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With eating disorders easy to miss, report urges screening of all youths :

December 21, 2020

It can be easy to overlook a patient with an eating disorder. Adding to the challenge is the fact that many adolescents and preteens tend to minimize or deny the eating disorder. Appearances also can be deceiving.

An updated AAP clinical report from the Committee on Adolescence provides pediatricians with guidance to recognize eating disorders, provide the initial evaluation of patients’ medical status and serve as part of the treatment team.

The report Identification and Management of Eating Disorders in Children and Adolescents is available at and will be published in the January issue of Pediatrics.

Screening, evaluation

“First and foremost, pediatricians really need to pay close attention to basic things like growth charts and note when patients are crossing percentiles — either up or down — on their charts,” said Laurie L. Hornberger, M.D., M.P.H., FAAP, a lead author of the report.

Pediatric practices should evaluate weight, height and body mass index using age- and gender-appropriate charts; assess menstrual status in girls; and be able to recognize changes in vital signs that may be a red flag for an eating disorder.

When weight loss is revealed on a growth chart, pediatricians should use sensitive language to ask how that weight loss was achieved. They can check for unhealthy or extreme weight control measures before praising desirable weight loss to avoid reinforcing an unhealthy practice.

“More and more, we’re seeing eating disorders in kids who start out with good goals … and generally wise methods, but something takes over and suddenly things spiral,” Dr. Hornberger said. “Their diets become too restricted, their exercise becomes too excessive and the weight loss becomes too extreme. And that’s what the pediatrician needs to be attentive to.”

The clinical report, updated from 2010, includes descriptions of eating disorders’ effects on the body, necessary medical evaluations, treatment strategies and opportunities for advocacy. Anorexia nervosa, bulimia nervosa, binge eating disorder and the relatively new diagnosis of avoidant/restrictive food intake disorder (ARFID) are described. Individuals with ARFID limit food intake for reasons other than a concern for body weight, such as issues related to sensory properties, lack of interest in eating or fear of adverse consequences.

Not all eating disorders result in thinness, Dr. Hornberger said. Many patients with eating disorders have obesity, and pediatricians may not think to ask them about their eating behaviors. In addition, binge eating disorder is thought to be much more common than realized, she said.


The mean age of onset for eating disorders is 12½ years, and females and males in all demographic groups are affected.

“There is not a specific population that you should target when you screen for an eating disorder,” Dr. Hornberger said. “It should be everybody.”

Preteens are more likely to have premorbid psychopathology, and sexual minority youths, especially transgender kids, are at heightened risk of eating disorders in general. Teens with chronic health conditions requiring dietary control (e.g., celiac disease, diabetes) also are at higher risk for disordered eating, as are athletes. The term female athlete triad now is called relative energy deficiency in sport (RED-S) to reflect increased awareness of the role of energy deficiency in disrupting overall physiologic function in both males and females.

Evaluation, therapy

When an eating disorder is suspected, pediatricians — along with appropriate consultants — should initiate a comprehensive evaluation that encompasses medical and psychological assessments as well as suicide risk appraisal. Once diagnosed, patients need monitoring for medical and nutritional complications.

Patients also can be referred to local treatment resources, if available.

Family-based treatment is a first-line treatment that can be duplicated by providers in locations where it is not available. In this model, the whole family attends appointments with a therapist. There are three phases: In the first phase, weight restoration is the goal. Parents take responsibility to help their child eat sufficiently and limit pathologic behaviors. In phase 2, after weight recovery has taken place, the teen gradually assumes responsibility for eating. By phase 3, therapy addresses general issues of adolescent psychosocial development.

Often, parents don’t realize their child may have an eating disorder.

“The story we hear over and over again is that ‘it was happening right under my nose. I didn’t realize how bad it was,’” said Dr. Hornberger, whose institution has an eating disorders clinic.

COVID-19 has highlighted the importance of mental health care, she said. Wait times at her institution’s clinic are up to several months, a situation she believes is occurring in treatment programs across the country.

Dr. Hornberger said one-on-one time with the physician and family support are essential to help teens with eating disorders, especially during the pandemic.

“The lockdowns, the social isolation from not having school, not having activities, not having interactions with friends — it really appears to have a negative effect on kids with mental health issues including eating disorders,” she said. “Pediatricians need to be especially vigilant these days.”

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