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Ed 2020 1
Ed 2020 1
Ed 2020 1
INTRODUCTION The guidance in this report does not indicate an exclusive course of
treatment or serve as a standard of medical care. Variations, taking
into account individual circumstances, may be appropriate.
Definitions
All clinical reports from the American Academy of Pediatrics
Although the earliest medical account of an adolescent patient with an automatically expire 5 years after publication unless reaffirmed,
eating disorder was more than 300 years ago,1 a thorough understanding revised, or retired at or before that time.
of the pathophysiology and psychobiology of eating disorders remains This document is copyrighted and is property of the American
elusive today. The Diagnostic and Statistical Manual of Mental Disorders, Academy of Pediatrics and its Board of Directors. All authors have filed
conflict of interest statements with the American Academy of
Fifth Edition (DSM-5) includes the latest effort to describe and categorize Pediatrics. Any conflicts have been resolved through a process
eating disorders,2 placing greater emphasis on behavioral rather than approved by the Board of Directors. The American Academy of
Pediatrics has neither solicited nor accepted any commercial
physical and cognitive criteria, thereby clarifying these conditions in those involvement in the development of the content of this publication.
children who do not express body or weight distortion. DSM-5 diagnostic DOI: https://doi.org/10.1542/peds.2020-040279
criteria for several of the eating disorders commonly seen in children and
Address correspondence to Laurie L. Hornberger, MD. Email:
adolescents are presented in Table 1. lhornberger@cmh.edu
Notable changes in DSM-5 since the previous edition include the
elimination of amenorrhea and specific weight percentiles in the diagnosis To cite: Hornberger LL, Lane MA, AAP THE COMMITTEE ON
of anorexia nervosa (AN) and a reduction in the frequency of binge eating ADOLESCENCE. Identification and Management of Eating
and compensatory behaviors required for the diagnosis of bulimia nervosa Disorders in Children and Adolescents. Pediatrics. 2021;
147(1):e2020040279
(BN). The diagnosis “eating disorder not otherwise specified” has been
eliminated, and several diagnoses restrictive food intake disorder previously categorized in the fourth
have been added, including binge- (ARFID).3–5 The diagnosis of ARFID edition (DSM-IV) as “feeding disorder
eating disorder (BED) and avoidant/ encompasses feeding behaviors of infancy and early childhood” and
increased risk of disordered young women acknowledged that requirements, or idealized body
eating.49–51 Among teenagers with their decision to become vegetarian shapes may be at particular risk of
type 1 diabetes mellitus, at least one- was primarily motivated by their relative energy deficiency in sport.
third may engage in binge eating, self- desire for weight loss, and most Signs and symptoms of relative
induced vomiting, insulin omission reported that they had done so at energy deficiency, such as
for weight loss, and excessive least a year after first developing amenorrhea, bradycardia, or stress
exercise,52,53 resulting in poorer eating disorder symptoms.60 fractures, may alert pediatricians to
glycemic control.54 this condition.
In an attempt to improve
Many adolescents engage in dietary performance or achieve a desired
practices that may overlap with or physique, adolescent athletes may SCREENING FOR EATING DISORDERS
disguise eating disorders. The lay engage in unhealthy weight-control
behaviors.61 The term “female athlete Pediatricians are in a unique position
term "orthorexia" describes the to detect eating disorders early and
behavior of individuals who become triad” has historically referred to (1)
low energy availability that may or interrupt their progression. Annual
increasingly restrictive in their food health supervision visits and
consumption, not based on concerns may not be related to disordered
eating; (2) menstrual dysfunction; preparticipation sports examinations
for quantity of food but the quality of offer opportunities to screen for
food (eg, specific nutritional content and (3) low bone mineral density
(BMD) in physically active eating disorders. Bright Futures:
or organically produced). The desire Guidelines for Health Supervision of
to improve one’s health through females.62–65 Inadequate caloric
intake in comparison to energy Infants, Children, and Adolescents,
optimal nutrition and food quality is fourth edition, offers sample
expenditure is the catalyst for
the initial focus of the patient, and screening questions about eating
endocrine changes and leads to
weight loss and/or malnutrition may patterns and body image.69 Reported
decreased bone density and
ensue as various foods are eliminated dieting, body image dissatisfaction,
menstrual irregularities. Body weight
from the diet. Individuals with experiences of weight-based stigma,
may be stable. This energy imbalance
orthorexia may spend excessive or changes in eating or exercise
may result from a lack of knowledge
amounts of time in meal planning and patterns invite further exploration.
regarding nutritional needs in the
experience extreme guilt or Positive responses on a standard
athlete or from intentional intake
frustration when their food-related review of symptoms may need
restriction associated with disordered
practices are interrupted.55,56 further probing. For example,
eating.
Psychologically, this behavior appears oligomenorrhea or amenorrhea
to be related to AN and obsessive- Hormonal disruption and low BMD (either primary or secondary) may
compulsive disorder57 and is can occur in undernourished male indicate energy deficiency.70 Serial
considered by some to be a subset athletes as well.66 Increased weight and height measurements
within the restrictive eating recognition of the role of energy plotted on growth charts are
disorders. Vegetarianism is a lifestyle deficiency in disrupting overall invaluable. Weight loss or the failure
choice adopted by many adolescents physiologic function in both male and to make expected weight gain may be
and young adults that may sometimes female individuals led a 2014 more obvious when documented on
signal underlying eating International Olympic Committee a graph. Similarly, weight fluctuations
pathology.58,59 In a comparison of consensus group to recommend or rapid weight gain may cue a health
adolescent and young adult females replacing the term female athlete care provider to question binge eating
with and without a history of eating triad to the more inclusive term, or BN symptoms. Recognizing that
disorders, those with eating disorders “relative energy deficiency in many patients who present to eating
were more likely to report ever sport.”67,68 Athletes participating in disorder treatment programs have or
having been vegetarian. Many of these sports involving endurance, weight previously had elevated weight
transaminases; urinalysis; and eating disorders; normal results do abnormality. A urine pregnancy test
thyroid-stimulating hormone not exclude the presence of serious and serum gonadotropin and
concentration.72 Screening for illness with an eating disorder or the prolactin levels may be indicated for
specific vitamin and mineral need for hospitalization for medical girls with amenorrhea; a serum
deficiencies (eg, vitamin B12, vitamin stabilization. An electrocardiogram is estradiol concentration may serve as
D, iron, and zinc) may be indicated on important for those with significant a baseline for reassessment during
the basis of the nutritional history of weight loss, abnormal cardiovascular recovery.79 Similarly, serum
the patient. Laboratory investigations signs (such as orthostasis or gonadotropin and testosterone levels
are often normal in patients with bradycardia), or an electrolyte can be useful to assess and monitor
Health care providers may be help ensure that deficits in recommendations for patients who
pressured by patients, their patients’ micronutrients are addressed. vomit include the use of topical
parents, or other health care To optimize bone health, calcium fluoride, applied in the dental office
providers to target a treatment goal and vitamin D supplements can be or home, or use of a prescription
weight that is lower than the previous dosed to target recommended fluoride (5000 ppm) toothpaste.
growth trajectory or other clinical daily amounts (elemental calcium: Because brushing teeth immediately
indicators would suggest is 1000 mg for patients 4–8 years of after vomiting may accelerate enamel
appropriate. If a treatment goal age, or 1300 mg for patients 9–18 erosion, patients can be advised to
weight is inappropriately low, there is years of age; vitamin D: 600 IU for instead rinse with water, followed by
an inherent risk of offering only patients 4–18 years of age).87,131 using a sodium fluoride rinse
partial weight restoration and Patients can be reassured that whenever possible.132
insufficient treatment.129 The the bloating discomfort caused
treatment goal weight is reassessed at by slow gastric emptying improves AN
regular intervals (eg, every 3–6 with regular eating. When
months) to account for changes in constipation is troubling, nutritional Collaborative Outpatient Care
physical growth and development (in strategies, including weight Most patients with AN are treated in
particular, age, height, and sexual restoration, are the treatments of outpatient settings.85,133
maturity).87,127 choice.111 When these interventions Pediatricians play an important role
are inadequate to alleviate in the medical management and
An important role for the pediatrician constipation, osmotic (eg, coordination of the treatment of these
is to offer guidance regarding polyethylene glycol 3350) or bulk- patients. The pediatrician plays
eating and to manage the physical forming laxatives are preferred over a primary role in assessing for and
aspects of the illnesses. For all stimulant laxatives. The use of managing acute and long-term
classifications of eating disorders, nonstimulant laxatives decreases the medical complications, monitoring
reestablishing regular eating patterns risks of electrolyte derangement and treatment progress, and coordinating
is a fundamental early step. Meals avoids the potential hazard of care with nutritional and mental
and snacks are reintroduced or “cathartic colon syndrome” that may health colleagues.85,130,134 Although
improved in a stepwise manner, be associated with abuse of stimulant some primary care pediatricians
with 3 meals and frequent snacks cathartics (senna, cascara, bisacodyl, feel comfortable coordinating care,
per day. Giving the message that phenolphthalein, others choose to refer patients
“food is the medicine that is required anthraquinones).99,114 to providers with expertise in
for recovery” and promoting pediatric eating disorders. Ideally,
adherence to taking that medicine To optimize dental outcomes, all members of the treatment team
at scheduled intervals often helps patients can be encouraged to are sensitive to the unique
patients and families get on track.130 disclose their illness to their developmental needs of children
A multivitamin with minerals can dentist. Current dental hygiene and adolescents.133
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