1. A Gentle Introduction to Eating Disorders in Childhood
And Adolescence
Dr Peiyoong Lam
Division of Adolescent Medicine and Provincial Specialized Eating Disorders Program for Children and Adolescents

2. Overview Brief outline of eating disorders
Common ways of presenting in the ED
What to do on 3M
Questions

3. Anorexia Nervosa
Restriction of energy intake relative to requirements leading to a significantly low body weight in the context of age, sex, developmental trajectory and physical health
Significantly low weight is defined as a weight less than minimally normal/expected
Intense fear of weight gain or becoming fat with behaviors that interfere with weight gain despite being at a low weight
Body image disturbance or lack of recognition of seriousness of low body weight and undue influence of body weight/shape on self evaluation

4. Changes Amenorrhoea no longer a criteria Restricting subtype
Binge/purge subtype
Severity rating based on BMI –
Mild >17
Mod 16-17
Severe 15-16
Extreme <15

5. Spectrum of eating disorders
Normal, natural eating
Dieting
Subclinical eating disorder
Clinical eating disorder
Occasionally binge or purge, take diet pills, feel disgusted/ preoccupied about body and/or behaviours, go for extended periods without eating much, feel some loss of control around food
Counting calories, skipping meals or food groups, eating from lists of ‘good’ and ‘bad’ foods, following a diet for a period of time.
Eat in response to hunger and satiety most of the time, accepting of body shape and size.
Anorexia nervosa, bulimia nervosa, binge eating disorder
From CEED Health prof ED resource

6. Trends in BMI weight categories in BC
2003
2008
2013
Males
Underweight 2% 4%
Healthy weight
72%
73%
70%
Overweight
19%
18%
Obese 7% 8%
Females 3%
84%
81%
11%
12%
2013 BC Adolescent Health Survey

7. Eating behaviors
One third of healthy weight males were trying to gain weight (nutritional supplement use**)
13% of healthy weight males were trying to lose weight (15% in 2008)
52% of healthy weight females were trying to lose weight (46% in 2008)
5% males and 10% of females vomited on purpose after eating. Overweight/obese females were more likely to have done so in the past year
2013 BC Adolescent Health Survey

8. Breakfast
2013 BC Adolescent Health Survey

9. Some common ED presentations…
Syncope/dizziness
Hypoglycemia
Hypokalemia
Hypotension and circulatory failure
Chest pain/palpitations
Anxiety
Electrolyte disturbance and ECG abnormalities
Bradycardia
Constipation
Suicidal ideation
Self harm
Overdose
Distressed parent on a wait list

10. Aims of Emergency management
RECOGNITION of the disease
Medical stabilization and begin correction of:
Hypoglycemia
Hypokalemia
Hypophosphatemia
Low magnesium
Screen for suicide risk
Contact Eating Disorders team
Transfer to 3M as required

11. What to ask if you suspect an eating disorder
“Do you think you may have an eating disorder ?”
The SCOFF questions*
S- Do you make yourself Sick because you feel uncomfortably
full?
C- Do you worry you have lost Control over how much you eat?
O- Have you recently lost more than One tenth of your body
weight in a 3 month period?
F- Do you believe yourself to be Fat when others say you are too
thin?
F- Would you say that Food dominates your life?
*One point for every “yes”; a score of ≥2 indicates a likely case of anorexia nervosa or bulimia

12. Risk Assessment BMI: High risk <13 Phys exam:
CVS, muscle power (SUSS test)
Bloods: Electrolytes, LFTs, Glucose
ECG

13. Criteria for urgent admission
AAP guidelines
Heart rate <50/min day; 45/min night
Systolic pressure <90 mm Hg
Orthostatic changes in pulse (20 beats per min) or blood pressure (10 mm Hg)
Arrhythmia
Temperature <35.6 degrees Celsius
<75% SBW or ongoing weight loss despite intensive management
Body fat 10%
Refusal to eat
BCCH guidelines
<75% IBW
HR <45/min
BP drop >20mmHg
Electrolyte derangement
Cardiac abnormalities

14. Cardiovascular complications
Bradycardia
Arrhythmia (irregular heart beat) – especially with low K+
Postural drop in BP
Postural tachycardia
Mottling/cool peripheries
Cold => abnormal hair growth (lanugo)
This is commonly what use to kill people routinely, we have only had 1 death in the 20 years I have been at chidlren’s (that I am aware of, while in our age group/ in our care), but at st pauls, over the longer duration, body becomes less resilient to the abuse… and deaths routinely happen there.. 20’s-30’s etc

15. Rehydration If the gut works, use it Oral/NG rehydration solution
4-2-1 rule for maintenance and add losses (in % of body weight) and replace over 24 hours
Rehydrate first then start food OR together with food

16. Refeeding Guidelines
More evidence that it is safe to start at >1000cal per day especially in adolescents (Montreal, Melbourne, San Francisco)
If there is self report of some oral intake (even minimal), it is best to start at 1500cal/day.
Concerns about underfeeding being just as dangerous as overfeeding (Marsipan UK)
Increase by 300cal (or meal plan change) every 1-2 days

17. Phosphate replacement
Oral phosphate 500mg daily/bid/tid depending on level of phosphate
Nadir during refeeding is day 3-5
Laxative abuse – check Mg and K and replace as these are likely to be low as well

18. Hypoglycemia Some present with hypoglycemia Iv Dextrose OR oral intake
Refeeding results in rebound hypoglycemia
Recommend checking in AM and post meals and consider checking at 2AM
Lasts for 2-3 days if eating

25. Each bottle of Ensure Plus is approx 350 cal

26. Details
– ED Intake Coordinator for consults/referrals to ED team
Fax no:
Need a separate consult for Adolescent Medicine – call Adolescent Medicine oncall
New resource folder on Medworxx
Guidelines
Sample meal plans
Daily intake logs
Resource list for parents

27. Questions