Bulimia and Other Eating Disorders: Recommendations for Identification and Treatment

Eating disorders among adolescents and children are a growing problem in the United States; the number of cases has steadily increased over the past 50 years. Up to 5% of female adolescents have bulimia nervosa, and an estimated 0.5% have anorexia nervosa.¹

Many teenage girls worry about their weight and restrict their caloric intake; most do not have an eating disorder.¹ When should you be concerned? Recommendations from the American Academy of Pediatrics (AAP) offer guidance on when to suspect—and how to manage—eating disorders.¹ Highlights follow.

IDENTIFYING AND EVALUATING EATING DISORDERS

Screening. To better identify eating disorders, the AAP advocates the routine use of screening questions for all preteen and adolescent patients.¹ Ask patients about weight fluctuations, exercise, current dietary practices, any previous therapy for eating disorders, menstrual history, and any history of substance abuse (Table 1). In addition, inquire about symptoms that suggest an eating disorder, such as dizziness, weakness, fatigue, and cold intolerance. Regular evaluation of weight, height, and body mass index against age-appropriate norms is also recommended.

Clues in the history that may signal an eating disorder include¹:

• Inappropriate dieting.
• Excessive concern about weight.
• A pattern of weight loss.
• Failure to achieve appropriate increases in weight or height in growing children.

Any evidence of an eating disorder warrants further investigation and monitoring. Observe patients with suspected eating disorders at frequent intervals (eg, as often as every 1 to 2 weeks) until the reason for the concern becomes evident. Be aware that patients with an eating disorder often deny their illness; in addition, no specific signs or symptoms may be present.

Workup. The goals of the initial evaluation are to determine the severity of the condition as well as the medical, nutritional, and psychosocial status of the patient. Laboratory studies should include a complete blood cell count, electrolyte measurement, liver function tests, urinalysis, and thyroid-stimulating hormone test.

If the diagnosis remains uncertain, the erythrocyte sedimentation rate and results of radiographic studies (such as CT or MRI of the brain or upper or lower gastrointestinal system studies) may be helpful. Order an ECG if the patient has bradycardia or electrolyte abnormalities.

In patients who have amenorrhea, order a urine pregnancy test and measure luteinizing and follicle-stimulating hormone, prolactin, and estradiol levels to rule out other causes. Bone densitometry is recommended if the patient has been amenorrheic for 6 to 12 months.

Assess the psychological status of the patient, or refer to a mental health specialist. Evaluate the patient’s ability to function in the home, school, and social environments as well as obsession with food and weight, awareness of the diagnosis and willingness to receive help. In addition, ascertain the presence of any comorbid psychiatric diagnoses, suicidal tendencies, history of physical or sexual abuse or violence.

After evaluating the severity of the eating disorder, determine the location and method of treatment. Patients with mild nutritional, medical, and psychosocial issues can be treated in the office—typically with the involvement of a dietitian and a mental health specialist. Refer more severe cases to a specialty team in an outpatient, inpatient, or day program setting.

TREATMENT IN OUTPATIENT SETTINGS

Increased caloric intake. Gradually increase caloric intake in a stepwise manner to an intake of 2000 to 3000 kcal per day with a weight gain of 0.5 to 2 lb per week. Base the goal weight on age, height, stage of puberty, premorbid weight, and previous growth charts. In postmenarchal adolescent females, the weight at the resumption of menses (typically 90% of standard body weight) can be used as an indicator in determining the goal weight. Re-evaluate goal weight every 3 to 6 months, based on increasing age and height, in growing children or adolescents. Patients resistant to increasing caloric intake may require the intervention of a specialist.

Psychiatric care. In conjunction with medical care, psychologic, social, and psychiatric care can improve the patient’s long-term prognosis. After malnutrition is successfully treated, options include individual, family, and group therapy as well as psychotropic medications.

Monitoring for complications. Be vigilant for complications during the outpatient treatment of eating disorders. Complications can affect all organ systems, and those that are most commonly seen in the outpatient setting are listed in the Table 2. A rare but dangerous complication of bulimia nervosa is the accidental ingestion of an object used to induce vomiting.

TREATMENT IN HOSPITALS AND DAY PROGRAMS

Hospital setting. The Society for Adolescent Medicine has outlined criteria for the hospitalization of children and adolescents with eating disorders. Among the criteria for patients with anorexia nervosa are the following¹:

• Weight less than 75% of ideal body weight, or ongoing weight loss despite intensive treatment.
• Refusal to eat.
• Body fat less than 10%.
• Heart rate of less than 50 beats per minute during the daytime, or less than 45 beats per minute at night.
• Systolic pressure of less than 90 mm Hg.
• Orthostatic changes in pulse (more than 20 beats per minute) or blood pressure (more than 10 mm Hg).
• Temperature lower than 96°F.
• Arrhythmia.

Hospitalization criteria for patients with bulimia nervosa include¹:

• Syncope.
• Serum potassium concentration of less than 3.2 mmol/L.
• Serum chloride concentration of less than 88 mmol/L.
• Esophageal tears.
• Cardiac arrhythmias including prolonged QTc.
• Hypothermia.
• Suicide risk.
• Intractable vomiting.
• Hematemesis.
• Failure to respond to outpatient treatment.

Treatment in an inpatient setting may require nutrition via a nasogastric tube or intravenously, as well as management of potential metabolic, cardiac, and neurologic complications. 

Day program setting. Patients who require an intermediate level of care should be enrolled in a partial hospitalization, or day treatment program. These programs provide both medical and psychological care. ■

REFERENCE:

1.Rosen DS. Identification and management of eating disorders in children and adolescents. Pediatrics. 2010;126(6):1240-1253.