Eating Disorders Mark A. Goldstein, Esther J. Dechant and … · Anorexia nervosa has the highest...

DOI: 10.1542/pir.32-12-5082011;32;508Pediatrics in Review

Mark A. Goldstein, Esther J. Dechant and Eugene V. BeresinEating Disorders

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Eating DisordersMark A. Goldstein, MD,*

Esther J. Dechant, MD,†

Eugene V. Beresin, MA,

MD§

Author Disclosure

Drs Goldstein,

Dechant, and Beresin

have disclosed no

financial relationships

relevant to this

article. This

commentary does not

contain a discussion

of an unapproved/

investigative use of a

commercial

product/device.

Objectives After completing this article, readers should be able to:

1. Identify behaviors in an adolescent that suggest an underlying eating disorder.2. Recognize the physical findings that can be seen in patients who have an eating

disorder.3. Understand the medical complications seen in teens who have anorexia and bulimia.4. Be informed about the types of therapies available for adolescents who have anorexia

and bulimia.5. Know the definition of the female athlete triad.

A 15-year-old girl is admitted to the pediatric intensive care unit with a long history ofweight loss and a serum sodium concentration of 189 mmol/L. She has been following ameal plan to gain weight and recently has stopped running 5 miles a day. Her fluid intakeis approximately 16 oz of water a day. She denies fear of weight gain and body imagedisturbances, and a symptom review is negative. Physical examination reveals an alert andcooperative adolescent girl. Weight is 68 lb (��3%); height, 62.75 in (34%); body massindex (BMI), 12.14 (��3%); blood pressure, 113/74 mm Hg; heart beat, 67 beats/minute; and axillary temperature, 36°C. She has no signs of pubertal development and ismildly dehydrated. After extensive evaluation, she is determined to have an underlyingeating disorder with no primary medical diagnosis. She is discharged from the hospital onday 16 without any complications, with follow-up care by an adolescent medicine specialistand therapist.

IntroductionEating disorders in children, adolescents, and young adults represent serious mental healthproblems. These disorders can cause significant morbidity to body systems as well asdevastating effects on the child’s psychosocial development, family dynamics, and educa-tion. Anorexia nervosa has the highest fatality rate of any mental health disorder. Thehallmark of anorexia is the refusal or inability to maintain a normal body weight. Thecurrent Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text

Revision (DSM-IV TR) (1) definition of anorexia nervosaalso includes amenorrhea of 3 months’ duration as part ofthis disorder; however, if the onset of the eating disorderoccurs before menarche, the patient will have, by definition,primary amenorrhea.

Other important psychological symptoms of anorexia in-clude body image distortions and fears of weight gain. Buli-mia nervosa, on the other hand, is marked by recurrentbinges (eating a large amount of food in a short period oftime in a way that feels out of control) along with “compen-satory” mechanisms such as purging, food restriction, andexercise to prevent weight gain. Patients who have bulimiaoften are at or above normal weight but still have concernsabout their weight and shape.

*Assistant Professor of Pediatrics, Harvard Medical School; Chief, Division of Adolescent and Young Adult Medicine,MassGeneral Hospital for Children, Boston, MA.†Instructor in Psychiatry, Harvard Medical School; Medical Director, Klarman Eating Disorders Center, McLean Hospital,Belmont, MA, (co-first author).§Professor of Psychiatry, Harvard Medical School; Director of Child and Adolescent Psychiatry Residency Training,Massachusetts General Hospital, Boston, MA, and McLean Hospital, Belmont, MA.

Abbreviations

BMI: body mass indexCBT: cognitive behavioral therapyDEXA: dual energy radiograph absorptiometryDSM-IV-TR: Diagnostic and Statistical Manual of

Mental Disorders, Fourth Edition,Text Revision

EDNOS: eating disorder not otherwise specifiedIOP: intensive outpatient treatmentOCD: obsessive compulsive disorder

Article GI and nutrition

508 Pediatrics in Review Vol.32 No.12 December 2011



Eating disorder not otherwise specified (EDNOS)includes clinically significant eating disorders that do notmeet the DSM-IV TR criterion for anorexia or bulimia.For example, EDNOS includes patients with symptomsof anorexia who do not meet the 85% of expected weightcriterion, or the amenorrhea criterion, as well as patientswho experience bingeing and compensatory behaviorsthat occur less than twice a week on average. The patientdescribed in the above vignette, who lacked the psycho-logical symptoms of eating disorders, would be classifiedas having EDNOS. Of note, patients who have bingeeating disorder, which is marked by recurrent bingeingwithout compensatory behaviors, currently are classifiedunder EDNOS. Because most patients who have bingeeating disorder are adults, this disorder will not be dis-cussed in this article.

Anorexia and bulimia are fairly rare conditions. Theprevalence of anorexia is 0.9% in women and 0.3% inmen; the prevalence of bulimia is 1.5% in women and0.5% in men. (2) The prevalence of EDNOS is 3.5% inwomen and 2% in men. (2) The onset of eating disordersusually occurs in mid adolescence for anorexia and lateadolescence for bulimia. However, a majority of patientsreport body image concerns and disordered eating be-fore adolescence.

The causes of anorexia and bulimia are complex andinclude biologic, psychological, and environmental com-ponents. The biologic underpinnings of eating disordersare not well understood. In studies of twins (usuallycomparing disordered eating), there is reasonable evi-dence that eating disorders have moderate to substantialheritability and that the inheritance pattern is multifac-torial. Eating disorders occur more frequently in patientswho have a family history of eating disorders, obesity,and mood disorders.

Girls who experience early puberty or are obese (whooften were teased) are at increased risk for developingeating disorders. In fact, eating disorders often arise inthe context of starting a diet to lose weight. Frequentcomorbid psychiatric disorders are present, as well aspersonality traits such as perfectionism, concerns overself-control, sensitivity to rejection, and low self-esteem.

A past history of abuse, often sexual, is frequentamong patients with eating disorders. It is unclear howmuch of the onset of an eating disorder during adoles-cence is due to environmental influences (eg, stress fromdevelopmental tasks of adolescence or pressure by ex-plicit or implicit demands of the family for performanceor appearance) or biologic factors (eg, increased hor-mones such as estrogen).

Social factors, such as the increase in obesity juxta-

posed with the stigmatization of obesity and media im-ages of ever-thinner women, clearly are important. Fi-nally, some sports, such as cheerleading, figure skating,gymnastics, wrestling, crew, dance, and long distancerunning, may promote weight loss or thinness, therebyencouraging an eating disorder to develop. Althougheating disorders more often are diagnosed in girls, boysare presenting with these problems increasingly.

Pediatricians can facilitate better outcomes for theirpatients who have eating disorders by early diagnosis andthe institution of appropriate referrals and treatments.Screening for eating disorders should be part of theannual examination of adolescents. To facilitate earlydiagnosis, pediatricians should educate parents and oth-ers who interact with adolescents to recognize symptomsof eating disorders in youth.

Suspicious BehaviorAdolescents who have an eating disorder may developchanges in behavior. Behaviors include the assumption ofa vegetarian, vegan, low fat, or “healthier” diet, scrutinyof ingredient lists, initiation of precise calorie counting,or weighing one’s self several times daily. Mealtime maydemonstrate an emerging pattern of taking smaller por-tions or taking a longer period of time to eat. Some teenslose weight by increasing the duration and intensity ofexercise in an attempt to utilize more energy.

As the eating disorder becomes more severe, an af-fected teen may have difficulty eating in social settingsand will avoid eating with family and friends or developdeceptive or secretive behaviors, such as hiding foodduring social meals. Signs of purging activity includefrequent trips to the bathroom after meals and discoveryof empty containers of diet pills or laxatives. An adoles-cent who has an eating disorder may dress with extralayers of clothing to cover up signs of emaciation and toretain body heat.

Psychological SymptomsThe psychological symptoms of eating disorders areprominent, especially in patients who have anorexia.Perhaps most striking are the quasi-psychotic body im-age distortions that frequently accompany anorexia.A majority of patients perceive their bodies as large andunattractive, despite their emaciated state. This imagedistortion often makes maintaining a healthy weightvery uncomfortable and sometimes intolerable for theaffected patient. Fears of weight gain, wishes to loseweight, feelings of being “fat,” and discomfort withweight or figure, or both, arise from a negative bodyimage. These psychological symptoms fuel food restric-

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tion, food avoidance, and other behaviors that causeweight loss. The illness is worsened by the oft-presentbehavior of “denial about the seriousness of the illness”that makes patients resistant to treatment.

Anorexia is an ego-syntonic illness; that is, patientsoften do not want to give up what they see as acceptablebehavior. Patients who have bulimia also have bodyimage concerns but often to a lesser degree. However,“self-image unduly influenced by weight and shape” is acore symptom of bulimia and is the reason for the com-pensatory behaviors, such as vomiting and the usualrestricting behaviors to prevent weight gain. Bulimia isan ego-dystonic illness; patients do not want their illnessand often experience considerable shame.

Suggestive Physical FindingsCertain physical findings, some of which are medicalcomplications, suggest that an adolescent may have aneating disorder (Table 1). In anorexia, nutritional insuf-ficiency eventually will affect most body systems on bothphysical and functional levels. For example, decreasedserum estrogen in females can cause delay of puberty,atrophy of the external genitalia, and bone demineraliza-tion. In males, decreasing testosterone concentrationsmay cause reduced beard growth. Increased vagal tone inmales and females can produce bradycardia and ortho-stasis. Significant weight loss also can cause loss of muscle

mass, resulting in diminished muscle strength and de-creased cardiac muscle mass.

The key physical parameters in anorexia are the ado-lescent’s height, weight, and BMI, which should betracked on a growth chart. Falling off from the usualpercentiles is the earliest signal of a significant problem.Because the physical findings in bulimia are more subtle(if present at all), historical information and laboratorytesting are particularly important to confirm the diagno-sis. The physical findings of an eating disorder usuallydiminish when the patient has appropriate weight gain.

Questions to AskIf an adolescent falls off the weight curve, slows downin statural growth, demonstrates a delay in onset ofpuberty or progression of pubertal development, hasprimary or secondary amenorrhea, or displays suspiciousbehaviors or certain physical findings, further question-ing is indicated. Questioning should address weight his-tory, body image concerns, exercise history, menstrualhistory, diet history, and a system review focused oneating disorders (Table 2). Another useful tool for eval-uating the symptoms of an eating disorder, includingbehaviors and psychological symptoms, is the Eating Dis-orders Examination–Questionnaire, which can be found atthe following website under assessment measures: http://

Table 1. Physical Findings in Adolescents Who Have an Eating DisorderSystem Anorexia Bulimia

Dermatologic Cheilosis, acrocyanosis, hypercarotenimia,alopecia, xerosis, acne, lanugo, pallor

Periorbital petechiae, Russell sign (callusesover the PIP joints in the hands)

Orofacial Halitosis Injury to the palate and posterior pharynx,dental caries, enamel erosion, parotidgland enlargement, submandibularadenopathy

Gastrointestinal Palpable stool secondary to constipation, rectalprolapse, scaphoid abdomen

Abdominal fullness, gastric dilatation

Cardiac Bradycardia, orthostatic hypotension,arrhythmia, mitral valve prolapse/murmur

Arrhythmia, orthostasis

Breasts and genitourinary Breast atrophy, atrophic vaginitis and atrophy ofthe female external genitalia

Pulmonary Pneumothorax or aspiration secondary tovomiting, pulmonary edema during refeeding

Pneumothorax, pneumonmediastinum,aspiration

Bone Fractures due to bone mineralization lossEndocrine and metabolic Delayed puberty, arrested growth, hypothermia,

weakness, reduced beard growth in malesNeurologic and mental

statusNeurocognitive deficit, diminished muscle

strength, peripheral neuropathy, movementdisorder

PIP�proximal interphalangeal.





www.psychiatry.ox.ac.uk/research/researchunits/credo/assessment-measures-pdf-files/EDE-Q6.pdf.

Comorbid Mental IllnessComorbid mental disorders are present in the majority ofpatients who have anorexia and bulimia. The most com-mon comorbid disorders in anorexia include major de-pression, anxiety disorders such as obsessive compulsivedisorder (OCD), generalized anxiety disorder, and socialphobia. Patients who have bulimia often have comorbidmood disorders (both major depression and bipolar dis-order), anxiety disorders, and substance use disorders.Bulimic patients tend to be more volatile and impulsiveand may exhibit high-risk behaviors, such as tobaccosmoking, excessive use of drugs or alcohol, sexual pro-miscuity, or stealing.

It is important to differentiate symptoms due to acomorbid mental illness from symptoms due to the eat-ing disorder itself. For example, patients who have an-orexia often have low or irritable moods, impaired sleep,loss of energy, impaired concentration, and withdrawal.These symptoms may be due to malnutrition or may bedue to a major depressive disorder. It is useful to deter-mine whether these symptoms of depression were pres-ent before the eating disorder or arose after the eatingdisorder began. OCD symptoms related to food andeating should not be confused with symptoms of a coex-isting OCD condition.

Assess Psychosocial ImpactEating disorders disrupt the developmental trajectory ofchildren and teens, which then places them under in-

creased stress. In the case of anorexia, the time taken upby the eating disorder can make it difficult for the patientto partake in extracurricular and social activities. Typi-cally, patients who have anorexia are compliant, dutiful,and hard-working, particularly in academics and sports.They rarely break rules or cause upsets with family orfriends. However, the progression of anorexia may resultin isolation from friends and families. Those aroundthem do not know how to react to the weight loss.

Patients who have bulimia often hide their illnessmore and continue to function more normally on thesurface, while suffering with their eating disorder. Dis-rupted schooling due to time spent attending treat-ment appointments or undergoing hospitalizations maystress a teen further. Academic performance and func-tioning at school may or may not be disrupted.

All children and teens should be considered in thecontext of stress in the family: the family’s messagesabout eating, food, and weight; the family’s pressure forperfectionist performance in a variety of areas; familyhistory of mental illness or eating disorders; and how theeating disorder is affecting the family. Families oftenreport increased stress and more difficult relationshipsbecause of the eating disorder.

Triage for Medical Stability and SafetySome patients, particularly patients who have anorexiaand are at low weight or purging and patients who havebulimia who are purging significantly, need immediatemedical attention. Suicidality is more common in pa-tients who have anorexia than in the general population;

Table 2. Questions for Adolescents With a Possible Eating DisorderWeight History What is your present weight, highest weight, lowest weight, and when did these occur?Body Image Are you satisfied, dissatisfied, distressed with your current weight; body shape?

Have you every thought that you were too fat or in danger of getting too fat?At what weight would you like to be?How often do you weigh yourself?What percent of the day are your thoughts occupied with food, eating, body size, or shape?

Exercise History Do you exercise? If so, how frequently do you exercise?What exercises do you do?How long are your workouts?

Menstrual History When was your very first menstrual period?When was your last menstrual period?How many menstrual periods have you had in the past 6 months?

Diet and Eating History: Do you restrict your calories?Do you restrict or avoid certain foods?Do you have problems controlling your food intake?Do you engage in any of these behaviors: vomiting, spitting, ruminating, use of laxatives,

diuretics, use of diet pills or syrup of ipecac?Symptom Review: Have you experienced: sensitivity to cold, thinning hair, swollen glands in cheek,

lightheadedness, irregular heart beat, weight loss, loss of periods, vomiting, or constipation?




suicide and cardiac complications are the leading causesof death. All patients should be assessed for medicalstability (including laboratory evaluation) and for safety.Patients with suicidality may require inpatient psychiatrichospitalization; patients with medical instability mayneed a medical admission.

Anorexia NervosaCase History

A 12-year-old boy who had a previous weight of 93 lb(60%) and a BMI of 19.6 (75%) is admitted to thepediatric gastroenterology service with a history of a20-lb weight loss over 5 months, early satiety, and de-creased appetite. Physical examination reveals a thin ad-olescent with a weight of 72.6 lb (14%), height of 57.8 in(34%), and a BMI of 15.6 (11%). His calculated idealweight was 84.9 lb (see formula below), and he is at87.9% of ideal weight. Screening laboratory tests, ab-dominal ultrasonography, and upper and lower endosco-pies are unremarkable. The patient displays anxietyaround meals, voices increasing concerns about caloriccounts and weight gain, and has initiated restriction ofhis caloric intake with deceptive behaviors. He continuesto lose weight in the hospital. A diagnosis of anorexiais established, and the patient is placed on an eatingdisorder treatment protocol. Over 3 weeks, he gainsweight and is transferred to residential care for treatmentof anorexia.

DefinitionIn the restrictive type of anorexia, the patient does notengage in binge eating or purging behaviors such asself-induced vomiting or using laxatives, diuretics, orenemas. In the binge-eating/purging type, the patientregularly engages in binge eating or purging behaviors.Most adolescents fall into the restrictive type. Table 3lists the current DSM-IV TR and proposed DSM-V diag-nostic criteria for anorexia.

Ideal Body Weight CalculationFor adolescents, the ideal body weight (in kilograms) iscalculated by the formula: Square of the height in metersmultiplied by the 50th percentile BMI for age and sex.

BMI information is available at:

Girls: http://www.cdc.gov/growthcharts/data/set1clinical/cj41l024.pdf

Boys: http://www.cdc.gov/growthcharts/data/set1clinical/cj41l023.pdf

For example, the ideal weight of a 14-year-old girlwho is 64 in (1.626 m) in height is calculated as follows:

(1.626 m)2 � 19.4 kg/m2 �1.626 � 1.626 � 19.4 � 51.3 kg (112.9 lb)

Conditions That May Cause Weight LossAdolescents who have anorexia may not disclose a com-plete or truthful history. Therefore, it is important for the

Table 3. Diagnostic Criteria for Anorexia NervosaCriterion DSM-IV-TR 2000 Proposed for DSM-V 2013

Body weight Refusal to maintain a body weight more than85% of weight expected for height and age;failure to gain weight during a period ofgrowth with body weight less than 85%expected for height and age.

Restriction of energy intake relative torequirements leading to a markedly low bodyweight (less than that minimally expected forage and height).

Menstruation In postmenarchal females, the absence of threeconsecutive menstrual cycles (hormonallyinduced menstruation is excluded).

This criterion is likely to be deleted.

Fear of weightgain

Although underweight, an intense fear ofgaining weight or becoming fat.

Intense fear of gaining weight or becoming fat,although underweight, or persistent behaviorto avoid weight gain, although at a markedlylow weight.

Body image A disturbance in the way one’s body weight orshape is experienced; denial of the seriousnessof low body weight; an undue influence ofbody weight or shape on self-evaluation.

No change from DSM-IV-TR.

DSM-IV-TR�Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision; DSM-V�Diagnostic and Statistical Manual of MentalDisorders, Fifth Edition.





pediatrician to consider and rule out other medical andmental health conditions that could lead to weight loss oramenorrhea. Such conditions are listed in Table 4. Theinitial laboratory evaluation should include a completeblood count with sedimentation rate; general chemis-tries; amylase, lipase, magnesium, phosphorus, calcium,and thyroid stimulating hormone concentrations; urinal-ysis; and serum human chorionic gonadotropin (HCG)concentration for females. If there are concerns aboutceliac disease, an immune globulin A and serum tissuetransglutaminase determination are helpful; a baselineelectrocardiogram is useful, especially if bradycardia, hy-potension, arrhythmia, or other cardiac problems arepresent. Besides the human chorionic gonadotropin test,measuring follicle-stimulating hormone, luteinizing hor-mone, prolactin, and estradiol concentrations may helpelucidate the cause of amenorrhea.

Anorexia: ComplicationsMedical complications of anorexia are listed in Table 5(see Table 1 also). The likelihood of these complicationsincreases as the anorexic patient further loses weight fromhis or her ideal weight. Generally, medical complicationsbegin to resolve once appropriate weight gain occurs, andachieving an adolescent’s ideal weight typically corrects

most complications. However, boneloss due to hypothalamic amenor-rhea in female patients or secondaryto low testosterone in male patientsdoes not automatically correct withweight gain, although some im-provement does occur. Fluctuationsin the patient’s weight, recurrent pe-riods of amenorrhea, elevated corti-sol concentrations, and lower thanoptimal insulin growth factor-1 con-centrations during recovery may leadto incomplete catch-up.

Although weight gain with resumption of normalmenstruation is the most effective means of increasingbone density in adolescent females who have anorexia, arecent research study has determined that physiologicestrogen replacement is effective in increasing bone massand may be a therapeutic option in girls with anorexianervosa and low bone density who are refractory tomultidisciplinary therapy and are unable to gain weight.(3) Oral estrogen has not been shown to help prevent ortreat bone demineralization in females; indeed, with-drawal bleeding from oral contraceptive use may falselyreassure the patient who is not gaining weight that bonedensity is recovering.

Anorexia: When to HospitalizeThe care for an adolescent with anorexia depends on thepediatrician’s initial review of the history, physical find-ings, and laboratory data. Guidelines for the hospitaliza-tion of adolescents and young adults who have anorexiaare listed in Table 6. Adolescents who are medicallyunstable and require admission often are 75% or less oftheir ideal weight and have other signs of medical insta-bility; in addition, the failure of outpatient treatment isan indication in itself for medical admission.

Table 4. Conditions That May Cause Weight LossWith or Without AmenorrheaGastrointestinal: Inflammatory bowel disease, celiac disease, achalasiaEndocrine: Hyperthyroidism, Addison disease, hypopituitarism, type 1

diabetes mellitusMalignancy: Lymphoma, central nervous system tumor, occult malignanciesInfectious: Human immunodeficiency virus, tuberculosisMental Health: Depression, substance abuse, use of medications such as

diet pillsOther: Pregnancy

Table 5. Medical Complications of Anorexia NervosaSystem Complication

Gastrointestinal Gastric dilatation and rupture, delayed gastric emptying, decreased intestinal motility, elevated liveraminotransferase concentrations, elevated serum amylase concentrations, superior mesentericartery syndrome

Cardiovascular Decreased left ventricular forces, prolonged QT interval corrected for heart rate, increased vagaltone, pericardial effusion, congestive heart failure

Hematologic Anemia, leukopenia, thrombocytopeniaEndocrine and

metabolicLow bone density, euthyroid sick syndrome, amenorrhea, refeeding syndrome, electrolyte

disturbances, decreased serum testosterone or estradiol, hypercholesterolemia, hypercortisolismRenal Increased blood urea nitrogen, calculiNeurologic Pseudo cortical atrophy, enlarged ventricles




Anorexia: Inpatient Medical ManagementIn many settings, an adolescent medicine specialist, ahospitalist, or a psychiatrist will manage the inpatientmedical rehabilitation of an adolescent afflicted withanorexia. However, in some circumstances the pediatri-cian will serve as the treating physician. The goals of amedical admission are several: initiate correction of theadolescent’s malnourished state, promote healthy eatingand weight gain, correct metabolic disturbances, preventthe refeeding syndrome, rule out psychiatric comorbidi-ties, and develop a plan of care after hospital discharge.

A multidisciplinary team consisting of a medicalspecialist, psychiatrist, nutritionist, and social workerachieves such care best. Using a written eating disorderprotocol helps prevent misunderstandings among all

parties; cooperation and weight gain allow the patient togain privileges and serve as incentives. See the referencesfor an example of an eating disorder protocol (5) aswell as the American Psychiatric Association guidelinesfor care. (6) A copy of the eating disorder protocol atMassGeneral Hospital for Children is available in theonline edition of this issue of Pediatrics in Review. http://pedsinreview.aappublications.org/.

At our institution, initially we place the adolescent onbed rest with a bedside commode. An intravenous line isestablished to provide quick intravenous access should anemergent situation develop. Administering intravenousfluids may account for initial weight gain on admission; itis important to establish a baseline weight the morningafter supplemental intravenous fluids are discontinued.In the acute hospital setting, the patient is expected togain approximately 1⁄2 lb daily.

Our procedure is to calculate the goal number ofcalories for weight gain; the starting daily calorie in-take is determined by estimating the patient’s 24-hourcaloric intake in the day before admission and adding250 calories. Typically, the initial 24-hour meal plan isno higher than 1,250 calories, and the caloric intake isincreased by 250 calories daily until goal calories arereached and appropriate daily weight gain occurs.Naso-gastric feedings may be used if the teenagerrefuses to take in appropriate calories or becomes medi-cally unstable. Nutritional rehabilitation of adolescentswho have anorexia very rarely requires parenteral nutri-tion.

The Refeeding SyndromeThe refeeding syndrome describes the metabolic distur-bances that occur as a result of reinstitution of nutritionto patients who are starved or severely malnourished.Reintroducing food to a patient with anorexia may causea rapid fall in phosphate, magnesium, and potassium,along with an increasing extracellular volume, that canlead to a variety of complications. As the adolescent’scaloric intake increases, low levels of serum phosphoruscan lead to rhabdomyolysis, decreased cardiac motility,cardiomyopathy, respiratory and cardiac failure, edema,hemolysis, acute tubular necrosis, seizures, and delirium.Serum phosphorus, magnesium, and electrolyte concen-trations should be measured daily during the first week inthe hospital. Some clinicians begin oral supplementationwith phosphorus on the first hospital day, while somewait until the serum phosphorus concentration begins todecline.

Table 6. Criteria forHospitalization of Adolescentsand Young Adults Who HaveEating Disorders (4)

Anorexia

Weight <75% of ideal body weight for age, gender,and stature

Continued weight loss despite intensive outpatienttherapy

Acute weight decline and refusal of foodHypothermia (body temperature <96°F)Systolic blood pressure <90 mm HgResting heart rate <50 beats/min during the day and

<40 beats/min during the nightOrthostatic changes in blood pressure (>10 mm Hg)Orthostatic changes in pulse (>20 beats/min)Electrolyte abnormalitiesArrhythmiaSuicidality (ideation, plan, or attempt)

Bulimia

SyncopeElectrolyte disturbances: serum potassium <3.2 mEq/L

or serum chloride <88 mEq/LEsophageal tearsCardiac arrhythmias including prolonged QTcHypothermiaSuicide riskIntractable vomitingHematemesisFailure to respond to outpatient treatment

AAP�American Academy of Pediatrics.Adapted from AAP, Committee on Adolescence. Identifying and treat-ing eating disorders. Pediatrics. 2003;111:204–211.




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Anorexia: Discharge PlanningGenerally, when an adolescent achieves a steady weightgain of about 1⁄2 lb daily, stabilizes vital signs, and hasnormal serum chemistries and a plan of care in place,discharge to the next level of care is appropriate. Inpa-tient medical admissions often range in duration from7 to 10 days.

Most adolescents do not go directly home after hos-pitalization for anorexia. Although stabilization of vitalsigns, initiation of weight gain, and initiation of healthyeating are goals for the hospitalization, the work arounddisordered thinking and eating and body image requiresa therapeutic milieu that is more appropriate for treatingthese problems such as a residential program devoted tothe treatment of eating disorders. The pediatrician canguide the family in finding the most appropriate pro-grams that are covered by the family’s health insurance.

Anorexia: Levels of CarePatients who have anorexia may be treated as an outpa-tient or may require residential or partial hospitaliza-tion. If a patient is treated as an outpatient, it is helpful tohave a back-up plan for a hospitalization if the patient isunable to make reasonable weight gains. Ideally, outpa-tient treatment should consist of a treatment team of atleast a mental health therapist (psychiatrist, psychologist,or social worker), nutritionist, and pediatrician who workin close collaboration. Often, a psychopharmacologistand family therapist are needed to complete the treat-ment team.

Levels of care for anorexia other than inpatient med-ical hospitalization include placement in inpatient psy-chiatric hospitals, acute residential hospitals, partial orday hospitals, intensive outpatient treatment (IOP), out-patient treatment, long-term residential centers, andtherapeutic boarding schools. Acute residential pro-grams provide treatment for weeks to months in anunlocked hospital setting. Partial or day hospitalizationprovides several hours a day of structured time at ahospital, including some meals, with the patients leav-ing the program at night. IOP consists of group therapy,and possibly a meal for a few hours a day, several days aweek. Long-term residential treatment centers or thera-peutic boarding schools can provide long-term (ie,months to years) treatment for difficult or intractablecases.

Anorexia: Pediatrician Role in OutpatientManagement

The pediatrician may serve as coordinator of the patient’scare or as referring doctor to an adolescent medicine

specialist or psychiatrist, depending on his or her comfortlevel with adolescents who have eating disorders. Somepediatricians prefer to coordinate care with another spe-cialist and see the patient periodically for weight checks.

Initially, it is helpful to place patients who have an-orexia into mild, moderate, or severe categories. Anadolescent who is 85% to 95% of ideal body weight ismildly ill, 75% to 85% of ideal body weight is moderatelyill, and �75% of ideal body weight is severely ill. Severelyill adolescents who have anorexia usually require a higherlevel of care. In general, as the teen’s percent of idealweight decreases, more medical issues arise and moreintervention is necessary. However, each teen afflictedwith anorexia has a unique set of medical, mental, family,and social issues.

As noted, a key element in the outpatient manage-ment of teens who have anorexia is the establishment ofa treatment team. Each member of the team should becomfortable working with adolescents who have an eat-ing disorder and each should have a clearly defined role.If there is a question of comorbidity, a psychiatric con-sultation is warranted. It is critical that team membersfrequently communicate with each other (often by email)for updates and to prevent miscommunication and teamsplitting. In this setting, the pediatrician can monitor theteen’s medical stability, weight, and laboratory data andcounsel the teen and his or her family. The pediatriciancan answer questions regarding medications, exercise,laboratory testing, menstruation, and diet. Pediatricianvisits frequently are on a weekly basis until steady prog-ress occurs.

Patients who have anorexia should have a daily mul-tivitamin supplementation with at least 400 to 800 IUof vitamin D; 1,200 mg elemental calcium is recom-mended daily also. Because low bone density is seenoften in anorexia, a dual energy radiograph absorptiom-etry (DEXA) scan is recommended for those adolescentswho have sustained 6 months of amenorrhea. The DEXAusually is repeated on an annual basis if amenorrheacontinues.

Teens who have mild anorexia should have a nutri-tional plan that will ensure weight gain of 1⁄2 to 1 lbweekly. Exercise usually is restricted, especially if weightgain does not occur or if the adolescent weighs less than90% of his or her ideal weight. The pediatrician shouldevaluate the teen every few weeks, and the teen shouldhave ongoing visits with the therapist and nutritionist.Clear guidelines, based on medical parameters (such asweight, blood pressure, and pulse), should be given tothe patient and his or her family as to when a higher levelof care is warranted.




Weekly medical evaluations generally are indicated ifthe teen is moderately ill with anorexia (75% to 85% idealweight). No exercise should be allowed. Clear guidelinesshould be set for a higher level of care and clearly com-municated to the adolescent, his or her family, and otherteam members. Typically, some patients may need IOP,partial hospitalization, or even residential care if outpa-tient care is not helpful.

Adolescents who weigh 75% or less than their idealweight generally are hospitalized at a residential treat-ment center. If medically unstable, they usually are sta-bilized in an inpatient medical setting and then trans-ferred to a residential treatment center.

It is important to have parents as allies in the treatmenteffort. At times, parents may not be helpful due to subtle,complex child–parent relationships that are counterproduc-tive. In this situation, family therapy may be helpful.

Anorexia: PsychopharmacologyA review of randomized controlled trials for the treat-ment of anorexia and bulimia was published in 2007 bythe Evidence-based Practice Center of the Universityof North Carolina at Chapel Hill. It was concluded thatthe evidence for medication treatment for anorexia was“sparse and inconclusive.” (7) In general, medicationsare used in patients who have anorexia to treat theircomorbid psychiatric conditions or psychiatric symp-toms. In addition, care must be taken to avoid, or usecautiously, medications that cause weight loss or weightgain, appetite suppression, hypotension, or prolongedQTc interval. There are no medications indicated forweight maintenance; a randomized, controlled trial com-paring time to relapse in patients on fluoxetine versusplacebo showed no difference. (8)

Anorexia: TherapiesThe types of therapies commonly used to treat patientswho have eating disorders include cognitive behavioraltherapy (CBT), dialectic behavioral therapy, psychody-namic therapy, and different modalities of family therapy.Nutritional therapy includes helping patients eat a varietyof foods (ie, stop food avoidance), improve eating habits,stop compensatory behaviors, and gain weight. The ex-pected weight gain for outpatients is 1⁄2 to 1 lb a week;for inpatient or residential patients, expected weight gainis up to 4 lb a week.

Good evidence exists for family-based therapy in thetreatment of anorexia in children and adolescents, butnot adults, (7) especially in children and adolescents whohave early onset and short duration of illness. Family-based therapy as developed at the Maudsley Hospital

in London is an outpatient treatment designed to avoidhospitalization. In the first stage of the treatment, thefamily takes control over food and eating and helps thechild or teen begin to restore his or her weight andnormal eating habits. In stage two, control is transferredback to the patient as recovery begins. Phase three is atermination phase that focuses on developmental issuesand relapse prevention. (9)

BulimiaCase History

An 18-year-old college freshman is seen for recurrentvomiting on recommendation by the college Dean’soffice after her roommates report witnessing her behav-ior of frequent vomiting. She has a history of restrictiveanorexia that evolved into bulimia. Physical examina-tion is remarkable for 105% of ideal weight and rightparotid gland enlargement. Laboratory examination re-veals mild hypokalemia. Despite enrolling in an IOPeating disorder program, she continues to induce vom-iting twice daily. A college administrator observed hereating eight desserts at one meal and going to the bath-room after each dessert was consumed. The collegeadministration mandates that she leave college and enterresidential care for the eating disorder. After 1 year ofresidential and outpatient care, she is symptom-free. Onreturn to college, she immediately begins to inducevomiting twice a day.

DefinitionThe current criteria for diagnosing bulimia and the DSMproposed changes in those criteria are listed in Table 7.Bulimia is divided into two subtypes, purging and non-purging. Binge eating is seen in both subtypes. Thepurging subtype describes an individual who engagesregularly in self-induced vomiting or the misuse oflaxatives, diuretics, or enemas. The nonpurging subtypedescribes an individual who uses other inappropriatecompensatory behaviors, such as excessive exercise orfasting to burn calories. It is important to note thatpatients who have bulimia often are not low weight andthus may easily hide their eating disorder.

Bulimia: Medical ComplicationsAs noted in Table 1, several physical findings signal amedical complication from bulimia, such as periorbitalpetechiae, Russell sign (calluses over the proximal interpha-langeal joints in the hands), injury to the palate and poste-rior pharynx, dental caries, enamel erosion, parotid glandenlargement, submandibular adenopathy, arrhythmia, or-thostasis, pneumothorax, pneumonmediastinum, and aspi-





ration. Table 8 lists specific gastrointestinal, cardiac, meta-bolic, endocrine, and dental complications. Electrolytedisturbances, depending on the method of purging, arecommon in bulimia secondary to induced vomiting or theuse of laxatives and diuretics. Syrup of ipecac can causecardiomyopathy; ipecac is still available for purchasethrough the Internet. Dentists may notice perimylolysis(loss of dental enamel), a sign indicative of purging activi-ties.

Indications for Inpatient Hospitalization forAdolescents Who Have Bulimia

Adolescents with bulimia may face life-threateningevents. Of most concern are electrolyte disturbances(particularly hypokalemia) and cardiac issues, such assyncope or a prolonged QTc interval. Table 6 listsguidelines for the hospitalization of adolescents who

have bulimia. Self-destructive actions such as cutting orsuicidal ideation generally warrant inpatient admission.

Bulimia: Pediatrician Role in OutpatientManagement

For patients who have bulimia, the pediatrician can co-ordinate the services of an interdisciplinary team thatincludes a nutritionist and therapist. Adolescents whohave bulimia should be seen periodically to assess medicalstability; teens who are purging may need to be seenweekly to monitor electrolyte levels. Hypokalemia iscorrected either by oral potassium supplementation orintravenous supplementation, depending on the severityof the hypokalemia. Indications for calcium and vitaminD supplementation are the same as those for patientswho have anorexia. Administration of a proton-pumpinhibitor may help teens who have reflux disease causedby recurrent vomiting. Promoting hydration, a high fiberdiet, and moderate exercise (unless contraindicated be-cause of medical instability) may help improve the healthof patients who are dependent on laxatives. Tooth brush-ing with sodium bicarbonate toothpaste after vomitingmay improve dental hygiene. Teens who have bulimiawho have been amenorrheic for 6 months or moreshould have a DEXA scan.

Bulimia: Levels of CarePatients who have bulimia generally respond to outpa-tient treatment, although patients experiencing escalat-ing or severe symptoms that do not respond often war-rant acute residential or partial hospitalization, or IOP.

Table 7. Diagnostic Criteria for Bulimia NervosaCriterion DSM-IV-TR 2000 Proposed for DSM-V 2013

Binge eating Eating an amount of food in a discrete periodof time (2 h) that is definitely larger thanmost people would eat

No changes

Compensatorybehavior

Recurrent inappropriate compensatory behaviorin order to prevent weight gain such as self-induced vomiting, misuse of laxative,diuretics, enemas, or other medications;fasting; or excessive exercise

No changes

Frequency of abovebehaviors

Binge eating and inappropriate compensatorybehaviors occur, on average, twice weekly forthe previous 3 mo

Binge eating and inappropriatecompensatory behaviors both occur, onaverage, at least once a week for 3 mo

Self-evaluation Unduly influenced by body shape and weight No changesRelation to anorexia

nervosaThe disturbance does not occur exclusively

during episodes of anorexia nervosaNo changes

DSM-IV-TR�Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision; DSM-V�Diagnostic and Statistical Manual of MentalDisorders, Fifth Edition.

Table 8. Medical Complications ofBulimia Nervosa

System Complication

Gastrointestinal Gastroesophageal reflux, Mallory-Weiss tear, gastritis

Cardiac Cardiomyopathy secondary to ipecacpoisoning, arrhythmia

Metabolic 12 sodium, 2 potassium,12 chloride, 12 bicarbonate,12 pH

Endocrine Irregular menstruationDental Caries, enamel loss




Acute residential care is particularly indicated when pa-tients with bulimia are unable to control their behaviorsat night.

Bulimia: PsychopharmacologyReasonable evidence indicates that fluoxetine helps re-duce the core symptoms of bingeing and purging. A dailydose of 60 mg appears to be more efficacious than a doseof 20 mg. (10) Of note, these trials were time-limited,and the medication treatments resulted in symptom re-duction not remission (ie, absence of symptoms). Iffluoxetine is not tolerated, other selective serotonin re-uptake inhibitors at maximal approved doses may be usedfor symptom reduction.

Bulimia: PsychotherapyStrong evidence indicates that CBT helps treat bulimia.CBT aims to change both patient cognition and behav-ior. In the CBT program by Fairburn, the core pathologyof the eating disorder is “over-evaluation of shape andweight and its control.” (11) In this time-limited treat-ment, the patient’s eating disorder is assessed and thepatient learns about eating disorders. After forming apersonalized plan for treating the eating disorder, thepatient starts “real time monitoring” of food intakeand behaviors. The patient tries to establish “regulareating,” eating meals and snacks in a normal way atnormal times, without using behaviors to compensate forfood intake. After establishing a pattern of regular eating,the patient learns “maintaining mechanisms” to addressdietary restricting or restraint, over-evaluation of weightand shape, control over eating, and monitoring events ormood changes in eating behaviors.

Eating Disorder Not Otherwise Specified andDisordered EatingPatients given a diagnosis of EDNOS whose symptomsresemble anorexia should receive the same care and treat-ment as patients who have anorexia. Similarly, patientshaving EDNOS whose symptoms resemble bulimiashould receive the same care and treatment as patientswho have bulimia. Care must be taken not to viewEDNOS as a less serious illness than anorexia. In addi-tion, a patient’s eating disorder often is dynamic andchanges with illness progression and treatment.

Disordered eating refers to eating disorder behaviorssuch as occasional restricting, fasting, overeating, avoid-ance of risk foods, use of purgatives, and heavy exercise tolose weight. If the symptoms are transient and not ac-companied by the psychological symptoms of eatingdisorders, these behaviors may represent a variant of

normal. On the other hand, these behaviors may be aharbinger of the development of an eating disorder.Patients who exhibit disordered eating should be moni-tored closely and evaluated for psychological symptomsassociated with eating disorders.

Female Athlete TriadThe term “female athlete triad” describes the constella-tion of low energy availability with or without an eatingdisorder, hypothalamic amenorrhea, and osteoporosis ina female athlete. Energy availability refers to dietaryenergy intake minus exercise energy expenditure. Energyavailability is the amount of dietary energy remaining forother bodily functions. Some athletes develop abnormaleating patterns, such as dietary restriction, fasting, bingeeating, and purging or may use diet pills, laxatives, di-uretics, or enemas to maintain or lose weight, therebycreating low energy availability.

Most of these affected athletes develop low body fatcomposition, which contributes to a hypoestrogenicstate and amenorrhea. Athletes who participate in sportsin which leanness is emphasized, such as gymnastics,ballet, diving, figure skating, aerobics, and running, areat risk for developing the female athlete triad. Unfortu-nately, low body weight and continued strenuous train-ing often is encouraged in certain sports, thereby makingit difficult for the patient to decrease her training toincrease energy availability and restart menstrual cycles.

As in patients who have anorexia, hypogonadotropichypogonadism along with estrogen deficiency contributeto reduction in bone mineralization density. As noted,there are no data to support the use of oral contraceptivesin the prevention of bone loss. At times, the femaleathlete may have a normal weight but still present withlow body fat and amenorrhea, placing her at risk for bonedemineralization.

The pediatrician should consider the possibility of apatient having the female athlete triad during a prepar-ticipation physical examination or if an athlete presentswith low weight, amenorrhea, stress fracture, or disor-dered eating. Treatment should be multidisciplinary,especially if an eating disorder is present, and may requirelimiting or eliminating participation in athletics. It isimportant for the pediatrician to work with the athlete’scoach to most effectively treat the patient. A writtencontract that includes the athlete, pediatrician, and coachmay be necessary to enforce treatment strategies.

The athlete’s energy availability must be increased andeating habits improved. Daily calcium (1,200 mg) andvitamin D (400 to 800 IU) supplementation along withweight bearing exercises are recommended to help pre-





serve bone health. A DEXA scan is indicated if there is astress fracture or a cumulative total of 6 months or moreof amenorrhea. The best protection for the female ath-lete’s bone health is to remain eumenorrheic and main-tain a healthy balance between exercise, energy availabil-ity, and body weight.

Pro-Mia and Pro-Ana SitesSome patients who have eating disorders visit Internetsites such as Pro-Mia or Pro-Ana that promote andencourage eating disorders as a chosen lifestyle. Parentsshould be educated about the presence of these sites,and, if possible, block access to these sites on homecomputers. Ultimately preventing a patient from search-ing such Internet sites depends on the patient’s motiva-tion, or lack thereof, to recover from his or her eatingdisorder.

PreventionPediatricians play an integral role in the early detectionand prevention of eating disorders. Prevention includesassessing for mental illness as well as stress that maypredispose a child or teen to an eating disorder, as well asreferring a patient early for mental health evaluation andtreatment. Pediatricians also should screen children andteens who are obese (especially those who are teased) andthose who have experienced early puberty for behaviorssuggestive of an eating disorder. Patients who are strug-gling with obesity should be encouraged to improvetheir diet and activity rather than simply “lose weight.”Routine screening for body image concerns or “disor-dered eating” practices by pediatricians often can pre-empt eating disorders. Finally, to facilitate early detec-tion and treatment, pediatricians should be vigilant forsymptoms and signs of eating disorders, such as newonset “healthy dieting,” weight loss, weight fluctuations,or electrolyte abnormalities.

PrognosisSteinhausen conducted an analysis of multiple outcomestudies for anorexia (12) and bulimia (13): 46% of pa-tients who had anorexia and 45% of patients with bulimiarecovered from their illnesses; 33% of patients who hadanorexia and 27% of patients who had bulimia showedimprovement; and 20% of patients who had anorexia and23% of patients who had bulimia had a chronic course.The mean crude mortality rates from these studies were5% for patients who had anorexia and 0.32% for patientswho had bulimia. Steinhausen noted great variation inoutcome parameters. Of note, Crow et al. used theNational Death Index and records from an outpatient

eating disorders clinic to complete an analysis of mortal-ity over 8 to 25 years for 1,885 individuals who hadanorexia nervosa. (14) In this analysis, they found crudemortality rates of 4.0% for anorexia, 3.9% for bulimia,and 5.2% for EDNOS, highlighting that the risks of thelatter two illnesses go against the general thought thatthese disorders are less fatal than anorexia.

AcknowledgmentThe authors would like to express their gratitude to Dr.David B. Herzog for his careful review of this article.

Summary• Based on widely accepted clinical practice,

pediatricians should monitor patients for warningsigns of anorexia. Warning signs include rapid orsevere weight loss, falling off of growth percentiles,excessive dieting or exercising, constriction of foodchoices, calorie counting, and excessive concern withweight or body shape.

• Pediatricians should monitor patients for warningsigns of bulimia, which include weight cycles,excessive concern with weight or body shape, tripsto the bathroom after meals, electrolyteabnormalities, swollen parotid glands, or knuckleabrasions.

• Based on strong research evidence, girls who haveanorexia have a high prevalence of hemodynamic,hematologic, endocrine, and bone densityabnormalities. (15)

• Based on good research evidence, medicationtreatment for anorexia is “sparse and inconclusive.”(7)

• Based on widely accepted clinical practice, patientswho have anorexia should refeed to a healthyweight range at a rate of 0.5 to 1 lb a week andmay need hospitalization if they are unable toimprove as an outpatient.

• Based on some research evidence, fluoxetine ishelpful in reducing some symptoms of bulimia. (10)

• Based on strong research evidence, CBT is helpful forbulimia. (11)

• Based on good research evidence, disordered eating,eating disorders, and amenorrhea occur morefrequently in sports that emphasize leanness. (16)

• Based on some research evidence, the long-termmedical consequence of anorexia is largely restrictedto bone loss, if the patient can restore weight. Thereare no long-term medical consequences of bulimia ifthe patient can recover without damaging his or herteeth or gastrointestinal tract or endure cardiacdamage.




References1. American Psychiatric Association. Diagnostic and StatisticalManual of Mental Disorders, 4th ed. Text revision: DSM-IV-TR.Washington, DC: American Psychiatric Association; 20002. Hudson JI, Hiripi E, Pope HG Jr., Kessler RC. The prevalenceand correlates of eating disorders in the National ComorbiditySurvey Replication. Biol Psychiatry. 2007;61:348–3583. Misra M, Katzman D, Miller KK, et al. Physiologic estrogenreplacement increases bone density in adolescent girls with anorexianervosa. J Bone Miner Res. 2011;26:2430–24384. Corrado S. Eating Disorders. In: Goldstein MA, ed. The Mass-General Hospital for Children Adolescent Medicine Handbook. NewYork, NY: Springer; 20115. Goldstein MA, Blais C, Brigham K, et al. MassGeneral Hospitalfor Children Eating Disorder Protocol. Boston, MA: MassGeneralHospital for Children; 20076. American Psychiatric Association. Practice Guideline for theTreatment of Patients With Eating Disorders. Washington, DC:American Psychiatric Association; 2006. Accessed January 4, 2011,at http://www.guideline.gov/content.aspx?id�93187. Bulik CM, Berkman ND, Brownley KA, Sedway JA, Lohr KN.Anorexia nervosa treatment: a systematic review of randomizedcontrolled trials. Int J Eat Disord. 2007;4:310–3208. Walsh BT, Kaplan AS, Attia E, et al. Fluoxetine after weightrestoration in anorexia nervosa: a randomized controlled trial.JAMA. 2006;295:2605–26129. Locke J, Le Grange D, Agras WS, Dare C. Treatment Manualfor Anorexia Nervosa: A Family-Based Approach. New York, NY:The Guilford Press; 200110. Shapiro JR, Berkman NK, Brownley KA, Sedway JA, Lohr KN,Bulik CM. Bulimia nervosa treatment: a systematic review of ran-domized controlled trials. Int J Eat Disord. 2007;40:321–336

11. Fairburn CG. Cognitive Behavior Therapy and Eating Disor-ders. New York, NY: The Guilford Press; 200812. Steinhausen HC. Outcome of eating disorders. Child AdolescPsychiatr Clin N Am. 2009;8:225–24213. Steinhausen HC, Weber S. The Outcome of bulimia nervosa:findings from one-quarter century of research. Am J Psych. 2009;166:1331–134114. Crow SJ, Peterson CB, Swanson SA, et al. Increased mortalityin bulimia nervosa and other eating disorders. Am J Psych. 2009;166:1342–134615. Misra M, Aggarwal A, Miller KK, et al. Effects of anorexianervosa on clinical, hematologic, biochemical, and bone densityparameters in community-dwelling adolescents girls. Pediatrics.2004;114:1574–158316. Nattiv A, Loucks AB, Manore MM, Sanborn CF, Sundgot-Borgen J, Warren MP. The female athlete triad. Med Sci SportsExerc. 2007;39:1867–1882

Suggested ReadingAmerican Academy of Pediatrics, Committee on Adolescence.

Identifying and treating eating disorders. Pediatrics. 2003;111:204–211

Goldstein MA, Herzog DB, Misra M, Sagar S. Case records of theMassachusetts General Hospital. Case 29–21008: a 19-year-oldman with weight loss and abdominal pain. N Engl J Med.2008;359:1272–1283

Mehler PS. Bulimia nervosa. N Engl J Med. 2003;349:875–881Work Group on Eating Disorders. Practice Guideline for the Treat-

ment of Patients with Eating Disorders, 3rd ed. Arlington, VA:American Psychiatric Association; 2006





PIR QuizQuiz also available online at: http://pedsinreview.aappublications.org.

NOTE: Beginning in January 2012, learners will be able to take Pediatrics in Review quizzes and claim credit onlineonly. No paper answer form will be printed in the journal.

1. A 15-year-old girl is hospitalized because of anorexia nervosa, with a BMI at 75% of ideal body weight.She gains weight and is discharged to a residential treatment setting. Her parents ask you if there are anymedical complications that they need to monitor in the future. Your best response is that, if she maintainsa normal body weight, she

A. Does not need medical monitoring.B. Is at increased risk of low bone density.C. Is at increased risk of diabetes.D. Remains at significant risk of cardiac arrhythmia.E. Will likely develop hypothyroidism.

2. A 14-year-old girl is hospitalized because of anorexia nervosa, with a BMI at 65% of ideal body weight.Tube feedings are initiated, and she receives vitamin and mineral supplements. The supplement she is mostlikely to require is

A. Phosphorus.B. Vitamin B6.C. Vitamin C.D. Vitamin D.E. Zinc.

3. The characteristic MOST common to individuals with bulimia is

A. Binge eating.B. Diuretics.C. Enemas.D. Induced vomiting.E. Laxative use.

4. A 14-year-old girl is an elite gymnast. She experienced menarche at age 12 but has had no periods in thepast year. Her weight is 85% of ideal body weight. Her coach has prescribed a strict dietary regimen, butshe limits her intake to 75% of the portions recommended by her coach. This girl is at highest risk for

A. Cardiac arrest.B. Low bone density.C. Refeeding syndrome.D. Renal failure.E. Short stature.




DOI: 10.1542/pir.32-12-5082011;32;508Pediatrics in Review

Mark A. Goldstein, Esther J. Dechant and Eugene V. BeresinEating Disorders

ServicesUpdated Information &

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MassGeneral Hospital for Children

Eating Disorder Protocol We believe that an Eating Disorder protocol is an effective tool in helping the patient and family understand and comply with the treatment plan. However, we acknowledge that there is not a uniform treatment plan that is entirely effective for the treatment of patients with eating disorders. You have been admitted to the pediatric inpatient unit at the Massachusetts General Hospital to assist in the treatment of an eating disorder. It is our goal to help you safely gain weight in a supportive environment and to assist you in addressing the complex issues involved with eating disorders. We hope to foster trust and open communications, a realistic body image, increased insight into food and eating behaviors and adaptive coping skills for you and your family. It is very important that you have a thorough understanding of this protocol, so we encourage you to bring all questions and concerns promptly to the attention of your treatment team. The goals of your inpatient hospitalization are as follows:

• Correct your malnourished state in a slow and steady manner • Promote weight gain • Fix any disturbances in your body electrolytes e.g. sodium, chloride,

phosphorous, sugar • Establish a normal pattern of bowel movements • Prevent self-induced vomiting or other types of purging behaviors • Increase your knowledge of your personal nutritional needs • Teach you healthy eating behaviors • Provide resources to help you address the complex emotional and family

issues that are involved in eating disorders • Support your continued physical and emotional development • Arrange your follow up treatment after hospital discharge

We have carefully developed this protocol for the treatment of patients with eating disorders. As an individual, we respect your rights. But we have found that a standard protocol of care is very effective in preventing misunderstandings related to the treatment plan, providing consistency in your care during the hospitalization and making clear the treatment team’s expectations of your behavior and participation. In addition, this protocol provides you and your family with information on the role of each team member. This protocol is a general guideline that the treatment team will use to outline your specific treatment goals and care plan. We approach your care with a multidisciplinary team, as there are a number of different team members who have specific areas of expertise that are used to plan your treatment. The team members are you, your parents, nurses, dietitians, physicians (pediatricians, adolescent medicine specialists, psychiatrists), social workers and child life specialists. The team will meet regularly with you to discuss the plan of care and any changes in the



plan that are needed based on your condition. All decisions will be made by the team to assist you and your family in meeting the goals of your hospitalization; your cooperation with the care plan is essential to your success. Team meetings are held shortly after your admission to the hospital and as often as necessary. You and your family are always encouraged to discuss any questions or concerns with members of the team. To encourage communications, we may invite you and your family to attend some of these team meetings. Patient’s Role Your role is the most important of all the team. The team expects that you will share what is bothering you by open and honest communication with team members. We anticipate that our interactions with you will encourage and foster this approach. We expect you to participate actively in your care and to offer suggestions to the team about your treatment plan. Our expectations include:

• Reviewing the eating disorder protocol and signing the treatment contract • Giving truthful information • Sharing questions and concerns with the team members • Completing your menu by 11:00 am each day • Maintaining scheduled meetings with team members • Adhering to the guidelines of the treatment plan and taking an active role in

your treatment plan Parent’s Role We understand there are many factors that can cause an eating disorder. Our intent is not to place blame on anyone. Rather, our goal is to help the patient and family. Throughout the child’s life, parents play a primary role. They assume the major responsibility for the child’s care. The team is here to support and nurture that role. We want to build on your family’s unique strengths and on the individual strengths of each family member. The treatment team recognizes that there is no single approach that is correct for all families, but over the years, this protocol has been ascertained to be an effective tool. The partnership between family members and professional staff is based on cooperation, respect, and the mutual goal of doing the best for the children in their care. The parent’s role will include:

• Reviewing the eating disorder protocol and signing the treatment contract • Maintaining an open and honest communication with the treatment team • Assisting with the patient’s medical history • Attending meetings with the social worker, psychiatrist and other team

members • Respecting the treatment plan • Maintaining the visitation plan and checking in at the nursing station with

your child’s nurse prior to visiting your child



Nurse’s Role The registered nurse caring for you is a graduate of a nursing program who is trained and skilled in caring for children and adolescents with eating disorders. The nurse’s role includes the following:

• Practicing primary nursing and accordingly a few nurses will play a key role in your care

• Obtaining a nursing assessment within 24 hours of your admission • Orienting you and your family to the unit and your room • Reviewing the Eating Disorder protocol along with a physician with you and

your family • Checking your room and your personal effects daily to be sure there are no

beverages, food or other prohibited items • Coordinating your daily activities according to your predetermined schedule • Answering your questions and acting as a liaison between you and other

members of your team

Patient Care Associate’s (PCA) Role The PCA has training and certification as a Patient Care Associate. The role of the PCA includes the following:

• Working very closely with your nurse • Taking your vital signs before you get out of bed and helping you to use a

commode • Obtaining your morning weight if not done by your nurse • Setting up your bedside bath • Answering questions is not part of the PCA role

Physician’s Role The attending physician, a pediatrician or adolescent medicine specialist, is responsible for and in charge of your overall care. This physician works with other team members, resident physicians in training as well as medical students to ensure you have appropriate high quality medical care while in the hospital. You will interact most frequently with resident physicians who will take an active role in your care. The roles of the physicians include the following:

• Performing an admission history and physical examination • Writing orders for medications, intravenous fluids, monitoring, laboratory work,

consultations and your activity levels • Rounding each day where they will examine you, discuss their findings, talk with

you about the care plan and answer your questions • Responding to any medical issues that occur during the hospitalization



• Working with the other team members to ensure optimal care • Reviewing your progress with you and your family and collaborating with other

team members to develop a treatment plan after you leave the hospital

The following is an explanation of the physicians’ titles and roles:

• Resident Physicians (a.k.a. House Officers): Residents are doctors who have graduated from medical school and are training in pediatrics. There is always at least one team of an intern and a senior resident in the hospital 24 hours a day who are available to address any questions or concerns. There is often a medical student working with the resident physicians.

o Intern: A first year resident who will examine you every day and is usually the first person called with any questions or concerns.

o Senior Resident: A third year resident who will oversee and help the intern with your care.

• Attending Physician: The supervising doctor who leads the team of doctors involved in your care. The attending will either be from your primary physician’s office, a hospital-based physician (a.k.a. Hospitalist), or a sub specialist physician.

• Consulting Physician: A physician with expertise in a particular subspecialty whom the team may ask to help them with the treatment plan. The consulting physician may make recommendations, but it is the attending physician who ultimately decides on the final treatment plan. Occasionally, consulting physician’s work with a “fellow,” who is a doctor who has completed residency and is obtaining further training within that subspecialty.

Psychiatrist’s Role

Your psychiatrist is a physician who has special training in the treatment of illnesses such as depression, anxiety, and eating disorders. On Ellison 18, your psychiatrist is a child and adolescent psychiatry fellow who has completed training in adult psychiatry. He or she works closely with an attending child and adolescent psychiatrist. Your psychiatrist will meet with you and your parents to help better understand the factors that contribute to the development of the eating disorder. Your psychiatrist will:

• Meet with you for an in-depth interview to fully assess your current function and safety status. Sometimes, patients have problems with anxiety, depression, and/or substance abuse in addition to the eating disorder. It is important to identify these issues so that they can be appropriately addressed. Some patients need direct observation during hospitalization, and the psychiatrist will help determine whether this is necessary.

• Determine whether there is a role for psychiatric medication in your treatment. Any decision to start medication will involve you, your parents, and the treatment team.

• Talk with you for 10-15 minutes each day, Monday through Friday, to discuss your feelings about your medical treatment and your hospitalization. Your psychiatrist will set aside a longer period of time (30-50 min) twice per week to



more fully discuss your feelings about treatment as well as the factors that contributed to your hospitalization *

• Work closely with the other members of the treatment team to define treatment goals and help plan the course of your treatment after you leave Ellison 18.

• Provide consultation to the pediatric team after hours if needed. • Discuss privileges with you and how you can gain them during your hospital stay

*You may wonder why your psychiatrist does not meet with you for daily psychotherapy. Ellison18 is a medical unit, and the focus of your care at this time needs to be on your physical health and medical stability. In our experience, therapy is much more effective after all medical concerns have been fully addressed.

Dietitian’s Role

A registered dietitian is a health care professional with a scientific background in food, nutrition, and metabolism, who applies this knowledge to promoting health, preventing disease, and providing counseling and education. The dietician is responsible for helping you choose foods that will restore your weight in a safe way. You will meet with the dietitian daily throughout your hospitalization to plan meals and snacks, and to learn more about nutrition in general. In addition the dietician will assist you in the following:

• Meet with you daily to plan meals and snacks and teach you about healthy eating • Familiarize herself with your eating pattern and your food likes and dislikes • Develop and adjust the amount of calories you need daily for appropriate weight

gain • Follow your blood work, vital signs and weight to see how your body is

responding to the meals and adjust your daily meal plan based on the response • Help you design a meal plan for weight stabilization when you are ready to leave

the hospital

Social Worker’s Role Clinical Social Workers are licensed mental health professionals who are trained to help people find solutions to many problems from daily issues to life’s most difficult situations. We accomplish this through a combination of counseling and direct connection with the network of hospital and community resources. Clinical Social Workers work with both inpatients and outpatients and help patients and families to:

• Deal with crisis • Cope with illness and life stressors • Identify and solve problems with relationship • Enhance communication with the medical treatment team to enable patients and

families to be active partners in their own healthcare • Access hospital and community resources

As part of this admission for an eating disorder, the social worker will be involved daily as part of the multidisciplinary team. Social worker duties include the following:



• Help you and your family cope with the feelings that come up for you during this

hospitalization. Patients and families often experience a variety of emotions resulting from an admission for an eating disorder. It is important to try to understand these emotions and how they impact you, your family and the course of your treatment.

• Meet to talk with you and in a more extensive way with your family throughout this admission

• Gather information about how your illness started and how it has progressed in order to assist your family in helping you to get better

• Assist you and your family, along with other members of your team, with aftercare planning and in obtaining any necessary resources

Child Life Specialist’s Role

The child life specialist is a member of the health care team who is certified in the assessment and treatment of the developmental, emotional and psychosocial issues of children and adolescents. Child life specialists have either a bachelor’s degree or master’s degree in the field of child life and family centered care. Their duties include the following:

• Provide emotional and social support to you and your family during your hospitalization

• Offer diversional materials to you while on bed rest (i.e. DVDs, books, crafts, games, music, video games)

• Arrange daily scheduled visits from volunteers, child life students, and/or child life specialists

• Help with creating a general, daily schedule (following the guidelines of the protocol)

• Assist in brainstorming ideas for your privilege list (must be approved by the team)

• Facilitate the transition from home to hospital to be as easy and comfortable as possible

Inpatient Eating Disorder Treatment Guidelines

As stated previously, the use of a protocol in your treatment helps prevent any confusion or misunderstanding. The following information is intended to provide you with an overview of the treatment plan; they are the guidelines of your care. As each individual is unique, modifications in the treatment plan may be made to keep you safe, and to help you and your family meet the goals of treatment. Privileges: Based on your adherence with this treatment plan, your clinical status and your ability to meet daily weight gain goals, you will be granted certain unit activities. Privileges are earned and they may be withdrawn if you fail to comply with the treatment plan or if you are not gaining weight. Privileges include, but are not limited to:



• Extended visits for immediate family (mother, father and siblings) • Bathroom privileges • Visitors outside of immediate family • Increased use of the hospital telephone (up to 1 hour three times daily) • Ward privileges: being able to walk on the unit (only if the team deems

that this is medically safe and appropriate) • Off unit privileges (such as visits to the hospital store or chapel and only if

the team deems that this is medically safe and appropriate) • Internet access for one hour per day (we expect that patients will only

access appropriate sites, and Internet use may be monitored/supervised) You and your psychiatrist will come up with a list of specific, approved

privileges. The team will also have input into whether your list is appropriate. If you attain your weight goal for the day, you will earn the next privilege on your list. If you fail to meet your weight goal for the day but do not lose weight, you will neither earn nor lose privileges. If you lose weight, you will lose the most recently granted privilege on your list. In addition to your individual privileges, there are specific guidelines that must be followed.

Vital signs: Your vital signs including blood pressure, pulse and temperature will be taken every morning before your weight is checked; if they fall below the certain parameters, you will be placed on bed rest. This means that you may not get out of bed for any reason. This is not a punishment; rather it is for your protection – your vital signs tell us how hard your heart is working and bed rest may be needed to prevent further stress to it. Your vital signs will then be taken every four hours or even more frequently until they are determined to be within a normal range. Weight: You will be weighed every morning after your vital signs and you have voided. You will be weighed with a hospital johnny and underpants only and with your back to the scale. The treatment team will determine which weight, after your hospital admission, will be used as a baseline for establishing future privileges. If your weight is not increased by 0.2 kg (approximately 1/2 pound) daily, a supplement will be given. Your body needs daily requirements to function at a baseline level; by not gaining weight you put too much stress on your system to function properly. Nutrition: The 24 hour meal pattern in the treatment protocol is dinner-breakfast-lunch (and up to three snacks daily). Your treatment protocol will begin with dinner on the first night of your admission. You will be served your meal tray alone in your room unless you require direct observation while eating by the nursing staff. You are required to receive a tray for every meal. Menu guidelines:

• You are allowed to choose 5 food items from the menu that you will never have to eat. These 5 foods must be separate menu items. Whole food groups will not be accepted.

• No “light” or “diet” foods or drinks will be allowed. • You will not be allowed to drink water even with medications.



• No food is allowed in the room except at meal and snack times. • You must complete your menu by 11am each day. The dietitian will pick up the

menu after this and make changes as needed. There is no negotiation to these changes.

• Once the menu has been turned in, no substitutions are allowed.

Mealtime guidelines: • Initially you may be restricted to only the meals and snacks on your pre-

determined meal plan. As you stabilize, you will be allowed to eat above and beyond your meal plan if you so desire, but those foods will not be included in the daily goal, and cannot be used in place of pre-determined meals and snacks.

• Only food provided by the MGH Department of Nutrition and Food Services will be included in your daily calorie goal.

• You must consume 100% of each meal and snack. • The Nutrition Service Coordinator will leave the tray outside the room, and the

nurse will check the tray before you receive it to be sure all the menu items are accurate and complete.

• You will have 30 minutes to consume each meal, and 15 minutes to consume each snack.

• You must remain on bed rest for 1 hour after each meal and 30 minutes after each snack.

• No visitors or phone calls are allowed during meal/snack times.

Supplement Guidelines: • If you do not meet the weight gain goal of 0.2 kg (1/2 pound) per day you will be

required to drink a Boost or Ensure supplement in the morning before breakfast. • At the end of each 24-hour meal and snack period, the dietitian will add up the

total calories you have not consumed from your meals and snacks (if any), and you will be required to make up those calories with an Ensure or Boost supplement.

• You will have 15 minutes to consume each supplement (if needed). If the supplement cannot be consumed in that time, a tube will be placed through your nose into your stomach, and the supplement will be administered through that tube.

• You must remain on bed rest for 30 minutes after each supplement. Hospital Procedure: Rules

• Personal computers are not allowed • Food and fluids may not be kept in your room • Cell phones are not allowed • Curtains must be open unless the patient is using the bathroom • Parents must check in at the nurses’ station with their child’s nurse prior to

visiting the patient • Patient may only use the hospital telephone when specifically allowed to do so



• Exercise is not permitted • Patient may have only one large duffel bag or suitcase of personal items including

clothing that is to be unpacked and then the bag or suitcase is to be taken home

You will be placed on bed rest on admission for at least the first 24 hours while your physical status is being evaluated. It may be unsafe for you to be out of bed at this time due to the stress your disease may have placed on your body. Your activity status will be a team decision. Exercise is not permitted. You must observe scheduled bed rest times following meals and supplements. If you are on bed rest, meetings and any other activities will take place in your room. When not on bed rest you are encouraged to dress in your own clothes and participate in activities in the recreation room. While on bed rest you will use a bedpan or a commode chair at the bedside. Your nurse must be called, and he/she will provide you with the bedpan or commode chair. The curtain to your room will be drawn but the nurse will remain in the room until you are finished. The amount of urine you produce and your stool will be monitored. You will not be allowed to use the bathroom until this privilege is obtained. Bathroom privileges will not be granted until it is determined that it is safe for you to be in the bathroom unsupervised. You will be provided with a washbasin until bathroom privileges are obtained. You may use your own hygiene products. Visitors are not allowed during meal times, supplement times, rest periods, or during scheduled meeting times with the team members. Initially only immediate family members are allowed to visit. This includes parents or guardians and brothers and sisters only. Visits with the family will take place during hospital visiting hours. Each visit may not exceed one hour per day. Additional visitors are a privilege that must be contracted with the team. Phone calls are not allowed during mealtimes. Phone use is one half hour three times a day and must not interfere with your treatment plan. Complete compliance with this treatment plan is mandatory and necessary for effective treatment during your hospitalization. Noncompliance, lying and manipulative behavior will not be tolerated. These types of behavior will be confronted and documented in your patient record. At team meetings your progress will be discussed. Your capability to be an active and cooperative participant in your treatment and your commitment to recovery will determine the treatment plan and be a major determinant of your future treatment once medical complications have been treated. Protocol Committee Members: Claire Blais RD, LPN, CNSD Kathryn Brigham M.D. Elizabeth Corrieri R.N. Jennifer Derenne M.D. Sacha Field MS, CCLS Mark Goldstein M.D, Chair Kristen Nuttall R.N. Alexandra Sobran MSW, LICSW March 2007



Eating Disorder Protocol Contract

Our eating disorder protocol is comprehensive and multidisciplinary. We feel that it is very important for everyone involved to have clearly defined roles and expectations in order to be most helpful to you and your family. For this reason, we ask that you read the protocol carefully and encourage you to ask the team for clarification if there are questions about the material. We will then ask you and your team to sign the following contract indicating your understanding of the protocol and your willingness to do the best you can to follow the expectations. I have read the MassGeneral Hospital for Children Eating Disorder Protocol, I understand the expectations for my role in the treatment team, and I agree to fulfill those expectations to the best of my ability. Patient Parent(s) Pediatric/ Adolescent Medicine Attending Physician Child and Adolescent Psychiatry Fellow Dietitian Social Worker Child Life Specialist Nurse



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