New Insights into the Field of Eating Disorders in Children and Adolescents Jorge L. Pinzon, M.D., FRCPC, FAAP, FSAHM Calgary Eating Disorders Program Clinical Associate Professor of Pediatrics & Psychiatry University of Calgary Post-Graduate Residency Program Teaching Day Department of Family Medicine University of Calgary January 28, 2016 Objectives Identify flags that may indicate eating disorders and initial work-up Describe the care related to medical complications for patients with eating disorders Learn approaches to help patients struggling with eating disorders Eating Disorders in Children and Adolescents Epidemiology Increase recognition of problem 8-14 year olds with anorexia nervosa (Lask & Bryant-Waugh, 1993) Male children form a larger proportion 19-30% Incidence rates steadily increasing Prevalence of anorexia nervosa in year olds = 0.48%, and overall 1% Prevalence of bulimia nervosa = 1- 3% Mortality rate in excess of 10% (Litt) ICD 10 (WHO) 2000 Pica (F98.3) Rumination Disorder (F98.21) Avoidant/Restrictive Food Intake Disorder (F50.8) Anorexia nervosa (F50.01 or F50.02) Atypical anorexia nervosa (F50.8) Bulimia nervosa (F50.2) Atypical bulimia nervosa (F50.8) Binge eating Disorders (F50.8) Purging Disorder (F50.8) Other specific feeding or eating disorders (F50.8) DSM 5 (APA) 2013 Pica (307.52) Rumination Disorders (307.53) Avoidant/Restrictive Food Intake Disorder (307.59) Anorexia nervosa (307.1) o Restrictive type o Binge eating / purging type Bulimia nervosa (307.51) Binge Eating Disorder (307.51) Other Specific Feeding or eating Disorders (307.59) Atypical AN; BN low frequency, lim duration ; BED; Purging Disorder Avoidant/Restrictive Food Intake Disorder (AFRID) New diagnostic category in the DSM-V Problem around eating inadequate intake of calories weight loss/FTT Ex: difficulty digesting certain foods, avoiding certain colours or textures of food, no appetite, fear of eating after a frightening episode of choking or vomiting New diagnostic category in the DSM-V Problem around eating inadequate intake of calories weight loss/FTT Ex: difficulty digesting certain foods, avoiding certain colours or textures of food, no appetite, fear of eating after a frightening episode of choking or vomiting Puberty & Menstruation Facts Menarche (median age): years Mean cycle interval: 32.2 days in first gynecological year Menstrual cycle interval: typically 21 45 days Menstrual flow length: < 7 days Menstrual product use: 3 6 pads/tampons per day American Academy of Pediatrics - Committee on Adolescent Health. American College of Obstetrics and Gynecology Committee on Adolescent Health Care. Menstruation in girls and adolescents: Using the menstrual cycle as a vital sign. Pediatrics 2006;118(5): /peds http://dx.doi.org/ Sequence of Pubertal Events in Females Breast 2 Breast 3 Pubic Hair 2 Breast 4 Pubic Hair 3 PHV Pubic Hair 4 Breast5 Pubic Hair 5 Menarche Adopted from: Adolescent Health Care: A Practical Guide. L. S. Neinstein, 4rd ed., 2002 Years old Figure Diagram of the sequence of events at puberty in males. An average is represented in relation to the scale in ages. The range of ages within which some of the changes occur is indicated by the figures below. These data are for British Children But boys in the United States would normally enter puberty between 9 years and 14 years. (From Marshall WA, Tanner JM: Variation in the pattern of pubertal changes in boys. Arc Dis Child 45:13, PUBIC HAIR TESTIS PENIS HEIGHT SPURT /2 14 1/ /2 13 1/ / /2 APEX STRENGTH SPURT Pubertal Events in Males AGE, YEARS SMR115.7% SMR218.9% SMR321.6% SMR426.7% SMR114.3% SMR211.3% CASE Mary is a 16 year old female who has lost 25% of her body weight over the past 8 months. Complains of cold hands and feet, fatigue, constipation and having lost her periods. In the past she has been diagnosed with food allergies and exercise induced asthma. O/E emaciated, acrocyanotic, BMI of 14. Evidence of orthostatic changes on BP and HR. Lanugo hair and scaphoid abdomen. The rest of examination is negative. Blood Test CBC#1 #2 CBC#1 #2 Hgb/Hct: 114/35.686/29.3 WBC: PMN: MCV: MCH: Platelets: LFTs LFTs TP: 63 Alb: 39 AST: 58 ALT: 48 ALP: 90 TB: 7 DB: 0 Biochemistry Na:143 K:3.5 CL:97 Gluc:3.2 Ca:2.1 Mg:0.7 Phos:0.9 BUN:7.2 Cr:87 Amylase:115 Hormones Hormones TSH: 1.2 LH: 20 orthostatic BP changes systolic>20 orthostatic HR changes >35 orthostatic HR changes >35 Temperature