SPECIAL ISSUE ARTICLE

Diagnosis and Evaluation of Eating

Disorders in the Pediatric Patient
Briana Sacco, MD; and Urszula Kelley, MD, CEDS

tally normal mouthing of objects by

ABSTRACT infants that result in ingestion. Gener-
Recognizing eating disorders in the pediatric population can be challenging for outpa- ally, those with pica are not averse to
tient providers. With the high prevalence of these disorders in children and adolescents, ingesting food. Pica can be diagnosed
it is critical that pediatricians recognize these disorders and connect these children and with another mental condition (such as
families with available treatments. This article provides a review of the current diagnostic intellectual disability, autism spectrum
criteria for pica, rumination disorder, anorexia nervosa, bulimia nervosa, avoidant restric- disorder, or schizophrenia) or medical
tive food intake disorder, binge-eating disorder, other specified feeding or eating disorder, condition if it is sufficiently severe to
and unspecified feeding or eating disorder as described in The Diagnostic and Statistical warrant additional independent clinical
Manual of Mental Disorders, fifth edition. Recommendations for initial medical evaluation attention (such as pregnancy or iron de-
and helpful screening measures are discussed. [Pediatr Ann. 2018;47(6):e244-e249.] ficiency anemia).1
Pica can result in severe medical

E
ating disorders are challeng- screening recommendations for these complications such as gastrointestinal
ing to diagnose in the pediatric disorders. obstruction by formation of bezoar or
population, as these disorders perforation of the stomach or intestines,
can have an insidious onset and those PICA heavy metal poisoning caused by the
suffering can have limited insight into Pica is an eating disorder that in- ingestion of metal-based substances, or
their illness. Due to the high prevalence volves eating items over a period of infections such as toxoplasmosis and
of these disorders and the associated at least 1 month that are not typical- toxocariasis.2,3 Although pica is more
morbidity and mortality, it is critical ly thought of as food and that do not common in pregnant women and chil-
that pediatricians accurately diagnose contain significant nutritional value. dren, prevalence in the general popula-
these conditions as early as possible. Non-nutritive foods could include pa- tion is unknown.4
This article provides a review of the per, soap, cloth, hair, string, wool,
current diagnostic criteria for eating soil, chalk, talcum powder, paint, gum,
disorders included in the Feeding and metal, pebbles, charcoal, ash, clay, RUMINATION DISORDER
Eating Disorders section of The Diag- starch, or ice. Pica can occur at any Rumination disorder (RD) involves
nostic and Statistical Manual of Men- age and gender, although the diagnosis the regular regurgitation of food that oc-
tal Disorders, fifth edition (DSM-5),1 is not made in children younger than curs for at least 1 month. Regurgitated
and discusses initial evaluation and age 2 years to exclude developmen- food can be re-chewed, re-swallowed,
or spit out. When someone regurgitates
Briana Sacco, MD, is an Assistant Professor of Psychiatry, Division of Child and Adolescent Psychiatry, their food, they do not appear to be try-
University of Texas Southwestern Medical Center; and the Medical Director, Center for Pediatric Eating ing to do so, nor do they appear to be
Disorders, Children’s Medical Center Plano, Children’s Health. Urszula Kelley, MD, CEDS, is a Professor of stressed, upset, or disgusted. Medical
Psychiatry, Division of Child and Adolescent Psychiatry, University of Texas Southwestern Medical Cen- etiologies, including gastrointestinal
ter; a Child Psychiatrist, Center for Pediatric Eating Disorders, Children’s Medical Center Plano, Children’s conditions, must be excluded before
Health; and the Director of Psychiatric Services, Children’s Medical Center Plano, Children’s Health. this diagnosis is made, and a child can-
Address correspondence to Briana Sacco, MD, Children’s Medical Center Plano, Children’s Health, not have this diagnosis concurrently
7601 Preston Road, Suite P4300, Plano, TX, 75024; email: briana.sacco@utsouthwestern.edu. with another eating disorder diagnosis
Disclosure: The authors have no relevant financial relationships to disclose. (such as avoidant restrictive food intake
doi:10.3928/19382359-20180523-02 disorder [ARFID], anorexia nervosa

e244 Copyright © SLACK Incorporated


[AN] or bulimia nervosa [BN]). RD, if
severe enough to warrant independent
clinical attention, can be diagnosed in
the presence of another mental disor-
der, including intellectual disability.1
Prevalence of RD in the general popu-
lation is unknown.4
AVOIDANT RESTRICTIVE FOOD
INTAKE DISORDER
Children suffering from ARFID
present with avoidance or restriction
of food intake resulting in clinically
significant failure to meet nutritional
requirements. To meet DSM-51 criteria,
children present with at least one of the
following features: weight loss (or lack
of expected weight and height gains for
age and gender), significant nutritional
deficiency or health impact, depen-
dence on enteral feeding or oral nutri-
tional supplements for growth, and/or
marked interference with psychosocial
functioning. The children do not ex-
press concerns about body weight or
shape. Exclusion criteria include devel-
opmentally normal picky eating behav-
iors and culturally or religiously sanc-
tioned practices. Before the diagnosis
can be made, medical etiologies must
be excluded.1
General Food Aversion
The DSM-51 diagnostic criteria for
ARFID is quite broad, but character-
istic subtypes have been described and
are helpful to keep in mind in the con-
text of clinical presentation and diag-
nostic formulation. In considering the
most common clinical presentations
and based on Chatoor’s work in infant
psychiatry,5 children and adolescents
presenting with ARFID can be further
described by 1 of 4 subtypes (Table 1).6
Although these children usually have
one prominent presenting type, they
can meet criteria for more than one type
based on their clinical history. The first
PEDIATRIC ANNALS • Vol. 47, No. 6, 2018
SPECIAL ISSUE ARTICLE
type is general food aversion. These
children typically eat a small amount of
food, and this is a pattern that develops
by age 3 years. These children may not
recognize hunger sensations, frequent-
ly demonstrate a lack of interest in food
or eating, and often they would rather
play or talk than eat. Given reduced
nutritional intake, these children are at
risk for significant growth deficiency,
often exhibiting both weight and height
deficiencies. For some children, these
restrictive eating behaviors will persist
into adulthood.1,5,6
Sensory Food Aversion
The second type is sensory food
aversion, in which a child may refuse to
eat foods due to specific taste, texture,
temperature, or smell experiences that
are aversive to the child. These children
will demonstrate food refusal after in-
troduction of a new or different type of
food that is aversive to the child, and
subsequently that child may general-
ize this aversion and refuse other foods
with similar color, appearance, or smell.
These children will eat preferred foods
without difficulty, so they may dem-
onstrate specific dietary deficiencies
depending on their eating preferences,
but may not show any signs of overall
growth deficiency. These children tend
to present in the first decade of life, al-
though their symptoms may also persist
into adulthood.1,5,6
Posttraumatic Feeding Disorder
The third type is posttraumatic feed-
ing disorder, in which a child demon-
strates acute onset of food refusal. This
typically presents after a traumatic
event (eg, choking) or repeated trau-
matic insults to the oropharynx or gas-
trointestinal tract (eg, intubation or up-
per endoscopy). The child’s consistent
refusal to eat can present in a variety
of ways based on the child’s traumatic
experience. This type can present in
a child of any age, from infancy into
adulthood.1,5,6
Concurrent Medical Condition
The fourth and final type is a concur-
rent medical condition. These children
can develop food refusal or inadequate
intake at any age, and these behaviors
may come and go depending on the
medical condition contributing to the
symptoms. These children will typi-
cally initiate feeding but may become
distressed or refuse to continue eating.
Based on the child’s medical experience
(eg, constipation causing cramping ab-
dominal pains, gastroesophageal reflux
causing sharp stomach pains), these
children associate discomfort with food
and eating, and this is thought to con-
tribute to the development of avoidant
eating behaviors. Medical management
of these children may improve their
symptoms but will not fully resolve
their avoidant eating behaviors, and as
a result they will continue to struggle
with adequate weight gain.1,5,6
Although ARFID has been observed
by medical and mental health providers
for years, the diagnosis was formalized
in DSM-51 in 2013, so epidemiological
data are limited. Prevalence of ARFID
in children treated for eating disorders
in the tertiary care setting ranges from
5% to 22%.6-8 One cohort of 13-year-
old adolescents screened for ARFID
in Switzerland had 3% prevalence of
ARFID symptoms. Of these children
with ARFID symptoms, 39% reported
general food aversion, 61% sensory
food aversion, and 15% posttraumatic
feeding disorder, with 15% reporting 2
or more ARFID symptom types. Medi-
cal comorbidities were not assessed
in this sample.9 In a psychiatrically
based eating disorder program, ARFID
prompting presentation to clinical care
was 43% sensory food aversion, 22%
e245

TABLE 1.
Common Clinical
Presentations of Avoidant
Restrictive Food Intake
Disorder
• General food aversion
• Sensory food aversion
• Posttraumatic feeding
disorder
• Concurrent medical condition
Adapted from Chatoor5 and Sacco and Schwalen.6
general food aversion, 22% posttrau-
matic feeding disorder, and 13% con-
current medical condition.6 Compared
to children diagnosed with AN or BN,
children with ARFID diagnosis often
present at younger ages, more likely
to be boys, with longer hospital stays,
increased used of enteral feeding meth-
ods, and greater likelihood of comorbid
mental health conditions.7,10,11
ANOREXIA NERVOSA
Children diagnosed with AN present
with persistent energy intake restriction
combined with disturbance in self-per-
ceived weight or shape. These children
demonstrate intense fear of gaining
weight or becoming fat, or persistent
behaviors that interfere with weight
gain. Behaviors can include restrictive
eating, overexercising, binge eating,
purging, and diet pill/laxative abuse.
DSM-51 eliminated specific weight cut
off and amenorrhea as diagnostic crite-
ria, although irregular menses are sup-
portive of AN diagnosis.
Restrictive Eating and Binge
Eating/Purging
If a child has been demonstrating
persistent restrictive eating and/or over-
exercising behaviors for a period of 3
months, this would be considered the
restrictive type. Children who engage
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SPECIAL ISSUE ARTICLE
TABLE 2.
Questions for Children with a Possible Eating Disorder
Topic Question
Weight What is your current, highest, and lowest weight (include dates)?
Body image How do you feel about your body? If you could wave a magic wand and
change something about your body, what would you change? Have
you ever felt afraid of gaining weight or being fat? What is your goal
weight?
Restrictive eating How do you decide what you are going to eat? Do you have a goal for
the number of calories per food item, per meal, or per day? Do you keep
track of calories that you eat? How much time do you spend reading
food labels or counting calories?
Exercise How often do you exercise? What do you do for exercise and how
much time do you spend exercising? Do you take days of rest between
days of exercising? Why do you like to exercise? Do you think about
burning calories or losing weight while exercising? Do you keep track of
the calories that you burn from exercising?
Purging Have you ever made yourself throw up? Have you ever taken diet pills
to lose weight or not get fat? Have you ever taken laxatives more
than prescribed by your doctor to lose weight or not get fat (include
frequency, first/most recent episodes)?
Diet Tell me about a typical day and what you eat for breakfast, lunch, and
dinner. What snacks do you have between meals? What fluids are you
drinking?
Menstruation When did you first start your periods? When was your last period?
Have your periods ever become irregular, lighter, or stopped (include
dates, duration)?
in binge eating or purging behaviors at of any psychiatric disorder.1,13 Adoles-
least once weekly for 3 months would cents diagnosed with AN report rates
be considered the binge eating/purging of attempted suicide as high as 10% to
type.1 Distinguishing between these 20%.14
subtypes is important, as children with
binge eating/purging type of AN can be BULIMIA NERVOSA
misdiagnosed with BN. Children with BN present with recur-
AN is the third most common chron- rent episodes of binge eating followed
ic disease among teenage girls and by inappropriate compensatory behav-
young women age 14 to 21 years, with iors to prevent weight gain. Classically
a 12-month prevalence of 0.4% among these behaviors include purging (self-
young women. AN has a bimodal peak induced vomiting, diet pill abuse, laxa-
incidence at age 13 and 18 years.1 AN tive abuse), but these children can also
is highly comorbid with other psychi- demonstrate restriction and overexercis-
atric illnesses, including mood disor- ing behaviors. These children have con-
ders (depression, bipolar), anxiety dis- cerns about their body shape and weight,
orders, substance abuse/dependence, which drives these compensatory be-
and obsessive-compulsive disorder.13 haviors. To meet DSM-51 criteria, the
Patients diagnosed with AN have a frequency of binge eating and compen-
mortality rate of 5% to 6%, the highest satory behaviors must occur at a mini-
Copyright © SLACK Incorporated

TABLE 3.
Anorexia Nervosa
Medical Admission
Recommendations
• Bradycardia (awake <50 beats/minute,
asleep <45 beats/minute)
• Hypotension (systolic blood pressure
<90 mmHg)
• Orthostatic changes in pulse or blood
pressure
• Cardiac arrhythmia
• Hypothermia (<96°F)
• Malnutrition (<75% ideal body weight,
body fat <10%)
• Refusal to eat
• Failure to respond to outpatient
treatment
Adapted from Campbell and Peebles.15
mum of once per week for 3 months, de-
creased from twice per week according
to DSM-IV-TR12 criteria.
The prevalence of BN is 0.9% to 3%
with peak incidence between ages 17
and 18 years.15 BN is highly comorbid
with other psychiatric disorders, includ-
ing mood disorders (depression, bipo-
lar), anxiety disorders, substance abuse,
and dependence.4 The mortality rate for
children diagnosed with BN is 2%, and
their risk of lifetime suicidality and sui-
cide attempts is higher than people with
a diagnosis of AN.15 BN should be con-
sidered a risk factor for suicide when
evaluating a child for suicidal ideation.4
BINGE-EATING DISORDER
Children with binge-eating disorder
(BED) present with recurrent binge-
eating episodes, associated with three
or more of the following: eating more
rapidly than normal, eating until feel-
ing uncomfortably full, eating large
amounts of food when not hungry, eat-
ing alone due to feeling embarrassed by
amount one is eating, feeling disgusted
with oneself, and/or depressed or feeling
PEDIATRIC ANNALS • Vol. 47, No. 6, 2018
SPECIAL ISSUE ARTICLE
TABLE 4.
Bulimia Nervosa
Medical Admission
Recommendations
• Syncope
• Electrolyte abnormalities (serum K
<3.2 mmol/L, serum Cl <88 mmol/L)
• Esophageal tears
• Intractable vomiting
• Hematemesis
• Cardiac arrhythmias
• Hypothermia
• Suicide risk
• Failure to respond to outpatient
treatment
Adapted from Campbell and Peebles.15
very guilty after eating. Binge episodes
are distressing to the child experiencing
them, and to meet DSM-51 criteria, the
frequency of binge episodes must aver-
age once per week for at least 3 months.
The prevalence of BED is between
1% and 3% with similar frequency in
boys and girls and average age of onset
is approximately age 12 to 13 years.4,16
BED among children increases risk
2-fold for development of obesity and
increased symptoms of depression.16
Children with BED demonstrate more
suicidal ideation and emotional distress.4
SPECIFIED AND UNSPECIFIED
FEEDING OR EATING DISORDERS
With the increased prevalence of pe-
diatric obesity, an important presentation
that pediatric providers must be aware of
is atypical AN. These are children who
would otherwise meet criteria for AN,
but their weight is in the normal range
despite significant weight loss. These
children often have a preceding history
of binge-eating behaviors and obesity.
Other examples include BN of low fre-
quency and/or limited duration of BED
TABLE 5.
SCOFF Questionnaire
• Do you make yourself Sick because you
feel uncomfortably full?
• Do you worry you have lost Control over
how much you eat?
• Have you recently lost more than One
stone (14 lbs) in a 3-month period?
• Do you believe yourself to be Fat when
others say you are too thin?
• Would you say Food dominates your life?
Adapted from Luck et al.21
of low frequency or duration. Children
who engage in purging behaviors with-
out preceding binge episodes and are not
better described as having RD would be
described as having purging disorder.
Children with disordered-eating behav-
iors who do not meet the criteria for any
of the available diagnoses would fall
into the category of unspecified feeding
or eating disorder.1
CLINICAL EVALUATION OF A
CHILD WITH SUSPECTED EATING
DISORDER
There are many published recom-
mendations to guide the clinician in
evaluating a child suspected of having
an eating disorder.15,17,18 When evaluat-
ing such a child, obtaining a thorough
history is important. In your history, be
specific in asking questions that explore
weight, body image, restrictive eating,
exercising, and purging behaviors. Also,
obtain a thorough diet history and, in
girls, menstrual history, including any
contraceptive use because this can mask
true menstrual history (Table 2).15,19
Symptoms endorsed on review of
systems and physical examination find-
ings will depend on the child’s nutri-
tional status. Children presenting with
menstrual changes, constipation, cold
intolerance, weight loss, hypotension,
e247

hypothermia and bradycardia are sug-
gestive of malnutrition processes, so af-
ter excluding medical causes, consider
a possible diagnosis of AN or ARFID.
Laboratory evaluation may show leuko-
penia, anemia, and/or thrombocytope-
nia, in addition to electrolyte changes
(elevated blood urea nitrogen, hypomag-
nesemia, hypophosphatemia). These
children may have sinus bradycardia
or arrhythmias on electrocardiogram.19
Young women who have demonstrated
oligomenorrhea or amenorrhea for 6 to
12 months can show increased risk for
or decreased bone mineral density for
age.20 Children presenting with exces-
sive weight gain should also be evalu-
ated for BED after consideration of
medical etiologies, and these children
may demonstrate signs of metabolic
syndrome.19 For children suspected of
having AN, the American Academy
of Pediatrics (AAP) has specific crite-
ria recommending medical admission
(Table 3).15
When children have vomiting or
laxative abuse, metabolic changes are
evident on laboratory results. Addition-
ally, these children may present with
erosion of dental enamel, dental carries,
and chipped teeth, in addition to parotid
gland enlargement or callouses on the
dorsal aspect of the hands (from self-
induced vomiting).20 In these children,
consider a diagnosis of BN as well as
ARFID and possibly RD with frequent
emesis. For children suspected of hav-
ing BN, the AAP has specific criteria
recommending medical hospitalization
(Table 4).15
There are several screening tools that
can be used in the pediatric office set-
ting for AN, BN, and BED. The SCOFF
questions are a quick, 5-minute screen
administered verbally during a patient
encounter (Table 5). If a child answers
with two or more “yes” responses, this
indicates a possible eating disorder and
e248
SPECIAL ISSUE ARTICLE
need for further evaluation and possibly
referral for eating disorder treatment.21
A more detailed screening tool for ado-
lescents with AN or BN would be the 26-
item self-report Eating Attitudes Test or
the modified Children’s Eating Attitude
Test, also a 26-item self-report measure
for children in third to eighth grade.22,23
To screen for BED in children suffering
from obesity, the Adolescent Binge Eat-
ing Scale questionnaire can help identify
patients who may need eating-disorder
specific treatment.24 There is no com-
monly used screening tool identifying
children at risk for ARFID, although
the Behavioral Pediatrics Feeding As-
sessment Scale and the Child Food Neo-
phobia Scale have successfully differ-
entiated a clinical ARFID sample from
children who are developing typically.25
There are no screening tools specific for
pica or rumination disorder.
CONCLUSION
Eating disorders are prevalent in the
pediatric population, so pediatricians are
likely to encounter it in clinical practice.
Familiarity with signs and symptoms
of eating disorders will help pediatric
providers recognize children at risk for
eating disorders, facilitating timely med-
ical evaluation and referral for eating-
disorder treatment.
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