Eating Disorders

Eating disorders are complex biopsychosocial disorders with significant medical sequelae and a high mortality rate. They exist across diverse populations regardless of age, race, ethnicity, gender, sexual orientation, body habitus and socioeconomic background. Over the past several years, eating disorder diagnoses have increased globally.

• Early intervention is associated with better outcomes, however there is practice variability in admission criteria and treatment for eating disorders across Canada.

This document addresses the acute medical and psychiatric complications of eating disorders presenting to the Emergency Department (ED). Many patients seen in the ED for other complaints may have undiagnosed disordered eating.

HISTORY

• Disordered eating behaviours: characterize the type and frequency of behaviours (fasting, bingeing, purging, excessive exercise), quantify current daily intake, determine weight changes and duration of symptoms (amount of weight loss/failure to gain weight during a period of growth, growth or pubertal delay).
• Concerning symptoms/risk factors for hospitalization: see Table 1 below.
• Mental health status: screen for suicidality and self-harm. Refer to TREKK’s Suicidal Risk Screening and Assessment Recommendations.
• Social: assess the social and familial context and determine barriers to outpatient care, impact on daily activities (i.e., school attendance, drop in grades or activity level, withdrawing from friends).

PHYSICAL EXAMINATION

• Weight and height (compare to previous, if available), % median BMI (see Table 1) or % weight loss
• Orthostatic vital signs with patient supine for 3-5 min, then standing after 3-5 min. If unable to stand, record while the patient is sitting with feet dangling.
• Temperature and hydration status
• Other changes: lanugo hair, skin integrity (e.g., ulcers/skin breakdown), bruising, muscle wasting, dentition, swollen salivary glands, signs of self-harm

SUGGESTED INVESTIGATIONS¹

Laboratory investigations may still be within normal limits even in cases of severe malnutrition.

Normal values do not rule out an eating disorder.

• CBC/differential, electrolytes, calcium, magnesium, phosphate, urea, BUN/creatinine, glucose, albumin, alkaline phosphatase, amylase, AST, ALT, CRP. If not already done, add: TTG, IgA, TSH, urinalysis, b-HCG (if applicable).
• 12 lead ECG; assess rate, rhythm, and calculate QTc.

MANAGE ACUTE COMPLICATIONS

Patients with eating disorders often present with poor perfusion and even chronic hypotension. If no concern for sepsis and/or altered mental status:

• Hypoglycemia: correct ORALLY or by NG with meal replacement (e.g., Boost^®).
• Hypotension: alterations of vital signs and even hypotension is common. Assess for alternate causes for hypotension (e.g., sepsis). If none, eating disorder-related vital sign instability will correct over time with management of the eating disorder.

• Admission: See Table 1 for factors supporting hospitalization. Admission practices are site specific and may vary with patient and social factors. Discussion is required with local eating disorder specialist, Pediatrics, or Pediatric Referral Center.
• Discharge: If admission is not required, a discharge plan for outpatient follow-up should be made in
  consultation with local eating disorder specialist, Pediatrics, or Pediatric Referral Centre.
• Discharge instructions: Return to the ED if complete food refusal >24hrs, acute medical complications
  (e.g., significant chest pain, syncope, seizure, altered mental status, and/or concern for self-harm/suicidal risk).
• Resources for families: FEAST (multiple languages); ANEB (English and French); CANPED: Online
  Educational Tool for Parents/Caregivers of a Youth with an Eating Disorder.

Thank you to the following content experts who led the development of the Eating Disorder Bottom Line Recommendations:

Jennifer Turnbull, MD, FRCPC; Assistant Professor, Division of Pediatric Emergency Medicine, McGill University Health Centre; Co-Director, McGill Global Child Health Program, Montreal Children’s Hospital

Roiya Farhan, MD; Pediatric Emergency Fellow; McGill University, Montreal Children’s Hospital Megan Cooney, MD; Adolescent Medicine Physician, HSC Winnipeg Children’s Hospital

Holly Agostino, MD; Adolescent Medicine Physician, Montreal Children’s Hospital; Associate Professor of Pediatrics, McGill  University Health Center

Thank you to the TREKK Editorial Committee, Parent and Youth Advisory Committee, and editor Dr. Sarah Reid (Children’s Hospital Eastern Ontario) who provided editorial support and expertise in the development of this resource and Megan Bale-Nick, TREKK Knowledge Broker (University of Manitoba) who coordinated the development process. To see our resource  development process please visit our website here.

1. Society for Adolescent Health and Medicine. Medical management of restrictive eating disorders in adolescents and young adults. J Adolesc Health. 2022.

For a complete list of the evidence that informed the creation of the Eating Disorders Bottom Line Recommendations see the Evidence Repository here.

The purpose of this document is to provide healthcare professionals with key facts and recommendations for the diagnosis and treatment of community acquired pneumonia in children in the emergency department. The TREKK Network is not liable for any damages, claims, liabilities, costs or obligations arising from the use of this document including loss or damages arising from any claims made by a third party. THIS DOCUMENT IS SUBJECT TO FULL DISCLAIMER HERE: trekk.ca/terms-of-use