Special

Pediatric
Focus

in Preadolescent
Children
44 The Nurse Practitioner • Vol. 32, No. 3 www.tnpj.com
 Eating Disorders

Jan D. Hamilton, PMhNP, BSN, MS more common in children than “pure” AN. Disordered eat-
ing may emerge as food-avoidance emotional disorder, se-
lective eating, food refusal, or functional dysphagia. These
ating disorders (ED) are occurring more frequently disorders do not fit into existing diagnostic categories, yet

E in preteen girls and boys. Most children with ED

have full- or partial-syndrome anorexia nervosa
these patients often need significant treatment and are at se-
rious medical risk.
(AN), and atypical presentations are common. Food restric-
tion is the dominant symptom. Eating disorders in children ■ Etiology/Risk Factors
have multiple origins—personality traits, self-esteem, family, Individuals with AN tend to be obsessional and perfection-
culture, and genetics. Because children may rapidly decom- istic, have negative self-evaluation, and difficulty recogniz-
pensate physically and permanently lose growth potential, ing their feelings. Individuals with BN tend to be impulsive
early and aggressive intervention is warranted, beginning and self-critical, demonstrating labile moods in response to
with nutritional rehabilitation. Treatment teams minimally environmental events.3 There is an observed relationship be-
include medical and psychiatric providers, a psychotherapist, tween obsessive compulsive disorder (OCD) and EDs; many
and a dietitian skilled in treating children with ED. There is children with ED have OCD or OCD symptoms.4
no Food and Drug Administration (FDA)-approved med- Family dysfunction is often implicated. Anorexia ner-
ication for children with ED, but medications may alleviate vosa can develop in overcontrolled and rigid families that
common co-occurring symptoms.
Anorexia nervosa and bulimia
nervosa (BN) were long-considered Individuals with AN tend to be obsessional and
diagnoses of adolescent and young perfectionistic, have negative self-evaluation,
adult females. Now EDs are occur-
ring more frequently in ages 6 to 12 and difficulty recognizing their feelings.
years and among both boys and
girls.1,2 At the author’s treatment
center, nearly 20% of patients reported ED onset before 13 have difficulty expressing and resolving conflict, and BN of-
years of age. With EDs becoming more common in younger ten develops in chaotic family systems.5 Sexual abuse is fre-
children, nurse practitioners (NPs) need to improve their quently identified as precipitating ED behaviors, particularly
understanding, assessment, and treatment of these vulnera- bingeing and purging. Onset of puberty is a critical time for
ble patients. ED development. Pubertal concerns and maturity fears are
often identified as contributing factors to ED development.5
■ Classification/Prevalence Genetics may play an important part in predisposing
In the Diagnostic and Statistical Manual of Mental Disorders, individuals to EDs through serotonin effects on metabo-
Fourth Edition (DSM-IV-TR), EDs are divided into three lism.6 Twin and family studies provide evidence of genetic
categories: AN, BN, and eating disorder not otherwise spec- transmission, possibly affecting body mass index, suscepti-
ified (EDNOS). Prevalence rates in adolescents are 0.7% for ble personality structure, and reactivity.3
AN and 1% to 2% for BN. Reliable prevalence statistics are Risk factors also include female gender, Western culture,
lacking for preteens. urban lifestyle, and dieting history. Socioeconomic status and
Anorexia nervosa includes refusal to maintain weight at ethnicity have no clear causal relationship to EDs. Two re-
or above 85% of ideal, intense fear of weight gain, body im- cent cultural trends may partially explain the increase in child-
age distortion, and secondary amenorrhea. Bulimia nervosa hood EDs: 1) the availability of food and obesity-promoting
includes episodic binge eating, recurrent inappropriate com- lifestyles; and 2) unattainable body size ideals. These can leave
pensatory behaviors to avoid weight gain, bingeing at least even the youngest children confused and dissatisfied with
two times per week for 3 months, and self-evaluation un- their appearance.Among girls 7 to 13 years of age,55% wanted
duly influenced by body shape or weight. Eating disorder to be thinner and 41% reported weight loss activities.
not otherwise specified captures partial-syndrome AN or The average American child spends more time watch-
BN and atypical presentations. ing TV than in school. The average American views over
Bulimia nervosa is rare in children. Most have AN or 3,000 advertisements per day through various media. Ad-
AN-spectrum issues; food restriction is the dominant symp- vertisements now specifically target children with messages
tom. Atypical eating disorders, diagnosed as EDNOS, are promoting dieting and dissatisfaction with body shape and

www.tnpj.com The Nurse Practitioner • March 2007 45

 Eating Disorders
Assessing Eating Disorders in Children
One useful tool for assessment in children is SCOFF.8
Affirmative responses to two or more items on the five-
item scale predict ED symptoms:
1. Do you make yourself Sick?
2. Do you worry you have lost Control over how much
you eat?
3. Have you recently lost more than One stone (14
pounds) in a 3-month period?
4. Do you believe yourself to be Fat?
5. Would you say Food dominates (is one of the most
important things) in your life?
Evaluation for ED among children assesses the following
key indicators:
• Weight loss: extreme thinness; loss of >15 lbs in 2 to 3
months; exhilarated by weight loss
• Intense fear of being overweight: preoccupied with
thinness; wants to be thinner than peers; complains of
being overweight when not; obsessed with clothing
size, scales, mirrors, weighing
• Preoccupation with dieting and food: uses diet
products; talks constantly about food; reads about
nutrition, dieting, exercise
• Eating little: skips meals; finicky about food; appears to
eat but does not
• Unusual eating habits: eats one thing at a time; eats
the same thing daily; cuts food into tiny pieces; fears
touching certain foods; sudden vegetarianism; won’t
eat with others
• Caffeine use: excessively drinks sugar-free, caffeinated
beverages
• Evidence of binge eating, such as empty food packages
• Onset of hyperactivity: constantly fidgets and exercises
• Intolerance of cold: shivering; bluish skin or fingers;
cold extremities
• Wears baggy clothes, long sleeves, pants, and coats
during summer months to hide thinness
• Skin and hair problems: sallow, dry skin; thin, dry hair;
hair loss; lanugo on face and arms
• Change in mood: depression, irritability
• Social withdrawal
• Perfectionism and low self-esteem
• Obsessions and compulsions
size. The image of a tall, very thin female body with precise
facial bone structure and other “perfectly” proportioned fea-
tures is often paired with images of pleasure, wealth, self-
confidence, and sexual prowess. This body type exists in only
2% of American females, leaving 98% of girls comparing
themselves to an ideal that is genetically impossible for
them to attain. When girls are exposed to unattainable and
computer-enhanced female bodies, the result is often body
dissatisfaction and hatred. Idealized male bodies are also be-
ing presented more commonly, possibly contributing to in-
creased EDs in boys.7
46 The Nurse Practitioner • Vol. 32, No. 3
■ Assessment
Children with EDs pose unique issues. Adults often do no
suspect an ED; they present atypically and are difficult to di-
agnose (see Table: “Assessing Eating Disorders in Children”).
There is less evidence in the literature of prevalence and less
comfort with strategies to guide treatment.5
Among children with ED, the percentage of boys is
higher—as much as 33% versus only 10% among teens and
adults with ED. Children present with less body image dis-
tortion, often admitting they are too thin but not knowing
what to do about it. Children are more susceptible to med-
ical complications, have less body fat, and exhaust their nu-
tritional stores more quickly than adolescents or adults.3,5
These factors emphasize the need for assessment and med-
ical intervention before irreversible damage occurs.
If an ED is suspected, the most important necessity of
the initial workup is a thorough history of nutritional, psy-
chological, behavioral, and motivational features.9 It is es-
sential to determine the functional impact of disordered
eating on the rest of the child’s life. Since younger patients
present atypically, the diagnosis is one of exclusion; the
workup needs to be more extensive with high suspicion of
underlying organic pathology.
Comprehensive medical and psychiatric evaluations are
critical for diagnosis and appropriate treatment. Evaluation
includes a full physical examination; substance abuse history
including substances used for weight loss such as diuretics,
laxatives, diet pills, stimulants, caffeine, and syrup of ipecac
for purging; psychiatric history and co-occurring mental
health conditions; mental status examination; eating patterns;
weight loss or fluctuation history; chronic or acute pain; and
self-harm, and suicidal ideation or plan. The American Psy-
chiatric Association recommends a laboratory workup, in-
cluding electrolytes, blood urea nitrogen, creatinine, liver
enzymes, serum albumin, thyroid function, complete blood
cell count, and urinalysis.10 If severely malnourished, calcium,
magnesium, and phosphate levels are indicated. If consistently
underweight, bone density tests are warranted.
■ Differential Diagnosis
Children with ED have a high risk of medical complications
and sequelae.1 Aggressive medical treatment is warranted as
children can rapidly decompensate physically and can lose
growth potential permanently. Medical complications of
EDs result from disruption of metabolism as the body at-
tempts to compensate for the malnourished state. Changes
in thyroid levels occur. General organ size and function di-
minish as the body becomes more compromised.
Growth and development issues to consider include pos-
sible irreversible stunting of growth, reproductive damage,
bone loss, enlarged brain ventricles, and decreased brain cor-
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tical mass.6 Anorexia nervosa is one of the most lethal psy-
chiatric conditions; mortality rates of 5% to 6% per decade
have been reported. Bulimia nervosa can lead to significant
medical and dental morbidity; binge eating itself can pre-
dispose vulnerable children and preteens to obesity and the
multiple health conditions related to chronic overweight.
Medical conditions that require immediate hospital care
include clinical evidence of hypokalemia on electrocardio-
gram (dispersed or prolonged QTc interval) or hyponatremia
(from water loading). Sinus bradycardia is characteristic of
starvation with heart rates as low as the
20s or 30s at rest. Such patients require
cardiac monitoring. Hypophosphatemia Sinus bradycardia is characteristic of
can occur with refeeding and needs to be starvation with heart rates as low as the
followed closely.
Differential diagnoses of ED include
affective disorder,unipolar or bipolar de-
pression, personality disorder, schizo-
phrenia,anxiety disorders including OCD and posttraumatic
stress disorder (PTSD), substance abuse, organic disease, in-
fection, thyroid disease, diabetes, cancer, malabsorption syn-
dromes, brain tumor, gastrointestinal function problems
(reflux, inflammatory bowel disease), central nervous sys-
tem lesions, migraines, and epilepsy.11 Co-occurring psychi-
atric disorders often overlap symptomologically with the ED
and can make diagnosis challenging. Mood disorders, OCD,
PTSD, and other anxiety disorders must be treated in con-
junction with the ED for successful recovery.
■ Treatment
All components of a biopsychosocial treatment model need
to be addressed in treatment plans. Multidisciplinary treat-
ment is necessary, providing developmentally appropriate
interventions. Treatment teams should minimally include a
medical provider, psychiatric provider, psychotherapist, and
dietician.
Nutritional rehabilitation is fundamental.Weight restora-
tion is primary for those underweight, and weight stabiliza-
tion is necessary for those in their weight range or above. Ideal
weight determination is based on the body composition de-
rived from skin fold caliper analysis, genetics, historical infor-
mation from growth charts, plus menstrual weight for girls.
The average weight percentile documented over time in the
patient’s medical history is extrapolated to obtain an appro-
12
priate weight range for the patient’s current age. Collaborat-
ing with a dietician who specializes in eating disorders and
has experience with children is ideal.
Yager et al. presented treatment goals applicable to chil-
dren and young adolescents with atypical symptomology.13
Individualized treatment plans are encouraged based upon
specific needs rather than tightly circumscribed approaches.
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Eating Disorders
Young patients who do not meet specific DSM-IV-TR crite-
ria (for instance, no menstrual history or patients admitting
they are too thin) may still respond to treatment modalities
typically utilized in adolescent populations but may need a
more behavioral rather than cognitive focus, coupled with
experiential therapies such as art, play, or equine therapies.
Treatment for ED in children needs to include resiliency
and self-esteem/identity therapy. Exposure with response
prevention therapy may be necessary for children with se-
vere OCD and anxiety symptoms related to food and weight
20s or 30s at rest.
gain. Dealing with denial and severe resistance is challeng-
ing, as well as anger issues, temper tantrums, and food re-
fusals. Treatment collaboration with an expert child therapist
is important. Family therapy is also essential and relapse is
predictable if the family dysfunction is not addressed.1 Fam-
ily treatment can actually produce better results than indi-
vidual therapy in children.5
There is no FDA-approved medication for ED in chil-
dren. Selective serotonin reuptake inhibitors are used as ap-
propriate for co-occurring psychiatric disorders such as major
depressive disorder, OCD, separation anxiety disorder, and
social phobia. These should be managed by a psychiatric NP
or psychiatrist with a background in ED treatment and child-
hood disorders. Monoamine oxidase inhibitors and tricyclic
antidepressants are rarely used in this population due to di-
etary concerns and side effects.Fluoxetine (Prozac) has shown
efficacy in weight maintenance of weight-restored patients.
Antihistamines (diphenhydramine), hydroxyzine (Vis-
taril, Atarax) are used adjunctively for insomnia related to
depression or anxiety. Hydroxyzine may be utilized for meal-
related anxiety, though sedation side effects may make this
less than desirable.
Atypical antipsychotics are also used judiciously for the
symptoms of excessive anxiety, body image distortions, ex-
cessive food phobias, and severe obsessions. These medica-
tions may reduce the anxiety related to food and weight gain,
facilitating the therapeutic process. Olanzapine (Zyprexa)
has been specifically studied for this indication.3 Atypical
antipsychotics are recommended for short-term use and if
continued on an outpatient basis would need to be closely
monitored. Risks of dyskinesia, sedation, and hyperglycemia
must be addressed.
When there are disabling medical or psychiatric symp-
The Nurse Practitioner • March 2007 47
 Eating Disorders
Indicators for Inpatient Referral10
I. Medical instability, including:
A. Heart rate in 40s
B. Low blood pressure: < 80/50 mmHg
C. Orthostatic blood pressure changes
D. Electrolyte imbalance
1. Hypokalemia (< 3 mEq/liter)
2. Hypophosphatemia
3. Hypomagnesemia
4. Hyponatremia or hypernatremia
E. Low body temperature (< 97 oF)
F. Dehydration
G. Hepatic, renal, or cardiovascular organ
compromise
H. Diabetic, insulin-dependent
II. Weight < 85% of healthy body weight
III. Failure or anticipated failure at lower level of care
A. Outpatient treatment can cost $100,000 if
protracted
B. Inpatient treatment may be more cost-effective
at $30,000 to $60,000
IV. Motivation for recovery
A. Fair or poor
B. Egosyntonic ED thoughts > 4 hours/day
V. Co-occurring psychiatric disorder requiring
hospitalization
A. Substance abuse
B. Suicide plan or intent, severe depression
C. Severe anxiety, PTSD, OCD
VI. Needs meal supervision or will restrict or
binge/purge
VII. Complete role impairment
VIII. Uncontrolled compulsive exercise
IX. Severe dysfunctional family system/lack of support
system
X. Resistant or uncooperative with treatment
XI. Geographic isolation from treatment service
toms that impair treatment in a less restrictive environment,
the patient may need referral to an inpatient facility (see
Table: “Indicators for Inpatient Referral”).10
■ Prevention and Outcomes
Rosen reviewed several published outcomes studies regard-
ing children and young adolescents.5 Mortality ranged from
0% to 18% with starvation or suicide as the most frequent
causes. Between 66% to 80% achieved therapeutic goals and
appropriate weight gain. After 10 to 15 years of follow-up
in one study, 75% met criteria for full recovery and 86%
demonstrated at least partial recovery. Earlier treatment
seems to improve response, though psychosocial dysfunc-
tions may linger for many.
48 The Nurse Practitioner • Vol. 32, No. 3
Prevention may be possible through education in nu-
trition, self-esteem enhancement programs, and parents
and educators emphasizing inner attributes of character
rather than outward appearance. The National Eating Dis-
orders Association has excellent educational materials avail-
able. Parents need to be aware of their own feelings about
and relationship with food, and the extent to which they
emphasize physical appearance. Parents can model mod-
erate exercise, balance in eating without labeling foods
“good” or “bad”, and refrain from using food as reward or
punishment.
Peer-based prevention strategies in school settings can
effectively reduce ED incidence. With guidance and educa-
tion, peer influence can improve body image and eating
habits. Merely asking children about risky weight control
methods and attitudes can discourage this behavior.14
Childhood EDs are among the most difficult and deadly
psychiatric conditions. Adequate treatment requires early
intervention, appropriate assessment, and a multidiscipli-
nary approach. Appropriate interventions can neutralize this
childhood disease and provide the opportunity for a child’s
normal growth and development.
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4. Anderluh M, Tchanturia K, Rabe-Hesketh S, et al. Childhood obsessive-com-
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ABOUT THE AUTHOR
Jan D. Hamilton is a Nurse Practitioner at Remuda Programs for Eating Disor-
ders, Wickenburg, AZ.
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