Identification and Management of Eating Disorders in Children and Adolescents
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CLINICAL REPORT Guidance for the Clinician in Rendering Pediatric Care
Identification and Management of
Eating Disorders in Children
and Adolescents
Laurie L. Hornberger, MD, MPH, FAAP,a Margo A. Lane, MD, FRCPC, FAAP,b THE COMMITTEE ON ADOLESCENCE
Eating disorders are serious, potentially life-threatening illnesses afflicting abstract
individuals through the life span, with a particular impact on both the physical
and psychological development of children and adolescents. Because care for
a
children and adolescents with eating disorders can be complex and resources Division of Adolescent Medicine, Children’s Mercy Kansas City and
School of Medicine, University of Missouri–Kansas City, Kansas City,
for the treatment of eating disorders are often limited, pediatricians may be Missouri; and bDepartment of Pediatrics and Child Health, Max Rady
called on to not only provide medical supervision for their patients with College of Medicine, Rady Faculty of Health Sciences, University of
Manitoba, Winnipeg, Manitoba
diagnosed eating disorders but also coordinate care and advocate for
appropriate services. This clinical report includes a review of common eating Clinical reports from the American Academy of Pediatrics benefit from
expertise and resources of liaisons and internal (AAP) and external
disorders diagnosed in children and adolescents, outlines the medical reviewers. However, clinical reports from the American Academy of
evaluation of patients suspected of having an eating disorder, presents an Pediatrics may not reflect the views of the liaisons or the
organizations or government agencies that they represent.
overview of treatment strategies, and highlights opportunities for advocacy.
Drs Hornberger and Lane were equally responsible for
conceptualizing, writing, and revising the manuscript and considering
input from all reviewers and the board of directors; and all authors
approve the final manuscript as submitted.
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
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PEDIATRICS Volume 147, number 1, January 2021:e2020040279 FROM THE AMERICAN ACADEMY OF PEDIATRICSTABLE 1 Diagnostic Features of Eating Disorders Commonly Seen in Children and Adolescents
DSM-5 Eating Disorder Diagnosis Diagnostic Features
Anorexia nervosa (AN)
A. Restricted caloric intake relative to energy requirements, leading to significantly low body weight for age, sex,
projected growth, and physical health
B. Intense fear of gaining weight or behaviors that consistently interfere with weight gain, despite being at
a significantly low weight
C. Altered perception of one’s body weight or shape, excessive influence of body weight or shape on self-value, or
persistent lack of acknowledgment of the seriousness of one’s low body weight
Subtypes: restricting type (weight loss is achieved primarily through dieting, fasting, and/or excessive exercise. In the
previous 3 mo, there have been no repeated episodes of binge eating or purging); binge-eating/purging type (in
the previous 3 mo, there have been repeated episodes of binge eating or purging; ie, self-induced vomiting or
misuse of laxatives, diuretics, or enemas)
Bulimia nervosa (BN)
Repeated episodes of binge eating. Binge eating is characterized by both of the following: within a distinct period of
time (eg, 2 h), eating an amount of food that is clearly larger than what most individuals would eat during
a similar period of time under similar circumstances and a sense that one cannot limit or control their overeating
during the episode
Repeated use of inappropriate compensatory behaviors for the prevention of weight gain, such as self-induced
vomiting; misuse of laxatives, diuretics, or other medications; fasting; or excessive exercise
On average, the binge eating and compensatory behaviors both occur at least once a week for 3 mo
Self-value is overly influenced by body shape and weight
The binge eating and compensatory behaviors do not occur exclusively during episodes of AN
Binge-eating disorder (BED)
Recurrent episodes of binge eating. An episode of binge eating is characterized by both of the following: within
a distinct period of time (eg, 2 h), eating an amount of food that is clearly larger than what most individuals would
eat during a similar period of time under similar circumstances and sense that one cannot limit or control their
overeating during the episode
The binge-eating episodes include 3 or more of the following: eating much more quickly than normal, eating until
uncomfortably full, eating large amounts of food when not feeling hungry, eating alone because of embarrassment
at how much one is eating, and feeling guilty, disgusted, or depressed afterward
Marked anguish is experienced regarding binge eating
On average, the binge eating occurs at least once a week for 3 mo
The binge eating is not associated with the use of inappropriate compensatory behavior as in BN and does not occur
only in the context of BN or AN
Avoidant/restrictive food intake disorder
(ARFID)
A disrupted eating pattern (eg, seeming lack of interest in eating or food; avoidance based on the sensory qualities of
food; concern about unpleasant consequences of eating) as evidenced by persistent failure to meet appropriate
nutritional and/or energy needs associated with 1 (or more) of the following: significant weight loss or, in children,
failure to achieve expected growth and/or weight gain, marked nutritional deficiency, reliance on enteral feeding
or oral nutritional supplements, significant interference with psychosocial functioning
The disturbance cannot be better explained by lack of available food or by an associated culturally sanctioned
practice
The eating disturbance cannot be attributed to a coexisting medical condition nor better explained by another mental
disorder. If the eating disturbance occurs in the context of another condition or disorder, the severity of the eating
disturbance exceeds that routinely associated with the condition or disorder
Other specified feeding or eating
disorders, examples
Atypical AN: all of the criteria for AN are met yet the individual’s weight is within or above the normal range despite
significant weight loss
BN (of low frequency and/or limited duration): All of the criteria for BN are met, but, on average, the binge eating and
compensatory behaviors occur less than once a week and/or for ,3 mo
BED (of low frequency and/or limited duration): All of the criteria for BED are met, but, on average, the binge eating
occurs less than once a week and/or for ,3 mo
Purging disorder: recurrent purging behavior (eg, self-induced vomiting; misuse of laxatives, diuretics, or other
medications) in the absence of binge eating with the intent to influence weight or body shape
Adapted from the DSM-5, American Psychiatric Association, 2013.2
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
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2 FROM THE AMERICAN ACADEMY OF PEDIATRICSexpands these into adolescence and BED prevalence rates of 2 to 4, with Eating disorders can occur in
adulthood. Individuals with ARFID a more equal distribution between individuals with various body
intentionally limit intake for reasons girls and boys, making it perhaps the habitus, and their presence in those of
other than for concern for body most common eating disorder among larger body habitus is increasingly
weight, such as the sensory adolescents.14 In contrast, the apparent.31–34 Weight stigma (the
properties of food, a lack of interest in diagnoses seen in treatment may undervaluation or negative
eating, or a fear of adverse belie the relative prevalence of these stereotyping of individuals because
consequences with eating (eg, disorders. In a review of 6 US they have overweight or obesity)
choking or vomiting). As a result, they adolescent eating disorder treatment seems to play a role. Adolescents with
may experience weight loss or failure programs, the distribution of larger body habitus are exposed to
to achieve expected weight gain, diagnoses was 32 AN, 30 atypical AN, weight stigma through the media,
malnutrition, dependence on 9 BN, 19 ARFID, 6 purging disorder, their families, peers, and teachers,
nutritional supplementation, and/or and 4 others. 15 This may reflect the and health care professionals,
interference with psychosocial underrecognition and/or resulting in depression, anxiety, poor
functioning.6–9 The category “other undertreatment of disorders such as body image, social isolation,
specified feeding and/or eating BED. unhealthy eating behaviors, and
disorder” is now applied to patients worsening obesity.35 When
whose symptoms do not meet the full Although previously mischaracterized presenting with significant weight
criteria for an eating disorder despite as diseases of non-Hispanic white, loss but a BMI still classified in the
causing significant distress or affluent adolescent girls, eating “healthy,” overweight, or obese
impairment. Among these disorders disorder behaviors are increasingly ranges, patients with eating disorders
is atypical AN in which diminished recognized across all racial and ethnic such as atypical AN may be
self-worth, nutritional restriction, and groups16–20 and in lower overlooked by health care
weight loss mirrors that seen with socioeconomic classes,21 providers36,37 but may experience the
AN, although body weight at preadolescent children,22 males, and same severe medical complications as
presentation is in the normal or children and adolescents perceived as those who are severely
above-normal range. Efforts are having an average or increased body underweight.38–40
ongoing to further categorize size.
Increased rates of disordered eating
abnormal eating behaviors and refine Preteens with eating disorders are may be found in sexual minority
diagnoses.10 more likely than older adolescents to youth.41–43 Analysis of Youth Risk
Epidemiology have premorbid psychopathology Behavior Survey data reveals lesbian,
(depression, obsessive-compulsive gay, and bisexual high school students
Prevalence data for eating disorders disorder, or other anxiety disorders) have significantly higher rates of
vary according to study populations and less likely to have binge and unhealthy and disordered weight-
and the criteria used to define an purge behaviors. There is a more control behaviors than their
eating disorder.11 A systematic review equal distribution of illness by sex heterosexual peers.44,45 Transgender
of prevalence studies published among younger patients and, youth may be at particular risk.46,47
between 1994 and 2013 found widely frequently, more rapid weight loss, In a survey of nearly 300 000 college
varied estimates in the lifetime leading to earlier presentation to students, transgender students had
prevalence of eating disorders, with health care providers.23 the highest rates of self-reported
a range from 1.0 to 22.7 for female
eating disorder diagnoses and
individuals and 0.3 to 0.6 for male Although diagnosis in males may
compensatory behaviors (ie, use of
indnividuals.12 A 2011 cross-sectional increase with the more inclusive
diet pills or laxatives or vomiting)
survey of more than 10 000 DSM-5 criteria,24,25 it is often delayed
compared with all cisgender groups.
nationally representative US because of the misperception of
Nearly 16 of transgender respondents
adolescents 13 to 18 years of age health care providers that eating
reported having been diagnosed with
estimated prevalence rates of AN, BN, disorders are female disorders.26 In
an eating disorder, as compared with
and BED at 0.3, 0.9, and 1.6, addition, disordered eating attitudes
1.85 of cisgender heterosexual
respectively. Behaviors suggestive of may differ in male individuals,27
women.48
AN and BED but not meeting focusing on leanness, weight control,
diagnostic thresholds were identified and muscularity. Purging, use of Adolescents with chronic health
in another 0.8 and 2.5, respectively. muscle-building supplements, conditions requiring dietary control
The mean age of onset for each of substance abuse, and comorbid (eg, diabetes, cystic fibrosis,
these disorders was 12.5 years.13 depression are common in inflammatory bowel disease, and
Several studies have suggested higher males.28–30 celiac disease) may also be at
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PEDIATRICS Volume 147, number 1, January 2021 3TABLE 2 Example Questions to Ask Adolescents With a Possible Eating Disorder
History/Information Example Questions
Weight history
What was your highest weight? How tall were you? How old were you?
What was your lowest weight? How tall were you? How old were you?
Body image
What do you think your weight should be? What feels too high? What feels too low?
Are there body areas that cause you stress? Which areas?
Do you do any body checking (ie, weighing, body pinching or checking, mirror checking)?
How much of your day is spent thinking about food or your body?
Diet history
24-h diet history
Do you count calories, fat, carbohydrates? How much do you allow? What foods do you avoid?
Do you ever feel guilty about eating? How do you deal with that guilt (ie, exercising, purging, eating less)?
Do you feel out of control when eating?
Exercise history
Do you exercise? What activities? How often? How intense is your workout?
How stressed do you feel when you are unable to exercise?
Binge eating and purging
Do you ever binge? On what foods? How much? How often? Any triggers?
Do you vomit? How often? How soon after eating?
Do you use laxatives, diuretics, diet pills, caffeine? What types? How many? How often?
Family history
Does anyone in your family have a history of dieting or an eating disorder? Anyone on special diets (eg, vegetarian, gluten-free)?
Anyone with obesity?
Does anyone in your family have a history of depression, anxiety, bipolar disorder, obsessive-compulsive disorder, substance abuse,
or other psychiatric illness?
Does anyone in your family take psychiatric medication?
Review of systems
Dizziness, syncope, weakness or fatigue?
Pallor, easy bruising or bleeding, cold intolerance?
Hair loss, lanugo, dry skin?
Constipation, diarrhea, early fullness, bloating, abdominal pain, heartburn?
Palpitations, chest pain?
Muscle cramps, joint pains?
Excessive thirst and voiding?
For girls: Age at menarche? Frequency of menses? LMP? Weight at time of LMP?
Psychosocial history
(HEADSS)
Home
Who lives in the home?
How well do the family members get along with each other?
Is the family experiencing any stressors?
Education
Where do you attend school? What grade? Regular classroom?
Is school challenging for you? What grades do you receive? Has there been a change in your grades?
Activities
What activities are you involved in outside of the classroom?
Do you have friends you can trust? Have you experienced any bullying?
What Web sites do you most often visit when you go online? How much time is spent each day online?
Drug use
Have you ever used tobacco, e-cigarettes, alcohol, or drugs? Which ones? How much? How often?
Have you ever used anabolic steroids or stimulants? Caffeine consumption? Other substances?
Depression/suicide
How is your mood? Increased irritability? Feelings of depression or hopelessness? Any anxiety or obsessive-compulsive thoughts or
behaviors?
Any history of cutting or self-injury?
Have you ever wished you were dead? How often do you have these thoughts? When was the last time? Any thoughts of suicide?
What methods have you imagined? Any attempts?
History of physical, sexual or emotional abuse?
Any previous mental health care?
Sexual history
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4 FROM THE AMERICAN ACADEMY OF PEDIATRICSTABLE 2 Continued
History/Information Example Questions
Do you feel that the gender you feel inside matches your body on the outside?
Are you romantically or sexually attracted to guys, girls, or both? Not sure?
Have you had any sexual contact with another person? If yes, was it with guys, girls or both? Use of condoms? Use of
contraceptives? History of pregnancy or sexually transmitted infection?
Has anyone touched you sexually when you didn’t want to be touched?
Adapted from Rome and Strandjord.89 LMP, last menstrual period.
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
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PEDIATRICS Volume 147, number 1, January 2021 5TABLE 3 Notable Physical Examination Features in Children and Adolescents With Eating Disorders may have been unrecognized
Features related to inadequate energy intake or malnutrition: previously.
Deviation from previous growth trajectory when plotted on height, weight, and BMI graphs
Abnormal vital signs: A comprehensive physical
Low resting HR or BP examination, including close attention
Orthostatic increase in HR (.20 beats per min) or decrease in BP (.10 mm Hg) to growth parameters and vital signs,
Hypothermia allows the pediatrician to assess for
Flat or anxious affect
signs of medical compromise and for
Pallor, dry sallow skin; carotenemia (particularly palms and soles)
Cachexia: facial wasting, decreased subcutaneous fat, decreased muscle mass signs and symptoms of eating
Dull, thin scalp hair or lanugo disorder behaviors; findings may be
Cardiac murmur (one-third with mitral valve prolapse), cool extremities; acrocyanosis; poor subtle and, thus, overlooked without
perfusion careful notice. For accuracy, weights
Stool mass left lower quadrant
are best obtained after the patient has
Delayed or interrupted pubertal development
Small breasts; vaginal dryness voided and in an examination gown
Small testes without shoes. Weight, height, and
Features related to purging: BMI can be evaluated by using
Abnormal vital signs: appropriate growth charts. Low body
Orthostatic increase in HR (.20 beats per min) or decrease in BP (.10 mm Hg)
temperature, resting blood pressure
Angular stomatitis; palatal scratches; dental enamel erosions
Russell’s sign (abrasion or callous on knuckles from self-induced emesis) (BP), or resting heart rate (HR) for
Salivary gland enlargement (parotid and submandibular) age may suggest energy restriction.
Epigastric tenderness Because a HR of 50 beats per minute
Bruising or abrasions over the spine (related to excessive exercise or sit ups) or less is unusual even in college-
Features related to excess energy intake:
aged athletes,76 the finding of a low
Deviation from previous growth trajectory when plotted on height, weight, and BMI curves
Obesity HR may be a sign of restrictive eating.
Elevated BP or hypertension Orthostatic vital signs (HR and BP,
Acanthosis nigricans, acne, hirsutism obtained after 5 minutes of supine
Hepatomegaly rest and repeated after 3 minutes of
Premature puberty
standing)77,78 revealing a systolic BP
Musculoskeletal pain
drop greater than 20 mm Hg,
Adapted from Rosen; American Academy of Pediatrics.208
a diastolic BP drop greater than 10
mm Hg, or tachycardia may suggest
according to criteria from the Centers the Academy for Eating Disorders.72 volume depletion from restricted
for Disease Control and Prevention,71 Relevant interview questions are fluid intake or purging or
it is worthwhile to carefully inquire listed in Table 2. A collateral history a compromised cardiovascular
about eating and exercise patterns from a parent may reveal abnormal system.
when weight loss is noted in any child eating-related behaviors that were Pertinent physical findings in children
or adolescent. Screening for denied or minimized by the child or and adolescents with eating disorders
unhealthy and extreme weight- adolescent. are summarized in Table 3. A
control measures before praising differential diagnosis for the signs
desirable weight loss can avoid A full psychosocial assessment, and symptoms of an eating disorder
inadvertently reinforcing these including a home, education, is found in Table 4, and selected
practices. activities, drugs/diet, sexuality, medical complications of eating
suicidality/depression (HEADSS) disorders are provided in Table 5.
assessment is vital. This evaluation
ASSESSMENT OF CHILDREN AND includes screening for physical or
ADOLESCENTS WITH SUSPECTED sexual abuse by using the principles LABORATORY EVALUATION
EATING DISORDERS of trauma-informed care and Initial laboratory evaluation is
A comprehensive assessment of responding according to American performed to screen for medical
a child or adolescent suspected of Academy of Pediatrics guidance on complications of eating disorders or
having an eating disorder includes suspected physical or sexual abuse or to rule out alternate diagnoses
a thorough medical, nutritional, and sexual assault73–75 as well as state (Tables 4 and 5). Typical initial
psychiatric history, followed by laws. Vital to the HEADSS assessment laboratory testing includes
a detailed physical examination. A is an evaluation for symptoms of a complete blood cell count; serum
useful web resource for assessment is other potential psychiatric diagnoses, electrolytes, calcium, magnesium,
published in multiple languages by including suicidal thinking, which phosphorus, and glucose; liver
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6 FROM THE AMERICAN ACADEMY OF PEDIATRICSTABLE 4 Selected Differential Diagnosis for Eating Disorders According to Presentation
Clinical Presentations Differential Diagnosis
Weight loss
Gastrointestinal Inflammatory bowel disease; celiac disease
Endocrine Hyperthyroidism; diabetes mellitus; adrenal insufficiency
Infectious Chronic infections, such as tuberculosis or HIV; intestinal parasite
Psychiatric Depression; psychosis; anxiety or obsessive-compulsive disorder; substance use
Other Neoplasm; superior mesenteric artery syndrome
Vomiting Gastroesophageal reflux disease
Gastrointestinal disease Gastroesophageal reflux disease
Eosinophilic esophagitis
Pancreatitis
Cyclic vomiting
Neurologic Increased intercranial pressure
Migraine
Other Food allergy
Binge eating or unexplained weight gain
Endocrine Hypothyroidism; hypercortisolism
Psychiatric Depression
Iatrogenic Medication side effect
Genetic Prader Willi syndrome; Kleine-Levin syndrome
Adapted from Rome and Strandjord89 and Rosen; American Academy of Pediatrics.208
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
TABLE 5 Selected Medical Complications Resulting From Eating Disorders
Eating Disorder Behaviors Medical Complications
Related to dietary restriction or
weight loss
Fluids and electrolytes Dehydration; electrolyte abnormalities: hypokalemia, hyponatremia
Psychiatric Depressed mood or mood dysregulation; obsessive-compulsive symptoms; anxiety
Neurologic Cerebral cortical atrophy; cognitive deficits; seizures
Cardiac Decreased cardiac muscle mass, right axis deviation, low cardiac voltage; cardiac dysrhythmias, cardiac conduction
delays; mitral valve prolapse; pericardial effusion; congestive heart failure; edema
Gastrointestinal Delayed gastric emptying, slowed gastrointestinal motility, constipation; superior mesenteric artery syndrome;
pancreatitis; elevated transaminases; hypercholesterolemia
Endocrinologic Growth retardation; hypogonadotropic hypogonadism: amenorrhea, testicular atrophy, decreased libido; sick euthyroid
syndrome; hypoglycemia/hyperglycemia, impaired glucose tolerance; hypercholesterolemia; decreased BMD
Hematologic Leukopenia, anemia, thrombocytopenia, elevated ferritin; depressed erythrocyte sedimentation rate
Related to vomiting
Fluid and electrolytes Electrolyte disturbance: hypokalemia, hypochloremia, metabolic alkalosis
Dental Dental erosions
Gastrointestinal Gastroesophageal reflux, esophagitis; Mallory-Weiss tears; esophageal or gastric rupture
Related to laxative use
Fluids and electrolytes Hyperchloremic metabolic acidosis; hypocalcemia
Gastrointestinal Laxative dependence
Related to binge eating Obesity with accompanying complications
Related to refeeding Night sweats; polyuria, nocturia; refeeding syndrome: electrolyte abnormalities, edema, seizures, congestive heart failure
(rare)
Seen among all eating disorder Suicide
behaviors
Adapted from Rosen; American Academy of Pediatrics.208
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PEDIATRICS Volume 147, number 1, January 2021 7for central hypogonadism in boys participants had deficits in executive increased growth of cariogenic oral
with restrictive eating. Bone functioning, including global bacteria.98,100
densitometry, by using dual processing and cognitive flexibility
radiograph absorptiometry analyzed but performed better than control Cardiovascular Effects
with age-appropriate software, may participants on measures of visual Reports of cardiac complications in
be considered for those with attention and vigilance.94 eating disorders are focused
amenorrhea for more than 6 to 12 predominantly on restrictive eating
months.80,81 If there is uncertainty Structural brain imaging studies to
disorders. Common cardiovascular
about the diagnosis, other studies date have yielded inconsistent results,
signs include low HR, orthostasis, and
including inflammatory markers, likely explained, at least in part, by
poor peripheral perfusion.
serological testing for celiac disease, methodologic differences and the
Orthostatic intolerance symptoms
serum cortisol concentrations, testing need to control for many variables,
(eg, lightheadedness) and vital sign
stool for parasites, or radiographic including nutritional state, hydration,
findings may resemble those of
imaging of the brain or medication use, and comorbid
postural orthostatic tachycardia
gastrointestinal tract may be illness.95 A longitudinal study
syndrome101,102 and may contribute
considered. In the occasional patient, revealed that global cortical thinning
to a delay in referral to appropriate
both an eating disorder and an in acutely ill adolescents and young
care if eating disorder behaviors are
organic illness, such as celiac disease, adults with AN normalized with
not disclosed or appreciated.
may be discovered.82 weight restoration over a period of
approximately 3 months.96 Cardiac structural changes include
decreased left ventricular (LV) mass,
MEDICAL COMPLICATIONS IN PATIENTS LV end diastolic and LV end systolic
Dermatologic Effects
WITH EATING DISORDERS volumes, functional mitral valve
Common skin changes in
Eating disorders can affect every prolapse, pericardial effusion, and
underweight patients include lanugo,
organ system83,84 with potentially myocardial fibrosis (noted in
hair thinning, dry scaly skin, and
serious medical complications that adults).103–105 Electrocardiographic
yellow discoloration related to
develop as a consequence of abnormalities, including sinus
carotenemia. Brittle nails and angular
malnutrition, weight changes, or bradycardia, and lower amplitude LV
cheilitis may also be observed.
purging. Details of complications are forces are more common in AN than
Acrocyanosis can be observed in
described in reviews85–89 and are in nonrestrictive eating disorders.106
underweight patients and may be
summarized in Table 5. Most medical One study reported a nearly 10
a protective mechanism against heat
complications resolve with weight prevalence of prolonged (.440
loss. Abrasions and calluses over the
normalization and/or resolution of milliseconds) QTc interval in
knuckles can occur from cutting the
purging. Complications of BED can hospitalized adolescents and young
skin on incisors while self-inducing
include those of obesity; these are adults with a restrictive eating
emesis.97
summarized in other reports and not disorder.107 Repolarization
reiterated here.84,90 abnormalities, a potential precipitant
Dental and/or Oral Effects to lethal arrhythmia,108 may prompt
Psychological and Neurologic Effects Patients with eating disorders clinicians to also consider other
Psychological symptoms can be experience higher rates of dental factors, such as medication use or
primary to the eating disorder, erosion and caries. This occurs more electrolyte abnormalities, that may
a feature of a comorbid psychiatric frequently in those who self-induce affect cardiac conduction.107,109
disorder, or secondary to starvation. emesis but can also be observed in
Initial symptoms of depression and those who do not.98 Normal dental Gastrointestinal Tract Effects
anxiety may abate with refeeding.91 findings do not preclude the Gastrointestinal complaints are
Rumination about body weight and possibility that purging is common and sometimes precede the
size is a core feature of AN, whereas occurring.99 Hypertrophy of the diagnosis of the eating disorder.
rumination about food decreases as parotid and other salivary glands, Delayed gastric emptying and slow
starvation reverses.92 Difficulty in accompanied by elevations in serum intestinal transit time often
emotion regulation occurs across the amylase concentrations with normal contribute to reported sensations of
spectrum of eating disorders but is lipase concentrations, may be a clue nausea, bloating, and postprandial
more severe in those who binge eat to vomiting.99 Xerostomia, from fullness110 and may be a presenting
or purge.93 Cognitive function studies either salivary gland dysfunction or feature of restrictive eating.
in a large population-based sample of psychiatric medication side effect, can Constipation is a frequent experience
adolescents revealed eating disorder reduce the oral pH, which can lead to for patients and multifactorial in
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8 FROM THE AMERICAN ACADEMY OF PEDIATRICSetiology.111 Esophageal mucosal supplemental thyroid hormone is not a healthy sense of self. Independent of
damage from self-induced vomiting, indicated when this pattern is a specific DSM diagnosis, treatment is
including scratches, and bleeding noted.116 Hypercortisolemia may be focused on nutritional repletion and
secondary to Mallory-Weiss tears can seen in AN.81,116 Hypothalamic- psychological therapy. Psychotropic
occur.99 Superior mesenteric artery pituitary-gonadal axis suppression medication can be a useful adjunct in
syndrome may develop in the setting may be attributable to weight loss, select circumstances.
of severe weight loss.111 Hepatic physical overactivity, or stress.
transaminase concentrations and Female individuals with AN may have The Pediatrician’s Role in Care
coagulation times can be elevated as amenorrhea, and male individuals can
After diagnosing an eating disorder,
a consequence of malnutrition and, have small testicular volumes117 and
the pediatrician arranges appropriate
typically, normalize with appropriate low testosterone concentrations.118
care. Patients who are medically
nutrition.110
Growth retardation, short stature, and unstable may require urgent referral
Renal and Electrolyte Effects pubertal delay may all be observed in to a hospital (Table 6). Patients with
prepubertal and peripubertal mild nutritional, medical, and
Fluid and electrolyte abnormalities
children and adolescents with eating psychological dysfunction may be
may occur as a result of purging or
disorders.115 AN is associated with managed in the pediatrician’s office in
cachexia.99,112 Dehydration can be
low levels of insulin-like growth collaboration with outpatient
present in any patient with an eating
factor-1 and growth hormone nutrition and mental health
disorder. Disordered osmotic
resistance.119 Catch-up growth has professionals with specific expertise
regulation can present in many
been inconsistently reported in the in eating disorders. Because an early
patterns (central and renal diabetes
literature; younger patients may have response to treatment may be
insipidus, syndrome of inappropriate
greater and more permanent effects associated with better
antidiuretic hormone).112 Patients
on growth.120,121 Adolescent boys outcomes,125,126 timely referral to
who vomit may have a hypokalemic,
may be at an even greater risk for a specialized multidisciplinary team
hypochloremic metabolic alkalosis
height deficits than girls; because is preferred, when available. If
resulting from loss of gastric
boys typically enter puberty later resources do not exist locally,
hydrochloric acid, chronic
than girls and experience their peak pediatricians may need to partner
dehydration, and the subsequent
growth at a later sexual maturity with health experts who are farther
increase in aldosterone that promotes
stage, they are less likely to have away for care. For patients who do
sodium reabsorption in exchange for
completed their growth if an eating not improve promptly with
potassium and acid at the distal
disorder develops in the middle outpatient care, more intensive
tubule level.113 Patients who abuse
teenage years.119 programming (eg, day-treatment
laxatives may experience a variety of
programs or residential settings) may
electrolyte and acid-base Low BMD is a frequent complication be indicated.
derangements.113 Dilutional of eating disorders in both male and
hyponatremia can be observed in female patients117 and is a risk in Often, an early task of the pediatrician
patients who intentionally water load both AN and BN.122 Low BMD is is to identify a treatment goal weight.
to induce satiety or to misrepresent worrisome not only because of the This goal weight may be determined
their weight at clinic visits. Abrupt increased risk of fractures in the in collaboration with a registered
cessation of laxative use may be short-term123 but, also, because of the dietitian. Pediatricians who are
associated with peripheral edema potential to irreversibly compromise planning to refer the patient to
and, therefore, motivate further skeletal health in adulthood.124 a specialized treatment team may opt
laxative114 or diuretic misuse. to defer the task to the team.
Acknowledging that body weights
Endocrine Effects TREATMENT PRINCIPLES ACROSS THE naturally fluctuate, the treatment goal
Restrictive eating disorders EATING DISORDER SPECTRUM weight is often expressed as a goal
commonly cause endocrine The ultimate goals of care in eating range. Individualized treatment goal
dysfunction.80,115 Euthyroid sick disorders are that children and weights are formulated on the basis
syndrome (low triiodothyronine, adolescents are nourished back to of age, height, premorbid growth
elevated reverse triiodothyronine, or their full healthy weight and growth trajectory, pubertal stage, and
normal or low thyroxine and thyroid- trajectory, that their eating patterns menstrual history.87,127 In a study of
stimulating hormone) is the most and behaviors are normalized, and adolescent girls with AN, of those
common thyroid abnormality.116 that they establish a healthy who resumed menses during
Functioning as an adaptive relationship with food and their body treatment, this occurred, on average,
mechanism to starvation, weight, shape, and size as well as at 95 of the treatment goal weight.128
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PEDIATRICS Volume 147, number 1, January 2021 9TABLE 6 Indications Supporting Hospitalization in an Adolescent With an Eating Disorder
One or More of the Following Justify Hospitalization
1. #75 median BMI for age and sex (percent median BMI calculated as patient BMI/50th percentile BMI for age and sex in reference population 3 100)
2. Dehydration
3. Electrolyte disturbance (hypokalemia, hyponatremia, hypophosphatemia)
4. ECG abnormalities (eg, prolonged QTc or severe bradycardia)
5. Physiologic instability:
a. Severe bradycardia (HR ,50 beats per min daytime; ,45 beats per min at night);
b. Hypotension (90/45 mm Hg);
c. Hypothermia (body temperature ,96°F, 35.6°C);
d. Orthostatic increase in pulse (.20 beats per min) or decrease in BP (.20 mm Hg systolic or .10 mm Hg diastolic)
6. Arrested growth and development
7. Failure of outpatient treatment
8. Acute food refusal
9. Uncontrollable binge eating and purging
10. Acute medical complications of malnutrition (eg, syncope, seizures, cardiac failure, pancreatitis and so forth)
11. Comorbid psychiatric or medical condition that prohibits or limits appropriate outpatient treatment (eg, severe depression, suicidal ideation, obsessive-
compulsive disorder, type 1 diabetes mellitus)
Reprinted with permission from the Society for Adolescent Health and Medicine.85 ECG, electrocardiogram.
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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10 FROM THE AMERICAN ACADEMY OF PEDIATRICSEducating young people and their restoration is the primary goal. pediatrician directs the care only
parents about the physiologic Parents, supported by the therapist, when there are immediate medical
and psychological effects of food take responsibility to ensure that safety concerns. If the pediatrician
restriction is an early component their child eats sufficiently and limit identifies an urgent medical issue
of care. Parents are empowered pathologic weight-control behaviors. that requires intervention or
to feed their children regularly Parents are encouraged to take hospitalization, he or she is obligated
(typically 3 meals and 2–3 snacks responsibility for meal planning and to provide recommendations to
per day) and adjust portion size preparation. Pediatricians can be the patient, the parents, and the
and energy richness based on helpful by reminding parents of the primary therapist. For the medically
weight progress. Many parents are importance of fighting the disease stable patient, the pediatrician acts
amazed to discover the amount of effectively in the early stages, with as a consultant to the parents and
energy (3500 kcal or more) that the goals of reaching a truly healthy primary therapist. When a parent
may be required to restore weight weight, resuming pubertal asks a question related to treatment,
for their children. Detailed tracking development, reversing medical instead of directly advising the
of caloric intake is not necessary. complications, and restoring normal parents what to do, the pediatrician,
Serving foods with high caloric cognitions. Early weight gain (4–5 ideally, redirects that treatment
density and ensuring that beverages pounds by session 4, typically decision back to the parent: “You
are energy rich (eg, choosing correlating with 4 weeks of know your child the best. What
fruit juice or milk instead of water) treatment) is predictive of better do you think will best help in your
are effective strategies to maximize outcomes in adolescents.126,137,138 child’s recovery?” In this way, the
energy intake without requiring By phase 2, substantial weight physician empowers parents to
large increases in volume. Parents recovery has occurred, and the make their own decisions, enhancing
can relieve adolescents of having adolescent gradually resumes their confidence to care for their ill
to decide on appropriate serving responsibility for his or her own child.
sizes by plating meals for them. eating. By phase 3, weight has been
Accommodating special diets, restored, and the therapy shifts to Day-Treatment Programs
such as vegetarian or vegan, can address general issues of adolescent Day-treatment programs (day
make meeting nutritional goals psychosocial development.136 This hospitalization and partial
especially challenging. Reintroducing therapy is detailed in manuals for hospitalization) provide an
foods that have been avoided or providers137 and families.139 FBT intermediate level of care for patients
that induce fear of weight gain with experienced providers is not with eating disorders who are
are essential steps on the path to available in all communities. medically stable and do not require
recovery. Nevertheless, community providers 24-hour supervision but need more
may integrate the essential principles than outpatient care.133,141 These
Family-Based Treatment and Parent- of FBT in their work with patients programs may prevent the need for
Focused Therapy and families.130 higher levels of care or may be
Over the past 2 decades, a specialized a “step-down” from inpatient or
Parent-focused therapy is an
eating disorder–focused, family-based residential to outpatient care. Day
adaptation of FBT wherein the
intervention, commonly referred to as treatment typically involves 8 to 10
therapist supports the parents to
family-based treatment (FBT), has hours per day of care (including
renourish the patient and limit
emerged as the leading first-line meals, therapy, groups, and other
weight-control behaviors but, after
treatment approach for pediatric activities) by a multidisciplinary staff
the initial appointment, meets only
eating disorders.135 Effectiveness is 5 days per week. Reported
with the parents.140 The patient has
well established for AN.133,136 Rather evaluations of child and adolescent
brief visits with a nurse or physician
than dwelling on possible causes of day-treatment programs are few and
for the assessment of weight and
the eating disorder, FBT is focused on observational in design.142–145
acute mental health issues but is not
recovery from the disease. FBT Despite the absence of systematic
directly involved with a therapist.
consists of 3 phases and contends data supporting their usefulness,
that parents are not to blame for their The role pediatricians serve in the these programs are generally believed
child’s illness, eating disorders are care of an adolescent in FBT differs to have an important role in the
not caused by dysfunctional families, from the customary role of continuum of care.
and parents play an essential role in a physician with patients.134 In the
recovery.136 During appointments, FBT setting, the pediatrician does not Residential Treatment
the entire family unit meets with the weigh the patient because that task is Residential treatment may be
therapist. In phase 1, weight performed by the therapist. The necessary for a minority of medically
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PEDIATRICS Volume 147, number 1, January 2021 11stable patients with eating disorders. remains to be seen how many severely malnourished (,70 median
Indications for residential treatment programs will pursue this BMI) children until further studies
include a poor motivation for accreditation. are reported.87,154
recovery, need for structure and
The National Eating Disorders Nasogastric tube (NGT) feeding may
supervision to prevent unhealthy
Association Web site offers be necessary for some hospitalized
behaviors (eg, food restriction,
useful suggestions for evaluating adolescents, but opinions vary
compulsive exercise), lack of
treatment programs (www. regarding when they should be
a supportive family environment,
nationaleatingdisorders.org). initiated.161 Most North American
absence of outpatient treatment in
programs reserve NGT feeds for when
the patient’s locale,146 or outpatient Hospital-Based Stabilization patients are not able to complete
interventions having been
Suggested indications for the meals; however, internationally, some
unsuccessful.133 Residential
hospitalization of children and centers report the routine use of NGT
treatment typically includes 24 hour
adolescents with eating disorders feeding, either exclusively at first or
per day supervision, medical
published by the Society for in combination with meals.162,163
oversight, group-based
Adolescent Health and Medicine are Potential benefits of NGT feeding
psychoeducational therapy,
listed in Table 6. include faster weight gain and
nutritional counseling, individual
medical stabilization, with
therapy, and family therapy. The The most common goal for hospital-
a possibility for a reduced hospital
length of stay can be weeks to based stabilization is nutritional
length of stay.162,163 Although viewed
months, depending on the severity of restoration. Variation occurs with
by some health care providers as
illness and financial resources. regard to how quickly hospitalized
invasive or punitive, others view
Outcome studies reported by patients with AN are refed.153,154 It is
NGT feeding as empathic, by reducing
residential programs, generally, important to balance 2 competing
both physical and psychological pain
reveal improved symptomatology at goals: achieve weight gain swiftly and
in the early treatment stages.161
discharge,147 but the results at long- avoid refeeding syndrome.155
There is insufficient evidence to
term follow-up are mixed.148,149 Refeeding syndrome refers to the
recommend one approach over
However, few outcome studies are metabolic and clinical changes that
another.154 Independent of whether
focused on adolescents, compare the occasionally occur when
NGT feeds are used routinely,
efficacy of residential to outpatient a malnourished patient is
physicians involved in the treatment
treatment, or make comparisons aggressively nutritionally
of hospitalized medically unstable
across programs or treatment rehabilitated; the hallmarks are
patients may be called on to provide
modalities. hypophosphatemia and multiorgan
nutrition via an NGT when nutritional
dysfunction.155–157 A systematic
Although some adolescents needs are not being met. The use of
review of hospitalized adolescents
require this higher level of care, total parenteral nutrition carries
with AN reported an average
health care providers and families higher risks of medical complications,
incidence of refeeding
are encouraged to exercise caution is costly, and is not recommended
hypophosphatemia (without
when selecting a residential unless other forms of refeeding are
necessarily organ dysfunction) of
not possible.154
treatment program. The number of 14.158 Over the past decade, a long
residential programs has more than followed maxim, “start low and go High-quality studies in which
tripled in the last decade, with many slow,” has been challenged.87,155 researchers examine the impact of
operated by for-profit companies. Several centers have described inpatient care are limited, and the
Marketing practices by some are starting calories at 1400 kcal or more best end point for hospital treatment
questionable.150 Outcome studies per day,154 including recent reports of children and adolescents is unclear.
demonstrating program efficacy may demonstrating safe treatment of A US multicenter research
be misleading because of a lack of mildly and moderately malnourished collaborative showed that, in
rigorous design or peer review.151 adolescents by using initial caloric a national cohort of low-weight 9- to
Until recently, there was no prescriptions of 2200 to 2600 kcal 21-year-olds with restrictive eating
certification process to ensure per day, while achieving a weight gain disorders, those who were
program quality and safety. In 2016, of approximately 3 to 4.5 pounds per hospitalized had a greater odds
The Joint Commission implemented week.159,160 Because the risk of of being at 90 of the median BMI
new accreditation standards for refeeding hypophosphatemia may at 1-year follow-up.164 However,
behavioral health care organizations correlate with the degree of a randomized controlled trial
that provide outpatient or residential starvation, pediatricians may opt to (RCT) of treatment of adolescent
eating disorder treatment.152 It take a more cautious approach in AN in the United Kingdom revealed
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