Diagnosis and treatment of eating disorders in children and adolescents

Robatto, Ana Paola; Cunha, Carla de Magalhães; Moreira, Luiza Amélia Cabus

doi:10.1016/j.jped.2023.12.001

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Sumário

Review article • J. Pediatr. (Rio J.) 100 (suppl 1) • 2024 • https://doi.org/10.1016/j.jped.2023.12.001 copy

Diagnosis and treatment of eating disorders in children and adolescents

Authorship SCIMAGO INSTITUTIONS RANKINGS

Abstract

Objectives

To provide a narrative review of the main eating disorders (ED), specifically focusing on children and adolescents. This review also aims to help the pediatrician identify, diagnose, and refer children and adolescents affected by this medical condition and inform them about the multidisciplinary treatment applied to these disorders.

Data source

The research was conducted in the Scientific Electronic Library Online (SciELO), Medical Literature Analysis and Retrieval System Online (Medline) databases via PubMed and Embase. Consolidated Guidelines and Guidebooks in the area were also included in the review to support the discussion of ED treatment in childhood and adolescence.

Data synthesis

ED are psychiatric condition that usually begins in adolescence or young adulthood but can occur at any time of life, including in childhood, which has been increasingly frequent. Pediatricians are the first professionals to deal with the problem and, therefore, must be well trained in identifying and managing these disorders, which can be severe, and determine physical complications and quality of life of patients and their families.

Conclusion

ED has shown an increase in prevalence, as well as a reduction in the age of diagnosed patients, requiring adequate detection and referral by pediatricians. The treatment requires a specialized multidisciplinary team and is generally long-lasting for adequate recovery of affected individuals.

Keywords
Eating disorders; Anorexia nervosa; Bulimia nervosa; Avoidant restrictive food intake disorder; Adolescents; Children

Anorexia nervosa	Bulimia nervosa	Binge Eating Disorder	Avoidant Restrictive Food Intake Disorder
A. Restriction of energy intake leading to significantly low body weight in the context of age, sex, developmental trajectory, and physical health. Significant underweight is defined as less than minimally normal or, for children and adolescents, less than minimally expected. B. Intense fear of weight gain or becoming fat, or persistent behavior that interferes with weight gain even at a lower weight. C. Disturbance in the way one experiences body weight, size or shape; excessive influence of body weight or shape on self-assessment; or persistent lack of recognition of the severity of current low body weight. Subtypes: - Restrictive: During the past 3 months, the individual has not had recurrent episodes of bingeing or purging behaviors. In this subtype, weight loss is achieved through diets, fasting and/or physical activity to lose weight. - Compulsive-Purgative: During the last 3 months, the individual has had recurrent episodes of compulsive or purgative behaviors (vomiting, abuse of laxatives and diuretics or enemas).	A. Recurrent episodes of binge eating. An episode of binge eating is characterized by both of the following criteria: 1. Ingestion, in a limited period of time (for example, within a 2-hour period), of a quantity of food definitely greater than most people would consume in a similar period, under similar circumstances; 2. A feeling of lack of control over the episode (for example, a feeling of not being able to stop or control what or how much you eat). B. Inappropriate compensatory behaviors to prevent weight gain, such as self-induced vomiting; abuse of laxatives, diuretics or other medications; fasting; or excessive physical exercise. C. Compulsion and inappropriate compensatory behavior must occur at least once a week for 3 months. D. Self-assessment unduly influenced by weight and body shape. E. The disorder does not occur exclusively during episodes of anorexia nervosa.	A. Recurrent episodes of binge eating. An episode of binge eating is characterized by both of the following criteria: 1. Ingestion, in a limited period of time (for example, within a 2-hour period), of a quantity of food definitely greater than most people would consume in a similar period, under similar circumstances; 2. A feeling of lack of control over the episode (for example, a feeling of not being able to stop or control what or how much you eat). B. Binge eating episodes are associated with three (or more) of the following criteria: 1. eating a lot and more quickly than normal; 2. eat until you feel uncomfortably full; 3. eating large amounts of food when not physically hungry; 4. eating alone out of embarrassment due to the amount of food consumed; 5. Feeling self-disgust, depression, or too much guilt after overeating. C. Marked anxiety related to binge eating. D. Binge eating occurs, on average, one day a week for three months. E. Binge eating is not associated with the recurrent use of inappropriate compensatory behaviors as in bulimia nervosa and does not occur exclusively during the course of bulimia nervosa or anorexia nervosa.	A. An eating disorder (e.g., apparent lack of interest in eating or foods; avoidance based on the sensory characteristics of food; concern about food aversive consequences) manifested by persistent failure to meet appropriate nutritional and/or energy needs associated with one (or more) of the following aspects: 1. Significant weight loss (or failure to achieve expected weight gain or stunted growth in children); 2. Significant nutritional deficiency; 3. Dependence on enteral feeding or oral nutritional supplements; 4. Marked interference with psychosocial function. B. The disorder is not better explained by the unavailability of food or a culturally accepted practice. C. The eating disorder does not occur exclusively during the course of anorexia nervosa or bulimia nervosa, and there is no evidence of disturbance in the way weight or body shape is experienced. D. The eating disorder is not attributable to a concurrent medical condition or better explained by another mental disorder. When the eating disorder occurs in the context of another condition or disorder, its severity exceeds that usually associated with the condition or disorder and warrants additional clinical attention.
Severity: Mild: BMI ≥ 17 kg/m² Moderate: BMI 16 to 16.99 kg/m² Severe: BMI 15 to 15.99 kg/m² Extreme: BMI < 15 kg/m²	Severity: Mild: average of 1 to 3 episodes of compensatory behaviors per week Moderate: average of 4 to 7 episodes of compensatory behaviors per week Severe: average of 8 to 13 episodes of compensatory behaviors per week Extreme: average of 14 or more episodes of compensatory behaviors per week	Severity: Mild: average of 1 to 3 binge eating episodes per week Moderate: average of 4 to 7 episodes of binge eating per week Severe: average of 8 to 13 binge eating episodes per week Extreme: average of 14 or more binge eating episodes per week	-

ED	Goals	Approaches
AN	Safely improve caloric intake and body weight. Overcome difficulties in making decisions and realizing one's real calorie and nutrient needs.	Structured eating plans that facilitate decision-making, helping individuals improve nutrient intake and restore weight. As individuals progress, nutritional therapy focuses on supporting increased flexibility in food selection and challenging food-related fears.
BN	Establish regular patterns of adequate food intake. Reducing the frequency of purging behaviors and compensatory methods.	Food planning to establish regular meals and snacks throughout the day that mitigate fluctuations in hunger and satiety, reducing the desire to binge eat and/or purge. Discourage dietary restriction, as it is often associated with binge eating.
BED	Mitigate the exaggerated response to food-related stimuli, which can contribute to the loss of control over consumption. Identify factors that motivate overeating, eating in the absence of hunger and feelings of loss of control.	Follow the nutritional interventions proposed for BN and instructions on conscious and intuitive eating principles. Active efforts to lose weight are contraindicated when binge eating behaviors are present.
ARFID	Recovery of nutritional status and growth. Discourage avoidance of foods that maintain eating problems.	Collective treatment plan with the distribution of goals and responsibilities with parents/guardians and the child. Identify avoided foods and reintroduce them slowly and steadily in treatment sessions and with continued exposure assignments at home.

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[1] * Corresponding author. E-mail:luizacabus@hotmail.com (L.A. Moreira)