(Pediatr Rev 2011;32:508; Pediatr Rev 2006;27:5)
Definition
• Eating disorder NOS: Pts meet some, not all of diagnostic criteria for above EDs, includes binge eating disorder (lack compensatory behaviors)
• Female athlete triad: Hypothalamic amenorrhea, osteoporosis, low energy availability (+/− eating disorder) in female athlete. Low body fat → ↓estrogen → amenorrhea and low bone mineral density
• Approximation of IBW 
: 100 lb for 60 in., + 5 lb each added in.; 
: 106 lb for 60 in., + 6 lb for each in. (Pediatr Rev 2006;27:5)
• Expected wt (kg) for adolescent: (Height in meters)2 × 50th percentile BMI for age and sex
Epidemiology
• AN: 0.9% of , 0.3% of . BN: 1.5% , 0.5% of . EDNOS: 3.5% in , 2% of
• Caucasian and Asian females > African-American and Latino
• Evidence for moderate to substantial heritability. Risk factors: Obese girls or early puberty, perfectionism, concerns over self-control, low self-esteem, past hx of abuse, certain sports (cheerleading, gymnastics, running)
• Suicidality and cardiac complications are leading causes of death
Evaluation: Eating Disorders Examination-Questionnaire
(http://www.psychiatry.ox.ac.uk/research/reserachunits/credo/assessment-measures-pdf-files/EDE-Q6.pdf)
• Hx obtain past, current, and ideal body weight; eating patterns, binge/purge, restrictive and other behaviors, exercise hx, body image concerns, menstrual hx; confirmation from family as patients may be manipulative
• ROS and PMH assess sx of malnutrition (i.e., constipation, feeling cold or faint), vomiting (chest pain, hematemesis)
• Assess for comorbid mental illness: Major depression, anxiety disorders, OCD, anxiety disorder, social phobia, other mood disorders, substance use, high-risk sexual behavior; ask about suicidality
• Labs: CBC, CMP, TSH, amy/lipase, ESR, hCG. Consider LH/FSH, estradiol, prolactin
• ECG if electrolyte abn, cardiac symptoms, significant weight loss, or bulimia
• Radiographic studies (upper or lower GI, abd, and/or head imaging) when indicated
• DEXA recommended if amenorrhea >6 mo, annually if amenorrhea persists
Medical Complications/Physical Findings
• Derm/orofacial: Erosion of tooth enamel/cavities, parotid gland hypertrophy, calluses on knuckles (Russell sign), hypercarotenemia, alopecia, acne, lanugo, halitosis
• Metabolic derangements: Hypernatremia 2/2 restricted intake; hyponatremia 2/2 water loading; hypokalemic, hypochloremic metabolic alkalosis 2/2 vomiting, and diuretics; hypophosphatemia as part of refeeding syndromein rx phase
• Cardiac: Bradycardia, HoTN, orthostasis, arrhythmia, prolonged QT, MV prolapse/ murmur, pericardial effusion, cardiomyopathy and CHF, sudden cardiac death
• Pulmonary: Aspiration PNA and PTX from forceful vomiting, pulm edema 2/2 refeeding
• GI: Vague abn pain, constipation, delayed gastric emptying, esophageal irritation and chest pain, hematemesis 2/2 Mallory–Weiss tears/esoph rupture, gallstones, rectal prolapse, SMA syndrome, LFT abn, usually nml albumin (if ↓, eval for other dx)
• GU: Renal stones, atrophic vaginitis, atrophy of genitalia
• Neuro: Szr (hypoNa), peripheral neuropathy, brain atrophy, long-term neurocog abn
• Endocrine: ↓LH/FSH and estrogen, amenorrhea, osteopenia, and osteoporosis (fractures); ↓ thyroid fxn (hypothermia), often sick euthyroid
• Heme/immuno: Mild anemia (folate or iron def), ↓ ESR, WBC, plt count, altered immunologic markers
Treatment: Requires multidisciplinary team; use of eating disorder protocol with privileges as incentives. Often stabilized inpatient, transferred to residential tx center.
• Monitoring and rx of electrolyte disarray, sudden death may occur from hypoK
• Cautious nutritional support in severely malnourished (<30% below IBW) to avert refeeding syndrome (hypoPhos, fluid and electrolyte shifts, edema, CHF, arrhythmia, stupor, hemolysis, ATN, coma). Start w/ 1,000–1,600 kcal/d, ↑ by 200–400 kcal daily, monitor and supplement phosphorous. Goal wt gain ∼1/2 lb/d. May require NGT or PN feedings
• Criteria to hospitalize in AN: <75% IBW or refractory weight loss despite intensive mgmt, refusal to eat, body fat <10%, HR <50 bpm AM, <45 bpm PM, SBP <90 mm Hg, orthostatic by HR (>20 bpm) or BP (>10 mm Hg), T < 96° F (35.6°C), arrhythmia, electrolytes abnml, suicidality
• Criteria to hospitalize in bulimia: Syncope, K <3.2 mEq/L, Cl < 88 mEq/L, esophageal tears, arrhythmia or ↑QTc, hypothermia, suicidality/cutting, intractable vomiting, hematemesis, failure to respond to outpatient treatment
• Psych mgmt w/ therapy (CBT, psychotherapy, family therapy) and/or medications (i.e., SSRIs – fluoxetine in particular in bulimia)
• Rx MVI with 400–800 IU Vit D and 1,200 mg Calcium, PPI if GERD, toothpaste with sodium bicarb if vomiting. No data to support use of OCPs to prevent bone loss
Prognosis
• Recovery in 46% of AN patients, 45% of bulimia pts; 20 and 23% respectively, had chronic course. Mortality: 5% in AN and 0.32–3.9% for bulimia, 5.2% for EDNOS