK of which it is
estimated 10% of sufferers have anorexia nervosa (AN; Table 1).
The lifetime prevalence of adolescent AN is thought to be around
0.3% with the incidence rates highest for females aged 15e19
years at around 100 per 100,000 each year. The UK incidence of
diagnosed eating disorders increased significantly between 2000
and 2009 and there has been an increase in hospital admissions
for eating disorders, however it is unclear if this reflects a true
increase of the disorder or rather a result of changes in diagnostic
criteria, public awareness and clinician behaviour. The peak
onset occurs in mid adolescence. Early onset is defined as onset
less than <13 years of age with cases as young as 6 years re-
ported. There is a marked gender bias in reported incidence and
it is estimated that 90% of young people affected are female.
Damian Wood MBChB DCH MRCPCH, Consultant Paediatrician,
Nottingham Children’s Hospital, Queen’s Medical Centre,
Nottingham, UK and Newbridge House National Centre for Eating
Disorders, Sutton Coldfield, Birmingham, UK. Conflicts of interest:
none declared.
Claire Knight BA(Hons) PG Dip RD, Clinical Lead Dietitian,
Nottinghamshire CAMHS Eating Disorders Team, Hopewood,
Nottingham, UK. Conflicts of interest: none declared.
PAEDIATRICS AND CHILD HEALTH xxx:xxx
Please cite this article as: Wood D, Knight C, Anorexia nervosa in adolescence, Paediatrics and Child Health, https://doi.org/10.1016/
j.paed.2019.06.006
Recognition, presentation and diagnosis
The initial recognition of an eating disorder and presentation to
healthcare professionals is often delayed for several months.
Body image concerns and dieting behaviours are so common in
young people that parents/carers may be unaware of the eating
disorder in the early stages and may initially support the young
person with their lifestyle changes. AN is described as an ego-
syntonic condition i.e. the illness is aligned with the young
person’s concept of themselves. This leads to denial of symptoms
and ambivalence towards treatment and recovery. AN will often
present as the parents/carers become concerned about the young
person being underweight, their rapid weight loss, or with con-
cerns about eating, exercise or other behaviours. By the time the
anorectic behaviours or their consequences are recognised the
weight loss can be considerable, with signs of physical adapta-
tion to malnutrition and physiological instability. Hence, a single
primary care consultation about restrictive eating behavior, un-
derweight or body image concerns in a young person is a strong
predictor of subsequent diagnosis of AN. Increasing numbers of
young people with restrictive eating disorders are presenting at
relatively normal weight after rapid weight loss after a period of
overweight. It is important to recognise that atypical AN can
present at normal or overweight.
History in a young person suspected to have AN
When taking the history it is important to track when and how
the initial concerns arose. The clinician should enquire about the
following.
A weight history

How much weight have they lost and over what length of
time?

How and when did they young person first attempt to control
their weight?

What has been the recent pattern of weight loss?

Was the weight loss intentional and were there any identi-
fiable triggers?When did people become concerned? Who
noticed first? When did the parents become concerned? Has
the young person become concerned?

Do they have a specific weight target they wish to achieve?

How have people responded? What has already happened?
A dietary history: young people with AN will avoid foods high in
fat and/or carbohydrates and may adopt specific diets (e.g. vegan)
to aid calorie restriction. Behaviours such as wanting to control the
food shopping or preparation, cooking but not eating, eating in
isolation, taking a long time to complete meals, hiding food or
crumbling and smearing food are common. A 24-hour dietary
recall can be revealing of current nutrition and eating behaviours,
however a more detailed dietary history by a dietician in
conjunction with a diary will a more detailed nutritional analysis.
Some young people with AN may restrict their fluid intake in
an attempt to lose weight by dehydration or in the mistaken
belief that water contains calorific content. Drinking excessive
amounts of fluid can also be a feature of AN. The motivations
behind this excessive fluid intake can vary and include using the
fluids to suppress the sensation of hunger or to falsify weight by
“fluid loading.” They may be drinking excessively in the
mistaken belief that it will “purify their system.” Ask specifically
1 Crown Copyright Ó 2019 Published by Elsevier Ltd. All rights reserved.
 OCCASIONAL REVIEW
Diagnostic criteria for anorexia nervosa from DSM 5 and ICD 10
DSM-5
Persistent restriction of energy intake leading to significantly low body
weight (in context of what is minimally expected for age, sex,
developmental trajectory, and physical health).
Either an intense fear of gaining weight or of becoming fat, or persistent
behaviour that interferes with weight gain (even though significantly
low weight).
Disturbance in the way one’s body weight or shape is experienced,
undue influence of body shape and weight on self-evaluation, or
persistent lack of recognition of the seriousness of the current low body
weight.
Table 1
about any targets they may have for their daily calorie intake or
periods of fasting and uncontrolled eating.
Compensatory behaviours: excessive exercise is a common
feature of AN and it is important identify all activities the young
person undertakes during the week. The amount of exercise done
alone or in secret is often underreported. Eating disorders are
more common in those engaged in competitive sport and activ-
ities which requires long hours of practice e.g. swimming,
cycling, or distance running or are associated with an aesthetic
e.g. dance, ice skating. Enquire about:

Programmed activities e.g. swim club

General activity levels e.g. walking to school or dog walks
with family

Home exercise or gym membership

Unusual activity e.g. standing to do homework, foot tapping,
inability to sit for any length of time
The clinician should enquire about purging behaviours (self-
induced vomiting, using laxatives or other medications). Purging
is often a hidden behaviour however parents may be alerted by
the smell of vomit or the young person spending excessive
amounts of time in the bathroom after meals. The use of laxa-
tives, emetics and other medications is less common amongst
young people with AN than vomiting and exercising behaviours.
Body image: it is necessary to enquire how the young person
perceives their weight, size and body shape by asking: are they
happy with their body? What would they change about it given
the chance? Enquire if they have specific body shape/image they
want to achieve. Ask about body checking behaviours such as:

excessively checking body in the mirror or reflective surfaces

pinching of one’s stomach, arms or thighs to assess subcu-
taneous fat

avoidance of changing rooms, swimwear or tight fitting
clothes
Physical symptoms: symptoms of hair loss, cold intolerance,
skin breakdown and infrequent stooling are often present but
may not be volunteered. Non-specific somatic pains, fatigue and
sleep difficulties are common and with more marked under-
weight impairment of concentration, recall and cognitive pro-
cessing become evident. Symptoms of dizziness or near syncope
PAEDIATRICS AND CHILD HEALTH xxx:xxx
Please cite this article as: Wood D, Knight C, Anorexia nervosa in adolescence, Paediatrics and Child Health, https://doi.org/10.1016/
j.paed.2019.06.006
ICD-10
There is weight loss, or in children, a lack of weight gain, leading to a
body weight at least 15% below the normal or expected weight for age
and height.
Weight loss is self-induced by avoidance of “fattening foods”.
There is a self perception of being too fat, with an intrusive dread of
fatness, which leads to a self-imposed low weight threshold.
There is a widespread endocrine disorder involving the hypotahalamic-
pituitary-gonadal axis manifest in women as amenorrhoea and in men
as loss of sexual interest.
are common. The clinician should enquire specifically about
episodes of syncope, which imply greater physical instability. It
is important to seek symptoms to suggest other causes of rapid
weight loss and underweight in young people (see Table 2) and
to undertake investigations if an alternative cause is suspected
(see Table 4).
Pubertal history: ask about features of puberty including acne,
sweating, growth spurt and voice changes in boys. A menstrual
history should be elicited in all female patients including age at
menarche, early menstrual pattern and information on recent
menstrual cycles (duration of bleeding and length of cycle) as
well as whether the cycles have stopped and if so when? Ask if
they know the weight when they last menstruated. Changes in
libido, bladder and erectile dysfunction may not be volunteered
but may be evident if enquired about.
The medical history should include information on early life
and include difficulties with attachment and feeding, traumatic
feeding experiences (choking, force feeding, anaphylaxis) and
any other developmental concerns. Exploration of predisposing
factors including family history of eating disorder, perfectionist
personality traits, precipitating events such as adverse childhood
experiences e.g. bullying, bereavement or abuse and perpetu-
ating factors (responses of family, coaches and friends) can help
inform the formulation and aid diagnosis.
Physical examination
The young person should be weighed (in light clothing with no
shoes and after voiding) and their standing height measured
Differential diagnosis for underweight or weight loss in
adolescents
Endocrine Diabetes mellitus, hyperthyroidism,
glucocorticoid insufficiency
Gastrointestinal Coeliac disease, inflammatory bowel disease
Malignancy Lymphoma, leukaemia, intracranial tumours
Other Depression, Other eating disorders eg ARFID,
Chronic fatigue, infections eg Tuberculosis
Table 2
2 Crown Copyright Ó 2019 Published by Elsevier Ltd. All rights reserved.
 OCCASIONAL REVIEW

lymphadenopathy and thyroid dysfunction. Examine for signs

Proposed classification of degree of malnutrition for
adolescents and young adults with eating disorders.
Adapted from Position Paper of the Society for
Adolescent Health and Medicine: Medical Management
of Restrictive Eating Disorders in Adolescents and Young
Adults. The Society for Adolescent Health and Medicine
Mild Moderate Severe
% median BMI 80e90% 70e79% <70%
BMI z score 1 to 1.9 2.0 to e2.9 e3 or less
Weight loss 10e15% 16e20% >20% body mass lost
in last year or >10% in
last 6 months
Table 3
followed by observations of temperature, heart rate, blood
pressure and lying/standing blood pressure and heart rate.
On inspection take note of the young person’s appearance,
body habitus and affect. Examination may reveal lanugo hair,
self harm marks, acrocyanosis or secondary Raynaud’s phe-
nomenon. Specific inspection should be made for Russell’s
sign which are calluses over the metacarpophalyngeal joints
of the index and middle fingers of the dominant hand from
repeated exposure of skin to gastric contents during self-
induced vomiting. Assess the pulse rate, rhythm and volume
for bradycardia. Inspection of the face may reveal parotid
swelling (a sign of repeated vomiting) and sometimes car-
otinaemia. It is important to assess hydration status and
capillary refill time as well as examine for signs of
of cardiac failure. Palpate the abdomen for tenderness, con-
stipation and masses and complete a pubertal assessment. A
targeted neurological examination including assessment of
muscle bulk, tone and power, tendon reflexes coordination
and gait along with fundoscopy, visual fields, pupillary re-
sponses and eye movements will provide reassurance that
there is no neurological deficit suggestive of intracranial pa-
thology. A pubertal assessment and mental state examination
by the clinician are also necessary parts of the examination.
Assessment and investigation
Risk assessment
AN has the highest standardised mortality rate of any psychiatric
disorder with 5e6 deaths per 1000 per year. Deaths in anorexia
often result from malnutrition and suicide. The risk of death is
highest in the first year after diagnosis and increased at presen-
tation due to the risk of refeeding syndrome. AN complicated by
binge-purge behaviours brings additional increase risk from
electrolyte/acid base disturbance and visceral rupture. There are
other risks of poor outcomes in young people with eating dis-
orders, which include the risk that they will not recover
adequately in adolescence and will remain affected into adult life
with a consequent physical and psychosocial morbidity and
increased risk of premature death.
The composite assessment of physical, psychological and
treatment risk is complex and multi-dimensional. As most young
people with AN can be treated on an outpatient basis assessing
and analyzing this risk is a key part of the multi-disciplinary
management. The Junior MARSIPAN guidance from the Royal
College of Psychiatrists provides tools to aid clinicians is
assessing this risk.

Investigations to be considered at presentation

Investigations to be considered at presentation
Full blood count Leucopenia and lymphopenia common and a risk factor for RFS
Electrolytes Electrolyte disturbance may be seen in binge-purge eating disorders
Creatinine may reflect increased muscle breakdown through exercise.
eGFR calculations are not accurate in underweight young people as they
make invalid assumptions about body mass composition
Glucose Often preserved within normal range
Bone profile Low phosphate of refeeding syndrome
Liver function Mild elevation of transaminases is common. Alkaline phosphatase
invariably low
Thyroid function A range of biochemical thyroid abnormalities may be seen with the
most common being “sick euthyroid syndrome”
ECG Sinus bradycardia. Look for U waves. Calculate QTc
Other investigations to consider at presentation if concerns regarding alternative diagnosis
Iron, ferritin and zinc proptoporphyrin, vitamin B12 and folate and zinc Severe malnutrition
Small bowel dysfunction
ESR, orosomucoid and faecal calprotectin Inflammatory bowel disease
Tissue transglutaminase Coeliac disease
Chest X-ray (Mantoux) Tuberculosis or lymphoma
MRI brain scan Intracranial tumors

Table 4

PAEDIATRICS AND CHILD HEALTH xxx:xxx 3 Crown Copyright Ó 2019 Published by Elsevier Ltd. All rights reserved.

Please cite this article as: Wood D, Knight C, Anorexia nervosa in adolescence, Paediatrics and Child Health, https://doi.org/10.1016/
j.paed.2019.06.006
 OCCASIONAL REVIEW
Red flags suggesting an urgent assessment is required:

weight loss of more than 1 kg per week for two consecutive
weeks

fluid and food refusal for more than 24 hours

syncope and/or seizures

BMI less than 13 Kg/m2 or percentage median BMI less than
70%

BP less than 0.4th centile

Sitting heart rate less than 40 bpm

Body temperature less than 35 C
Anthropometrics
The young person’s height and weight should be plotted both on
growth and BMI charts. Assessment of malnutrition also requires
an understanding of the rate (grams per week) and extent of
weight loss (percentage of pre-morbid weight). Percentage me-
dian BMI (¼ observed BMI/median BMI x100) is now a stan-
dardized measure used in assessment of eating disorders in
children and young people. It is important to note that medical
instability and malnutrition can occur when the young person’s
weight or BMI is in the normal range especially in those who
were previously overweight and have lost weight quickly
through severe restriction. The assessment of malnutrition in-
cludes both current percentage median BMI and degree of weight
loss (see Table 3).
Refeeding syndrome
Refeeding syndrome (RFS) occurs when there is a rapid change
from a prolonged state starvation to high calorie intake. This
leads to a switch in physiological homeostatic processes from
catabolism to anabolism largely mediated by insulin. The result
is an influx of extra cellular ions into cells to support anabolism
with consequent hypophosphataemia and other serum electro-
lyte deficits. Most commonly RFS is asymptomatic and manifests
as biochemical hypophosphataemia within the first five days of
refeeding. Deaths in young people with anorexia from RFS are
rare. The risk of RFS is thought to be increased in severe un-
derweight, severe restriction of calorie intake, rapid weight and
those with abnormal electrolytes, low phosphate or low white
cell count prior to re-feeding. Clinical features of RFS include
symptoms and signs of cardiac failure and neurological features
such as delirium, confusion. Wernicke’s encephalopathy has also
been reported.
AN is associated with reduced left ventricular mass, asymp-
tomatic pericardial effusions, and reduced left atrial and ven-
tricular chamber dimensions. Overall despite the changes
ejection fraction and stroke volume are preserved but other
measures suggest impaired overall cardiac performance. All of
these changes are reversible with weight restoration.
Some studies have suggested that AN is associated with
delayed cardiac repolarization (prolonged QTc interval) and this
has led to a presumption that sudden cardiac death in anorexia
may be related to prolongation of the QTc. This association is
debated however QTc should be measured is young people pre-
senting with AN. If it is prolonged then a cause such as electro-
lyte imbalance or drugs should be sought. Caution should be
exercised when prescribing medications which may prolong QTc
for young people with AN.
PAEDIATRICS AND CHILD HEALTH xxx:xxx
Please cite this article as: Wood D, Knight C, Anorexia nervosa in adolescence, Paediatrics and Child Health, https://doi.org/10.1016/
j.paed.2019.06.006
Sinus bradycardia is very commonly seen at presentation in
AN is thought to be a vagally mediated adaptive response to
malnutrition. In addition both systolic and diastolic blood pres-
sures are decreased and resting heart rates of 35e40 bpm whilst
sleeping are not unusual. Orthosatic changes can be marked and
resemble those seen in postural orthostatic tachycardia syn-
drome. Improvement correlates in these measures is related to
weight restoration. Syncope or seizures in the context of AN are a
red flag and may represent a cardiac arrhythmia.
Monitoring
A physical and laboratory monitoring plan should be agreed with
the young person and family. Twice weekly weight monitoring
after voiding and before breakfast is common practice. For in-
patients during the first week of refeeding there should be daily
monitoring of clinical status, blood count, electrolytes. A base-
line ECG should be undertaken and in those with prolongation of
the QTc daily monitoring may be appropriate. Syncope, seizures,
junctional escape rhythm or bradycardia less than 40 bpm should
prompt continuous cardiac monitoring. Observations of temper-
ature, pulse, respirations, blood pressure and neurological status
should be undertaken and the frequency matched to the level of
clinical concern for those with cardiovascular instability, ECG or
electrolyte abnormalities.
Management
Adolescents with AN are best managed by a multi disciplinary
team (MDT) providing collaborative medical, nutritional and
psychological interventions. The team usually includes the fam-
ily, dietician, psychiatrist, psychological and occupational ther-
apists, nurses, paediatrician and GP.
Location of care
Most adolescents with AN can be managed as outpatients and this
is thought to be more cost-effective than in-patient admission as a
first line treatment. There is evidence of increasing numbers of
hospital admissions for eating disorders however the factors
driving this increase have not been clearly elucidated and are likely
to include early recognition as well as an increasing access to
stabilization on paediatric wards for those who require it. There is
a trend towards structured supported admissions to acute paedi-
atric wards with a focus on stabilization, nutritional management,
supporting weight restoration and onward care planning. In some
cases admission to specialist CAMHS in-patient units are required.
Decisions regarding inpatient treatment need to take into account
the severity of the young person’s physical and mental illness,
outpatient resources, geographical factors and family circum-
stances. For inpatients with AN, a structured symptom focused
treatment programme with the expectation of weight gain should
be provided. Psychological treatment should be provided alongside
weight restoration with a focus on; eating behaviours and attitudes
to weight and shape as well as wider psychological issues.
Family-based treatment (FBT)
FBT is the first line outpatient, psychological intervention for
children and adolescents with AN. The leading principle of FBT
is parental involvement in treatment which is essential to the
therapeutic success. Mobilizing and empowering parental
4 Crown Copyright Ó 2019 Published by Elsevier Ltd. All rights reserved.
 OCCASIONAL REVIEW
strengths are central to change the behaviours of the young
people with AN. There are generally three phases to treatment.
Phase 1: Weight restoration
Phase 2: Return control of eating back to the young person
(approx 87% median BMI)
Phase 3: Address adolescent development and treatment
termination (90e100% median BMI)
Paediatricians play a critical role in family based therapy by
acting as a consultant to the young person, family and MDT
around physical health issues and will work alongside the die-
tician to ensure nutritional rehabilitation and the completion of
adolescent development. GPs have an have an important role in
recognition and monitoring for medical complications at each
stage of treatment.
Nutritional management
Nutritional rehabilitation is a fundamental component of treat-
ment and recovery for adolescents with AN. The Dietitian de-
velops a meal plan in consultation with the patient and family
and then supports them with the MDT throughout implementa-
tion with the aims of initiating safe re-feeding, weight restoration
and re-establishing a healthy relationship with food.
Safe refeeding: concerns of RFS have led to a "start low, go
slow" approach to nutritional rehabilitation of hospitalised pa-
tients with AN. Previously a low calorie regimen (ranging from
200 to 1200 kcal/day) was prescribed and increments were
gradual 200 kcal every other day. As a result "under-feeding
syndrome" defined by initial weight loss, slow weight gain and
prolonged illness were observed. Recent evidence supports a
more aggressive approach to refeeding adolescents to promote
weight gain, and shorten admission without an increase in the
risk of RFS. In clinical practice refeeding protocols are being
safely prescribed at a higher calorie intake starting from 1500
kcal/day and higher are being prescribed. Oral phosphate sup-
plements are used to treat RFS in those with a low serum
phosphate and may be used prophylactically in high risk group.
Nutritional rehabilitation: when admitted to hospital patients
with AN are expected to gain 0.5e1 kg a week (0.5 kg/week
expected in outpatient settings). Whenever possible all energy
and nutrients should be provided by food orally: meals, snacks
and drinks. This supports normal eating, and enables the patient
to physically experience and tolerate the amount of food neces-
sary for weight gain. Meal time supervision is essential for this to
be a successful method of feeding.
Prescribed meal plans are used in hospital settings to clearly
define what should be eaten and drank at each meal and snack
time. A consistent approach in inpatient settings must be taken to
ensure all people involved in food provision have the same in-
formation. The meal plan is a communication tool for the young
person, family and team. Within outpatient treatment a meal
plan may not be necessary depending on stage of treatment and
progress with recovery.
Supplemental and enteral feeding: oral nutritional supplements
(ONS) and enteral feeding via a nasogastric tube can be used as
part of the nutritional rehabilitation process, both having the
ability to provide 100% of an individual’s recommended daily
PAEDIATRICS AND CHILD HEALTH xxx:xxx
Please cite this article as: Wood D, Knight C, Anorexia nervosa in adolescence, Paediatrics and Child Health, https://doi.org/10.1016/
j.paed.2019.06.006
intake of nutrients. They may be used to "top up" when meals
and snacks from the prescribed meal plan are not completed.
ONS can be an adjunct to food in those who struggle to meet
the nutritional requirements for weight gain. Liquid supplements
can be seen as a type of medicine and therefore less anxiety
provoking to consume than food. Frequent use of liquid sup-
plements can become an unhelpful safety behaviour, in which
the patient is able to avoid the experience of food and foster a
dependency on artificial and measured sources of nutrition. The
decision to utilize ONS should be made in conjunction with a
dietitian.
The initiation of enteral feeding, via a nasogastric tube, may
be a lifesaving measure or a means to restore weight when other
options have been unsuccessful. It is usually considered a short
term measure and does not help the patient overcome fears
around eating and drinking. Enteral feeding is always used with
caution and ideally in collaboration with the patient. The MDT
should work closely together to determine the aim of enteral
feeding and the end point of this treatment method. Feeding
against the will of the patient (with or without restraint) is a
highly specialised procedure requiring expertise and should be
done in the context of the Mental Health Act 2007 or Children Act
2004 following the principles of least restrictive practice. As the
young person is able to eat more food orally the nasogastric feed
can gradually be titrated down and stopped.
Re-establishing a healthy relationship with food: young people
often need intensive support to establish a healthy relationship
with food, weight and shape. The team will work with the young
person, parents/carers to facilitate an improved relationship with
food. In the later stages of recovery this includes independence,
social eating and returning to developmentally appropriate
adolescent lifestyle.
Recovery and outcomes
The natural history of an AN can be highly variable with some
young people affected for relatively short periods of time and
seeming to make a full recovery whereas for others onset in
adolescence may lead to a chronic enduring illness extending
into adulthood sometimes with a fatal outcome. Remission rates
for adolescent AN at the end of treatment range from 23 to 33%
with one third of these young people in remission at four year
follow up. In broad terms approximately 50e75% of patients
have a good outcome, 10e40% have intermediate outcomes with
ongoing symptoms, and approximately 14e20% have a poor
outcome. Crude mortality rates for AN are 5e6% and the
standardised mortality ratio for adolescent onset AN has been
reported as 3.2 with the highest risk for death in the first year
after diagnosis. Major morbidities are impaired psychological
and social functioning with impact on employment, relationships
and increased levels of other mental health problems including
self harm. Most of the physical effects of AN appear to resolve
with weight restoration; however there are long term effects of
bone mineral density accretion and an increased fracture risk.
Resumption of menstruation
Most young people with anorexia nervosa will resume
menstruation when they have weight restored to a BMI which is
at or above 92e95% of the median BMI for their age. It can take
5 Crown Copyright Ó 2019 Published by Elsevier Ltd. All rights reserved.
 OCCASIONAL REVIEW
up to a year at healthy weight before menstruation returns. In
such cases measurement of serum LH, FSH, Oestradiol, andro-
gens and thyroid function may assist the clinician in reassuring
the young person that menstruation will resume with time. There
is emerging evidence that Insulin-like growth factor (IGF-1) may
be a more sensitive indicator of resumption of menstruation.
Medical follow up should continue until the young person starts
or resumes menstruation and completes pubertal growth. Some
advocate the use of pelvic ultrasound or body composition
assessment to predict the resumption of menstruation although
the evidence for the accuracy of these investigations is limited.
Bone density
Adolescence is a time of rapid bone density accretion and
malnutrition during this critical period is associated with reduced
bone mineral density and increased fracture risk later in life.
Bone density measurements should be undertaken in young
people who have remained underweight for more than a year or
who have a history of severe underweight or early onset eating
disorder. In older adolescents who have low bone mineral den-
sity remain underweight and have not resumed menstruation the
use of transdermal 17-B-oestradiol. A
FURTHER READING
Academy of Eating Disorders Medical Care Standards Task Force.
AED report 2012 eating disorders: critical points for early recog-
nition and medical risk management in the care of individuals with
eating disorders. Deerfield, Illinois, 2012.
American Dietetic Association. Position of the American dietetic as-
sociation: nutrition a intervention in the treatment of eating disor-
ders. J Am Diet Assoc 2011; 111: 1236e41.
Hart S, Franklin RC, Russell J, Abraham S. A review of feeding
methods used in the treatment of anorexia nervous a. J Eat Disord
2013; 1: 36.
Katzman DK, Peebles R, Sawyer SM, Lacl J, Le Grange D. The role of
the pediatrician in family-based treatment for adolescent eating
disorders: opportunities and challenges. J Adolesc Health 2013;
53: 433e40.
Lask B, Bryant-Waugh R, eds. Eating disorders in childhood and
adolescence. London: Routledge, 2007.
National Institute for Health and Clinical Excellence Nice Guideline
[NG69]. Eating Disorders: recognition and treatment. London:
NICE, 2017.
PAEDIATRICS AND CHILD HEALTH xxx:xxx
Please cite this article as: Wood D, Knight C, Anorexia nervosa in adolescence, Paediatrics and Child Health, https://doi.org/10.1016/
j.paed.2019.06.006
Nicholls D, Hudson L, Mahomed F. Managing anorexia nervosa. Arch
Dis Child 2010; 96: 977e82.
Nicholls DE, Lynn R, Viner R. Childhod eating disorders: British na-
tional surveillance study. Br J Psychiatry 2011; 198: 295e301.
Norrington A, Stanley R, Tremlett M, et al. Medical management of
acute severe anorexia nervosa. Arch Dis Child Educ Pract Ed 2012;
97: 48e54.
Royal College of Psychiatrists UK. CR168. Junior MARSIPAN: man-
agement of really sick patients under 18 with anorexia royal College
of psychiatrists. London, 2012.
Society of Adolescent Health and Medicine. Refeeding hypo-
phosphatemia in hospitalized adolescents with an: a position
statement of the society for adolescent health and medicine.
J Adolesc Health 2014; 55: 455e4578.
Society of Adolescent Health and Medicine. Medical management of
restrictive eating disorders in adolescents: position paper of the
society of adolescent health and medicine. J Adolesc Health 2015;
56: 121e5.
The New Maudsley method. In: Treasure J, Schmidt U, MacDonald P,
eds. The clinicians guide to collaborative caring in eating disorders.
London: Routledge, 2010.
Practice points
C Anorexia nervosa is a common and potentially fatal mental
and physical illness which usually has it’s onset in
adolescence
C Paediatricians and dieticians have a key role in as consul-
tants to the young person, family and eating disorders team
on aspects of physical health and nutritional rehabilitation
across the treatment pathway
C GPs and paediatricians should be able to recognise eating
disorders and differentiate them from other causes of
weight loss in adolescence
C The assessment of risk is complex and includes aspects of
both physical and mental health. Clinicians should be aware
of how to monitor for and treat refeeding syndrome.
C Most young people are successfully treated as out patients
although for some in-patient and/or compulsory treatment
are necessary.
6 Crown Copyright Ó 2019 Published by Elsevier Ltd. All rights reserved.