An Introduction to Eating Disorders in Childhood & Adolescence

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

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

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

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

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

6. Trends in BMI weight categories in BC 2013 BC Adolescent Health Survey

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

8. Breakfast 2013 BC Adolescent Health Survey

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

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

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

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

13. BCCH guidelines <75% IBW HR <45/min BP drop >20mmHg Electrolyte derangement Cardiac abnormalities Criteria for urgent admission AAP guidelines - 2014 • Heart rate <50/min day; 45/min night • Systolic pressure <90 mm Hg • Orthostatic changes in pulse (20 beats per min) or blood pressure (10 mm Hg) • Arrhythmia • Temperature <35.6 degrees Celsius • <75% SBW or ongoing weight loss despite intensive management • Body fat 10% • Refusal to eat

14. Cardiovascular complications • Bradycardia • Arrhythmia (irregular heart beat) – especially with low K+ • Postural drop in BP • Postural tachycardia • Mottling/cool peripheries • Cold => abnormal hair growth (lanugo)

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

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

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

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

25. Each bottle of Ensure Plus is approx 350 cal

26. Details • 604 875 2106 – ED Intake Coordinator for consults/referrals to ED team • Fax no: 604 875 2271 • Need a separate consult for Adolescent Medicine – call Adolescent Medicine oncall • New resource folder on Medworxx • Guidelines • Sample meal plans • Daily intake logs • Resource list for parents

27. Questions