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Recognizing Early Eating Disorder Signs in Pediatrics · Pediatrics in Practice: A CME Podcast

• 0:03
  Sarah Gubara (Host): Welcome to Pediatrics in Practice, a CME podcast.
• 0:07
  I'm Dr.
• 0:08
  Sara Gubara, and I'm joined by Dr.
• 0:10
  Sarah Gold, a board-certified clinical child and adolescent psychologist and
• 0:16
  certified eating disorders specialist at Children's Mercy Kansas City.
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  Today, we'll be talking about the diagnosis and
• 0:24
  treatment of eating disorders.
• 0:26
  Dr.
• 0:27
  Gold, thank you so much for taking the time to join us this morning
• 0:31
  Sara Gould, PhD: I appreciate being here
• 0:33
  Sarah Gubara (Host): Wonderful to have you.
• 0:35
  Now, Dr.
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  Gold, what are some of the early signs of eating disorders that pediatricians
• 0:39
  should watch out for, especially those that can be missed in routine visits?
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  Sara Gould, PhD: Two primary areas include those physical symptoms, and then
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  the second is the behavioral symptoms.
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  So in terms of physical presentation, looking for changes in growth
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  trajectory, particularly in weight, whether it is up or down, either one.
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  Sometimes, changes up are missed or overlooked a little bit in
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  terms of potential eating disorder.
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  And also looking for potential, micronutrient deficiencies can
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  be another area of concern.
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  And in terms of behaviorally, sometimes the earliest changes that we see are
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  things that look very positive, very mature, kids eating more healthfully,
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  as we tend to look at it, things like decreasing the number of sweets or higher
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  calorie foods, increasing the amount of fruits and vegetables, things like that.
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  And those can be positive changes, but perhaps warrant a few more
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  follow-up questions to understand the motivation and reasons for them.
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  Another thing that can be overlooked is kids who have been historically
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  lower weight on the growth curve.
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  And so it's not a marked change, but has been where they've just
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  kinda hung out all the time.
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  We do see some kids, particularly with an ARFID or a really picky
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  eating presentation, who simply have a neurological difference that they
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  don't sense hunger cues as commonly as others do, and they're therefore
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  just fairly disinterested in food.
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  But even though they're responding to their cues, that can
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  underestimate their body's needs.
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  Finally, in terms of weighing vitals and exam, looking for kids who get
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  nervous before getting on the scale, looking for kids who tense up with
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  physical exam, particularly when they haven't done so historically,
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  can be a sign of body image concerns
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  Sarah Gubara (Host): Those are wonderful early signs to look for.
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  How else can pediatricians distinguish between typical picky eating,
• 2:51
  disordered eating, and conditions like anorexia, bulimia, or ARFID?
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  Sara Gould, PhD: In terms of picky eating, one consideration is developmental stage.
• 3:01
  We all know those toddlers who were eating mixed foods, gloppy foods,
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  whatever, fine, and then suddenly they're pushing it off their plate.
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  So that would be developmentally typical, but if an eight-year-old is
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  doing that, if those changes have hung around for an extended period of time,
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  that might be worth another look.
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  Picky eaters usually, generally speaking, are eating a less variety
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  than their peers may be, but it's not hitting them physically or socially.
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  So they're able to navigate their world just fine with the limited foods that
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  they're comfortable with, and their bodies are getting all of the things that
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  they need to grow and develop just fine.
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  Disordered eating often is a change from previous presentation and
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  in some way is a mismatch between what food is coming in or how it's
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  coming in and what the body needs.
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  So for example, with overeating, emotional eating, then, the nutrition
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  is beyond what the body is utilizing.
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  And then obviously the reverse, if there's some restriction or
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  more heightened selectivity, the body is not getting enough.
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  chaotic eating can also fall into that category.
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  So perhaps overall the energy balance is in place, but there's large periods of
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  the day in which kids are not eating or not eating much, and then short periods
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  in which they're eating more than you would usually think in that timeframe.
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  another consideration finally is are caregivers seeing and what are they
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  thinking about what's going on?
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  How are they changing their lives to meet their kids' needs?
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  For example, we have enough fortified foods in our food environment that
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  kids with ARFID and that really selective eating pattern can be fine
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  nutritionally, but parents are jumping through hoops praying that a certain
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  specific kind of chicken nugget stays on the shelves, things like that.
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  having difficulty with travel or environments where their preferred
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  foods are harder to have available.
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  Things like that are really good distinguishing
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  characteristics between the three.
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  Sarah Gubara (Host): That makes a lot of sense.
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  Dr.
• 5:16
  Gold, when an eating disorder is suspected, what initial
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  medical evaluation and monitoring should occur in primary care?
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  Sara Gould, PhD: Absolutely.
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  Primary care is very well situated in terms of the length of time that
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  they've followed kids, and they have the historical data right at their
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  fingertips to be able to see how things are progressing over time.
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  And in addition, that trust that has been built with caregivers really
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  opens the door for them to ask questions that maybe they're not quite
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  comfortable asking in those settings.
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  And so that's a really positive place to start.
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  We've already touched on growth and looking for changes or
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  differences in that respect.
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  If there seems to be a mismatch between the energy coming in and that is,
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  undershooting what the body needs, checking out cardiac hea-health through,
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  even just the simple pulse heart rate that's taken in office and looking
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  potentially at an EKG to sort that out.
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  And also screening out other potential explanations for changes in weight
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  or growth, such as celiac disease, s-thyroid conditions, things like that.
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  Another really helpful tool can be to gain a 24-hour recall.
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  It's very brief.
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  I know time is short in these visits, but just asking kids,
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  "What was the last thing you ate?
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  How about before that?
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  How about before that?"
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  Until you have about a day's worth, and asking a bit about
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  amounts as well and fluid intake.
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  Sometimes that can get a lot of information pretty quickly.
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  And all kids, I would say ages 10 and up, are at, just by nature
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  of their developmental period, at increased risk for disordered
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  eating and eating disorders.
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  So there aren't any physical markers, demographic markers that would exclude a
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  child from benefiting from being screened.
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  In addition to those pieces for ongoing monitoring, keeping an eye
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  on that growth, and then if you have recommended changes to the family to
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  correct some difficulties that you've noticed, are those changes happening?
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  So for example, sometimes athletes, just due to their high energy expenditure
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  and increased time in th-their schedule that's sucked up by their sport, can
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  accidentally undernourish themselves.
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  But with those recommendations, the explanation that it will help their
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  sports performance implement the changes without blinking an eye.
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  But if those recommendations have been made and change is not
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  occurring or parents are sharing with you that their child is really
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  resistant to those changes, that is a marker of increased concern
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  Sarah Gubara (Host): In terms of collaboration, what does evidence-based
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  multidisciplinary treatment, for pediatric eating disorders look like today?
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  Sara Gould, PhD: We are at a really exciting point in our field because the
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  tools continue to grow, which means that we can really understand which components
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  of interventions are most effective and pull those out, and we can really
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  tailor interventions to a child's unique presentation in terms both of eating
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  disorder symptoms, of other medical or psychiatric comorbidities, family context,
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  local resources, all kinds of things.
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  And that's really different from when I started in this field just 15 years ago.
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  Across the board, however, one common component is critical and should take
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  priority to proceed with that nutritional rehabilitation or normalization.
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  authors who conducted a scoping review likened it to neurological recalibration.
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  That is because our nutrition, particularly that energy balance, has
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  a huge impact on how our brain uses information, processes information,
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  and how effectively it can do its work.
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  And so what we know is being malnourished for any reason really
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  increases mental health concerns just itself, including and especially
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  anxiety and depressive symptoms.
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  But it can also really impact the body's ability to become renourished.
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  We have slew of adaptations that equip us to survive famines, and those
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  same things, slowing the motility of the gut, the decrease of digestive
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  enzyme production to save resources that aren't being used, can make the
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  refeeding progress more challenging and painful with some bloating,
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  abdominal pain, symptoms like that.
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  And so coming alongside families to push through those challenges and get
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  that nutrition right back on track, very often we see all the other symptoms
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  that were present decrease or fully resolve without other intervention.
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  And that is very promising because it means we can
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  streamline treatment for families.
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  Traditionally, it has involved multiple disciplines for every patient, and now
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  we're able to use a step care model.
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  For example, we have started utilizing medical providers for some patients
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  as the sole interventionist who are pushing forward that behavioral work,
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  and then we're seeing what else children need as they progress in that realm.
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  For other kids, they need, medical nutrition and therapy.
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  For others, they're doing great medically.
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  This can be particularly the case in conditions such as binge eating
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  disorder or ARFID where there are no medical complications.
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  Those kids sometimes can work solely with a dietician, solely with a therapist, or
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  solely with an occupational therapist.
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  And so we have really prioritized comprehensive and solid assessment of
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  patients at the get-go of treatment so that we can select the pieces that will
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  make the most difference from them and not overburden the family with, perhaps
• 11:30
  extras unless we have an indication that those are needed for progress and healing.
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  Sarah Gubara (Host): Those sound like really intentional interventions.
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  When it's time to refer to a specialized eating disorder center, what
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  information typically helps ensure that families have timely access to care?
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  Sara Gould, PhD: So some of the pieces that are really helpful are related to
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  that historical data and the current look that pediatricians are getting now.
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  So those growth records are invaluable in helping us plan
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  treatment and estimate where we need to help families land over time.
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  Recent labs can be very helpful, and if you've run an EKG, those
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  results are very helpful as well.
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  That helps us get a more, comprehensive look at families right away and prevents
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  us from asking them to perhaps redo lab work or procedures because we don't
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  have those data at our fingertips.
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  right now we are triaging briefly.
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  Usually families are offered an appointment with us within about a week.
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  sometimes families need longer than that to make arrangements
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  with work or pieces, and so we, we see them when they can come in.
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  We are moving in just a couple of weeks to eliminating that first triage piece
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  and simply scheduling families with a medical provider with the intention to
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  have that turnaround as fast as possible.
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  In the meantime, between families call us or you refer to us and when
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  they're actually seen in clinic, we will continue to try to get those
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  records so that we can be the most prepared to serve them as we can.
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  but they will have it on the books and be able to move forward seamlessly.
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  And from that medical visit and that evaluation, that will help us select
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  the other interventions potentially that would be of benefit for that family.
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  Sarah Gubara (Host): Wonderful.
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  Well, Dr.
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  Gold, last question for you.
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  What common misconceptions do you see among pediatric providers,
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  and how can better education and collaboration address them?
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  Sara Gould, PhD: I'll start with the second part of that.
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  I think collaboration always teaches us as we go along, and we know
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  whatever we discussed for this patient when we're evaluating the
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  next patient with similar concerns.
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  And so that ongoing two-way communication, I think, is really
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  valuable, both in effective patient care but in helping us have a growing
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  shared understanding over time.
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  Returning to some of the common misconceptions, I would say
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  these are similar to those held by the larger community.
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  And so one of them we've already touched on is the perception that
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  because these are mental health concerns, the psychological aspects
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  of the condition need to be addressed first, and then the physical
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  complications will resolve after that.
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  And as I said, we really know the biological changes related to malnutrition
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  necessitate that physical healing come first, and that facilitates the behavioral
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  and psychological progress over time.
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  Another misconception is that eating disorders are a lifelong
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  condition that can only be managed.
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  And the research and our experience is very, very clear.
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  With early consistent quality intervention, these can be conditions
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  that are in kids' rearview mirror, that they may be at increased risk of relapse,
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  similar to a patient who has had cancer will always be at increased relapse risk.
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  But that doesn't mean it will happen again, and it means that full
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  remission is absolutely possible.
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  There's also a perception that eating disorders require a
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  patient being low weight or lower than their historical weight.
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  And we know that most individuals with eating disorder are actually in the
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  average BMI range or higher, so not being falsely reassured by weight status.
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  And then we also know there continues to be a perception, although I think
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  we're making headway with this one, that this is a young middle class
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  or rich white girl's condition.
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  And we know that there are no demographic variables that decrease
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  the risk for eating disorders.
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  Presentations are somewhat different across some ethnic groups or pieces
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  like that, but eating disorders occur with equal prevalence, and
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  so having them on the differential for every patient that presents
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  Sarah Gubara (Host): Thank you for educating us on the diagnosis and
• 16:08
  treatment of eating disorders, Dr.
• 16:10
  Gold.
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  And as a reminder to our audience, claim your CME credits after listening
• 16:15
  to this fascinating episode today.
• 16:18
  You could do so by visiting cmkc.link/cmepodcast
• 16:20
  and then click the Claim CME button.
• 16:28
  If you enjoyed this podcast, please share it on your social channels
• 16:32
  and check out the entire podcast library for topics of interest to you.
• 16:37
  I'm Dr.
• 16:38
  Sarah Kobara, and this has been Pediatrics in Practice, a CME podcast