Episode Transcript
Introduction
Hi and Welcome to Clerkship Ready - Pediatrics - A podcast aimed at helping you excel during your clinical clerkship in Pediatrics.
I am Dr. Sam Baldazo, and I am a pediatric resident at the University of Virginia
Today, we will be reviewing what you need to know before your first patient with an eating disorder.
Case:
First, we’ll start with a clinical scenario. Feel free to pause this podcast at any point if you want a moment to apply the information you are learning to the case.
You’re seeing a 14 year old girl in your primary care clinic. She has no known medical conditions, but has been seeing a therapist in the community for anxiety for the last year or so.
She plays for her junior varsity soccer team, and also runs track in the offseason. She enjoys reading mystery novels and sketching. She hopes to take an AP Art class next year in high school. Her grades are generally As and Bs, but she got her first C last semester.
On your one on one exam, she reveals that she has some concerns about her body, saying “I look fat compared to my friends.” She tells you that she often skips breakfast because she doesn’t have time before school, and usually eats a light lunch and light dinner because she feels full.
Reviewing her growth curve, she has lost 20 lbs in the last 6 months
- At this point, it’s important to ask why she has lost weight. It is important that you do this respectfully and without judgment. Use open ended questions and let her fill in the story
. Is she intentionally attempting to lose weight? Why?
. Any new medical diagnoses?
. Any other symptoms like diarrhea, vomiting
- Be careful using BMI as a measure, as it is not an accurate predictor of health and a drop from a high BMI into a lower percentile can be mistaken as appropriate. Any sudden weight loss, regardless of starting point, should be worked up
Let’s review the diagnostic criteria for the various eating disorders, all taken from the Diagnostic and Statistical Manual of mental disorders, or DSM5
- Anorexia Nervosa
. DSM5 criteria
. Restriction of energy intake relative to requirements leading to a significantly low body weight
. Intense fear of gaining weight or becoming fat, or persistent behavior that interferes with weight gain
. Disturbance in the way in which one’s body weight or shape is experienced
. Restricting type: symptoms have been primarily restricting for the last 3 months
. Binge/Purge type: symptoms have included binge eating and/or purging episodes in the last 3 months
- Bulimia Nervosa
. Recurrent episodes of binge eating
. eating an amount of food that is larger than others would eat in a discrete time
. sense of lack of control over eating during the episode
. Recurrent inappropriate compensatory behaviors to prevent weight gain
. Self evaluation unduly influenced by body shape and weight
- Avoidant Restrictive Food Intake Disorder or ARFID
. An eating or feeding disturbance (e.g., apparent lack of interest in eating or food; avoidance based on the sensory characteristics of food; concern about aversive consequences of eating) as manifested by persistent failure to meet appropriate nutritional and/or energy needs associated with one (or more) of the following:
. Significant weight loss (or failure to achieve expected weight gain or faltering growth in children).
. Significant nutritional deficiency.
. Dependence on enteral feeding or oral nutritional supplements.
. Marked interference with psychosocial functioning.
. The disturbance is not better explained by lack of available food or by an associated culturally sanctioned practice.
. The eating disturbance does not occur exclusively during the course of anorexia nervosa or bulimia nervosa, and there is no evidence of a disturbance in the way in which one’s body weight or shape is experienced.
. The eating disturbance is not attributable to a concurrent medical condition or not better explained by another mental disorder. When 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 and warrants additional clinical attention.
- Binge Eating Disorder
. Recurrent episodes of binge eating. An episode of binge eating is characterized by both of the following:
. Eating, in a discrete period of time (e.g., within any 2-hour period), an amount of food that is definitely larger than what most people would eat in a similar period of time under similar circumstances.
. A sense of lack of control over eating during the episode (e.g., a feeling that one cannot stop eating or control what or how much one is eating).
. The binge-eating episodes are associated with three (or more) of the following:
. Eating much more rapidly than normal.
. Eating until feeling uncomfortably full.
. Eating large amounts of food when not feeling physically hungry.
. Eating alone because of feeling embarrassed by how much one is eating.
. Feeling disgusted with oneself, depressed, or very guilty afterward.
. Marked distress regarding binge eating is present.
. The binge eating occurs, on average, at least once a week for 3 months.
. The binge eating is not associated with the recurrent use of inappropriate compensatory behavior as in bulimia nervosa and do
- Eating Disorder not otherwise specified EDNOS, the category into which eating disorders that are hard to classify fall.
Case
Returning to our case, the patient reports that she does not engage in binge eating episodes, she does not vomit after meals or take medicines that cause her to vomit or to increase stooling
She does report that she gets significant anxiety when she sees women in magazines at the store, and she weighs herself at home to determine if she should eat dinner.
She reports that she had menarche, or initial menstrual cycle, at age 11, but has not had one in the last 7 months.
What eating disorder do you think our patient might have?
At this point, her symptoms mostly align with anorexia nervosa, restrictive type, but a true diagnosis will take some time and further discussion.
So, you suspect an eating disorder in this patient you are seeing. What are your next steps?
Look out for the following physical exam findings
Small or thin body habitus
Hair loss
Loss of subcutaneous fat, which you can see on the face or around the joints
Lanugo, or a layer of long, thin hair
Also, if you’re concerned about vomiting as a purging behavior, look out for
Knuckle calluses
dental enamel erosion
salivary gland enlargement
Vitals
Patients with eating disorders may be bradycardic, hypotensive, or even hypothermic.
Case
Returning to our case, you have left the patient’s room and are reviewing the patient’s chart
She has a blood pressure of 95/60, and our clinic did not do orthostatic vitals
Her pulse is 48 beats per minute at rest
Her vital signs are otherwise within normal ranges
She is reporting some lightheadedness, especially with standing up, and one episode of syncope about 2 weeks ago
What do you think we should do right now with our patient?
Based on her heart rate, she is unsafe to go home and should go to the emergency room for further evaluation and likely hospitalization for management of malnutrition.
Remember, if any patient has abnormal or concerning vitals or appears unwell, please check in with your resident or attending so you can make a plan together.
You should also consider getting labs, especially a basic metabolic panel or a comprehensive metabolic panel to look at electrolytes. These are crucial in the evaluation for refeeding syndrome If you have concern for liver function or the patient has no baseline CMP, it may be beneficial to have that lab as a baseline going into her hospital evaluation. Also, remember your differential and consider other labs to work up celiac disease, inflammatory bowel disease, hypothyroidism, or others that are clinically relevant.
Hospital management
Now that our patient has been successfully admitted to the hospital, what are our next steps?
Nutritional Rehabilitation consists of multiple aspects
We would definitely benefit from support from a nutritionist. At our program, a nutritionist is consulted immediately on admission and a diet plan is made for the patient. Most centers have a protocol that consists of an initial calorie baseline and advances towards a patient specific goal, with other policies to promote weight gain to improve cardiac and electrolyte status.
These patients are at a high risk of refeeding syndrome, electrolyte abnormalities that can occur when the patient is fed from a relatively starved state. We generally get a daily BMP, magnesium, and phosphorus to track as we initiate nutritional rehab
With the bradycardia that often brings these patients in, it’s a good idea to get an EKG to ensure there is no underlying heart concern or arrhythmia related or unrelated to the malnutrition
Once the patient is medically stable, it is important to connect them with the next steps for care. Let’s talk for a moment about settings of care for eating disorders.
Five main settings for the care of eating disorders
Outpatient specialist appointments (ie, adolescent clinic visits)
intensive outpatient programs
partial hospitalization
residential programs
inpatient hospitalization
Methods of outpatient treatment
Individual therapy with cognitive-behavioral therapy or CBT
Family based treatment
Focus is not on the etiology of the condition, but the current state
3 phases of recovery
Physical, which consists of weight restoration
Behavioral, which consists of transfer of control, step by step, back to the patient in a developmentally appropriate way
Psychological, which consists of a focus on preventing relapse and addressing other psychological concerns contributing to the eating disorder
Intensive Outpatient
Offered for a particular part of day, often centered around a meal
Residential involves living in a facility, but not with the medical monitoring you’d see in a hospital
Takeaways
Identification of eating disorders can be difficult, and it is important to give adolescents time one-on-one to share confidential details about their lives. Look out for acute changes in weight, delay or change in menstrual cycles, reported body insecurity or concerning behaviors around eating or exercise
Patients with eating disorders are at a high risk for future complications, so intervention is important. Studies show that time away from treatment leads to a lower rate of remission. These patients often do not initially want help or want to improve their nutrition, so maintaining that physician-patient connection is important. Remember to treat the eating disorder and have compassion for the person
Pay close attention to the vitals and labs for these patients, as they are at risk for cardiac and electrolyte complications related to malnutrition. Orthostatic vitals can be very helpful to determine current symptoms and risk. Remember to get your resident or attending if you are concerned.
Hospital management is all about watching as we work on nutritional rehabilitation, as well as connecting these patients to the resources they’ll need for the next step. Treatment of eating disorders is often a long road and they’ll need a lot of different team members to help them reach a healthy weight and improved behaviors around food and body image.
Conclusion:
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