Eating disorders in children and

adolescents
Nina K. Anderson, and Olivier F. Nicolay

The incidence of eating disorders (ED) is increasing, not only in Westernized

societies, but developing countries as well. Individuals having EDs may
develop significant functional impairments across organ systems with
serious life-threatening consequences, leading to the highest rates of
mortality and morbidity among mental disorders. (Semin Orthod 2016;
22:234–237.) & 2016 Published by Elsevier Inc.

T he Diagnostic and Statistical Manual of

Mental Disorders (DSM-V) recognizes six
primary feeding and eating disorders including
anorexia nervosa (AN), bulimia nervosa (BN)
and binge-eating disorder, pica, rumination dis-
order, and avoidant/restrictive food intake dis-
order (ARFID). The residual category “eating
disorder not otherwise specified” has been
renamed “other specified feeding or eating dis-
order” and includes five disorders atypical ano-
rexia, binge eating with low frequency and/or
limited duration, purging disorder, and night
eating syndrome.
At-risk children frequently present with sub-
clinical, heterogeneous eating symptoms, tend to
present premorbid psychopathologies (depres-
sion, obsessive-compulsive disorder, or other
anxiety disorders) and are less likely to have
binge/purge behaviors associated with their ED
than adults. Childhood and adolescence are
critical periods of neural development and
physical growth. The malnutrition and related
medical complications resulting from ED such as
AN, BN, and eating disorder not otherwise
specified may have more severe and potentially
more protracted consequences during youth
than during other age periods.
Given the frequency with which oral health
practitioners, particularly pediatric dentists and
orthodontists, see their patients, they might be in
Department of Developmental Biology, Harvard School of Dental
Medicine, Boston, MA; Department of Orthodontics, New York
University School of Dentistry, New York, NY.
Address correspondence to: Nina K. Anderson, PhD, Department
of Developmental Biology, Harvard School of Dental Medicine, 188
Longwood Ave, Boston, MA 02115
& 2016 Published by Elsevier Inc.
1073-8746/16/1801-$30.00/0
http://dx.doi.org/10.1053/j.sodo.2016.05.010
a position to be the first healthcare provider to
detect and recognize the signs and symptoms of
an ED, and contribute to the early referral for
intervention/treatment. It therefore behooves
them to become cognizant and knowledgeable
about the manifestations of ED.
The incidence of eating disorders (ED) is
increasing, not only in Westernized societies, but
developing countries as well. Up to 30 million
people suffer from an ED in the United States,
with worldwide estimates at 70 million1 affected
by these disorders. Patients having EDs may
develop significant functional impairments
across organ systems with potentially serious
life-threatening consequences. The mortality
and morbidity rates associated with EDs are
among the highest of any mental disorders. The
mortality rate associated with anorexia nervosa
(AN) is 12 times higher than the death rate
associated with any other causes of death for
females age 15–24.1 Pediatric EDs are more
common than type 2 diabetes mellitus.6 Between
1999 and 2006, hospitalizations for ED rose by
119% for children under the age of 12.1,2 Female
athletes (e.g., cheerleaders, gymnasts, dancers, and
skaters), males competing in weight class sports (e.
g., wrestling and combat), or homosexual males
are the highest risk groups for developing ED.
Given the frequency with which general practi-
tioners, pediatric dentists, and orthodontists see their
patients, they are in a position to be the first
healthcare providers to recognize the signs and
symptoms of an ED, and contribute to the early
referral for intervention/treatment.3,4 Thus, it is
important that dental professionals are knowledge-
able about the types of ED and their manifestations.
The Diagnostic and Statistical Manual of
Mental Disorders (DSM-V)5 recognizes six
primary feeding and eating disorders including

Seminars in Orthodontics, Vol 22, No 3, 2016: pp 234–237 234

 Eating disorders in children and adolescents 235

anorexia nervosa (AN), bulimia nervosa (BN)
and binge-eating disorder, pica, rumination dis-
order, and avoidant/restrictive food intake dis-
order (ARFID). The residual category “eating
disorder not otherwise specified” has been
renamed “other specified feeding or eating dis-
order” and includes five disorders: atypical
anorexia, binge eating with low frequency and/
or limited duration, purging disorder and night
eating syndrome.
Many resources cover eating disorders in
adolescent and adult populations, but the
research and data on pediatric patients and ED is
scant. Children at risk present frequently with
sub-clinical, heterogeneous eating symptoms,
tend to have premorbid psychopathologies
(depression, obsessive-compulsive disorder, or
other anxiety disorders) but are less likely to have
binge/purge behaviors associated with their ED
than adults.6 Childhood and adolescence are
critical periods of neural development and
physical growth. The malnutrition and related
medical complications resulting from ED such
as AN, BN, and eating disorder not otherwise
specified may have more severe and potentially
more protracted consequences during youth than
during other age periods. The Workgroup for
Classification of Eating Disorders in Children and
Adolescents (2010) and The Society for Adolescent
Medicine recommend that the diagnoses and
treatment thresholds for pediatric ED should be
lower than for adults due to the potentially
irreversible effects of ED including pubertal delay,
growth retardation, short stature, structural brain
changes, low bone mineral density.6,7 In addition, it
has been reported that in young women suffering
from BN, unstimulated saliva flow rate was decreased,
with frequent complaints of dry mouth.8 Moreover,
signs and symptoms of temporomandibular joint
disorders appear to be more prevalent in patient
populations with eating disorders.9,10
Avoidant/restrictive food intake disorder
(ARFID), previously known as “feeding disorder
of infancy or early childhood,” refers to pediatric
feeding patterns that are restrictive such aversion
to or avoidance of certain foods which may relate
to appearance, smell, texture, taste, and/or
temperature of food, lack of appetite, using

Table. DSM-V disorder, observable characteristics, questions.

DSM-V disorder Physical characteristics Questions

Anorexia nervosa Low body weight Hypothermia

If purging type see bulimian Fatigue Participates-organized sports
Carotenemia/dry skin
Nervosa purging type Baggy clothing Excessive exercise
Atypical tattoos/piercings Perfectionist
Vegetarian
History of dieting
Ritualistic eating behaviors
Self-injurious behavior
Amenorrhea
Teased/bullied
Depressed/moody
Bulimia nervosa purging type Swollen parotid glands Eats large meals
Petechial hemorrhages Drinks acidic fluids
Perimolysis Vegetarian
Chipped/notched maxillary Tooth sensitivity
incisors V-shaped lesions on labial aspects
Angular cheilitis Frequent tooth brushing
Halitosis Athletic
Esophageal tear Participates-organized sports
Downy facial hair (lanugo) Tooth sensitivity
Callouses on back of hands (Russell’s sign) Body dissatisfaction
Depressed/moody
Obsessive/compulsive
Avoidant/restrictive food intake disorder Delayed development Picky eater
Low body weight Avoids new foods
Speech problems Mealtime struggles
Lethargy Trouble pronouncing words
Trouble maintaining focus
236 Anderson and Nicolay
feeding behaviors to self-soothe (e.g., rumina-
tion). It is estimated that up to 25% of infants and
young children have feeding problems.11 These
children may eat only foods of a certain color,
usually white/neutral such as bread, and plain
pasta or foods of certain texture, nothing lumpy,
no strong smells, a particular brand, or only cold
or hot foods. Children who will only eat purees
and smooth textures may have compromised/
delayed oral motor skills, as they have not learned
to chew, which may also adversely affect their
speech. Due to nutritional deficiencies, children
with ARFID can experience extreme lethargy,
difficulties of concentration, or delayed growth/
weight gain for their age and gender.
Dental providers who suspect that a patient
may have an ARFID (Table) should check for
physical signs including halitosis, early childhood
caries, speech problems, and trouble sitting
through a dental exam. During the dental
appointment, they should also ask parents if
the child is reluctant to eat new foods, has trouble
gaining weight, eat only certain textures, has
trouble chewing/swallowing food, avoids eating,
enjoys re-chewing food, misses school, or has
trouble making friends. If so, referral to a
pediatrician specialist may be indicated. Children
with ARFID have been found to have significant
comorbidities including, an underlying medical
disorder (86%) oropharyngeal dysfunction (60%)
or behavioral problem (18%).11,12
AN and BN are diagnosed more frequently
between the ages of 16 and17. Recently however,
there has been a significant increase of eating
disorders diagnosed in 10 years old children, and
boys.2,6
The defining characteristic of a non-purging
type AN patient is low body weight due to
insufficient caloric intake. Low body weight is
relative to the expected weight based upon age,
gender, history of weight gain, and growth/
Figure. Examples of cheilosis, and damage to central incisors.
pubertal trajectory. Young adolescents and chil-
dren, males and females, may be equally affected.
During dental appointments any pediatric or
young adolescent patient who presents with some
of the physical characteristics of AN (Table)
should be checked more specifically for buccal or
facial surface erosion due to consumption of
highly acidic foods, caries, halitosis, xerostomia
or reduced salivary flow, orthostatic changes in
pulse, bloating.
For both AN and BN, purging subtypes may
exist. Dental problems resulting from the purg-
ing behaviors can appear as early as 6 months
after onset. In addition to physical characteristics
previously described (Table), common mani-
festations of purging include dental erosion,
particularly on lingual surfaces of maxillary
teeth (perimolysis), chipped/notched maxillary
incisors, angular cheilosis (Fig.), raised
amalgams, gingival recession, V-shaped abfrac-
tion lesions on labial aspect of teeth as a result of
vigorous/frequent brushing, swollen parotid
glands, trauma to mucosal membranes, pharynx
and soft palate, petechial hemorrhages, lanugo
hair, and sensitivity to hot/cold foods.
Unfortunately, the EDs are among the few
diseases for which support groups exist to
encourage the disordered eating behaviors, to
endorse the condition, and represent the dys-
morphic relationship with food as a life style
choice and way to maintain control. Pro-ana for
anorexia and pro-mia websites offer inspiration
and information for concealment of the eating
disorders from others, or information on how to
avoid eating.
Secrecy and concealment are common
behaviors in young people with EDs. They can be
so successful that many ED go unrecognized,
under-diagnosed or misdiagnosed by primary
care physicians.13 This is rather unfortunate
since, when asked about what could have
 Eating disorders in children and adolescents
facilitated their own recognition of having an ED
or their willingness to seek help, 60% of patients
reported that, had a healthcare professional
recognized the signs of an ED it would have
facilitated their willingness to spontaneously
disclose their behaviors. Eating disorders are
associated with the highest rates of morbidity and
mortality of any mental disorders among
adolescents. Early detection therefore increases
the odds of recovery and of better long-term
prognosis. As one of the first medical pro-
fessionals to have an opportunity to detect
ED in patients, it behooves dentists to become
cognizant and knowledgeable about the
manifestations of ED.
References
1. Agency for Healthcare Research and Quality (AHRQ): AHRQ
News and Numbers; April 1, 2009.
2. Rosen DS. American Academy of Pediatrics Committee
on Adolescence. Identification and management of
eating disorders in children and adolescents. Pediatrics.
2010;126(6):1240–1253.
3. Hague AL. Eating disorders: screening in the dental
office. J Am Dent Assoc. 2010;141(6):675–678.
4. DeBate RD, Tedesco LA, Kerschbaum WE. Knowledge of
oral and physical manifestations of anorexia and bulimia
237
nervosa among dentists and dental hygienists. J Dent Educ.
2005;69(3):346–354.
5. American Psychiatric Association. Diagnostic and Statistical
Manual of Mental Disorders , 5th ed. Washington, DC; 2013.
6. Campbell K, Peebles R. Eating disorders in children and
adolescents: state of the art review. Pediatrics. 2014;134
(3):582–592.
7. Shaughnessy BF, Feldman HA, Cleveland R, Sonis A,
Brown JN, Gordon KM. Oral health and bone density in
adolescents and young women with anorexia nervosa.
J Clin Pediatr Dent. 2008;33(2):1–6.
8. Dynesen AW, Bardow A, Petersson B, Nielsen LR,
Nauntofte B. Oral Surg Oral Med oral Pathol Oral Radiol
Endod. 2008;106:696–707.
9. Akhter R, Hassan NMM, Nameki H, Nakamura K, Honda
O, Morita M. Association of dietary habits with symptoms
of temporomandibular disorders in Bangladeshi adoles-
cents. J Oral Rehabil. 2004;31:746–753.
10. Johansson AK, Johansson A, Unell L, Norring C, Carlsson
GE. Eating disorders and signs and symptoms of
temporomandibular disorders. Swed Dent J. 2010;34:
139–147.
11. Bryant-Waugh R, Markham L, Kreipe RE, Walsh BT.
Feeding and eating disorders in childhood. Int J Eat
Disord. 2010;43(2):98–111.
12. Chatoor I. Feeding disorders in infants and toddlers:
diagnosis and treatment. Child Adolesc Psychiatr Clin N Am.
2002;11(2):163–183[Review].
13. DeBate RD, Tedesco LA, Kerschbaum WE. Knowledge of
oral and physical manifestations of anorexia and bulimia
nervosa among dentists and dental hygienists. J Dent Educ.
2005;69(3):346–354.