Pediatric Anorexia Nervosa Treatment & Management

  • Author: Bettina E Bernstein, DO; Chief Editor: Caroly Pataki, MD   more...
 
Updated: Jan 18, 2012
 

Approach Considerations

The medical modality in managing anorexia nervosa is directed toward correcting and preventing the complications of this disorder. Restoring normal eating patterns is crucial because, otherwise, the restoration of health cannot occur.[58]

Anorexia nervosa is difficult to treat because of the shame, denial, and lack of insight concomitant with the disorder.[59]

Maintaining safety is important; therefore, hospitalization should not be shunned, as anorexia nervosa is a complex chronic disorder that is associated with high comorbidity and significant mortality and complications (see Prognosis).[60, 61]

No treatment is needed for euthyroid sick syndrome,[62] and estrogen has no established effect on bone density in patients with anorexia nervosa, although vitamin supplementation with calcium should be started.

Outpatient treatment should be undertaken only with very close monitoring, such as weekly weight measurement with the patient wearing only a gown.

Go to Emergent Management of Anorexia Nervosa and Bulimia Nervosa for complete information on these topics.

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Hospitalization

Those at risk medically or psychiatrically require inpatient treatment. Indications for inpatient treatment include the following:

  • Low weight (85% or less of expected weight) and/or low body mass index (BMI) or rapid weight loss
  • Lack of any weight gain
  • Significant edema
  • Physiologic decompensation including but not limited to: (1) severe electrolyte imbalance (life-threatening risks created by sodium and potassium derangements), (2) cardiac disturbances or other acute medical disorders, (3) altered mental status or other signs of severe malnutrition, and (4) orthostatic differential greater than 30/min
  • Temperature less than 36°C
  • Pulse less than 45 beats per minute
  • Psychosis or a high risk of suicide
  • Symptoms refractory to outpatient treatment

Inpatient management should be approached in such a way as not to seem like punishment to the patient in order to preserve self-esteem and to prevent suicidality and hopelessness. The goals of inpatient therapy should be fully discussed with the family and the patient, including elements such as the development of a healthy meal plan, addressing underlying conflicts (low self-esteem, planning new coping strategies), and enhancing communication skills.

It is essential to monitor the patient's weight, vital signs, and serum electrolyte levels. Although weight gain is a primary goal of treatment, the weight gain should not be excessive, because rapid refeeding can lead to excessive bloating, edema, and, rarely, congestive heart failure (CHF).

Leptin and cortisol levels may be helpful in predicting the time to weight recovery.[63]

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Refeeding Strategies

Nutrition is an important part of the treatment for the individual with anorexia nervosa. A nutritionist or dietitian should be an integral part of the treatment plan, because the well-recognized refeeding syndrome can occur during the early stages of refeeding the patient with anorexia. This syndrome encompasses cardiovascular collapse, starvation-induced hypophosphatemia, and dangerous fluctuations in potassium, sodium, and magnesium levels. Assessment of vitamin D and calcium intake is helpful in the design of a successful refeeding plan.[42]

Tube feeding must often be initiated on an inpatient basis when the patient's weight is less than or at 85% of expected weight, as outpatient refeeding can be too uncomfortable, and the weight gain can be too rapid for the patient to tolerate, resulting in the patient sabotaging treatment. Tube refeeding does not impair efficacy of any psychologic therapies.[64]

Mehler et al proposed the following strategies to avoid the refeeding syndrome to avoid pitfalls during the refeeding period[15] :

  • Identify patients at risk.
  • Measure serum electrolyte levels and correct abnormalities before refeeding.
  • Obtain serum chemistry values every 3 days for the first 7 days and then weekly during the rest of the refeeding period.
  • Attempt to increase daily caloric intake slowly by 200-300 kcal every 3-5 days until a sustained weight gain of 1-2 pounds per week is achieved. (Rapid refeeding can lead to excessive bloating, edema, and, rarely, congestive heart failure.)
  • Monitor the patient carefully for development of tachycardia[65] or edema.
  • Monitor for pellagra and administer niacin supplementation if needed.[66]

A small but well-done study (N=35) of hospitalized patients with anorexia nervosa found that increased fluid output and less-dilute specific gravity at the start of refeeding may be causally related to the common finding that initial weight loss occurs at the start of treatment until day 8. Thus, it may be better to refeed anorexic patients with a higher caloric intake (average, 1966 cal) than has been recommended by the American Psychiatric Association and the American Dietetic Association, which generally results in a low weight gain (1 kg/wk maximum on an initial 1200-cal/d diet) despite initial weight loss until day 8. Refeeding more aggressively did not result in refeeding syndrome, as phosphorus levels did not decrease to an unacceptable level. The result was a reduction in the duration of hospital stay by almost 1 day, without increased risk of medical complications.[67]

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Family-Based Therapy

Individuals with anorexia nervosa may respond best to family therapy, an established treatment modality in achieving and maintaining remission from anorexia nervosa.[34, 68] This treatment modality should take into account the level of negative expressed emotion and be performed only conjointly if the level of expressed emotion is not excessive[20, 69] ; simultaneous sessions can be more productive because, if patients feel intense negative emotions from their families, they are more likely to be noncompliant with treatment.

A large, randomized, controlled study of 121 adolescents and young adult subjects found that although family-based therapy was equally as effective as adolescent-focused therapy,[70] family-based therapy resulted in more successful maintenance of improvement after 12 months, as measured by superior outcomes at 6 months and 12 months posttreatment.

Although an earlier meta-analysis/review did not find a difference in outcome between family-based therapy and educational interventions, that review incorrectly grouped several studies together that were different in approach.[71] Specifically, some of those studies did not have a standardized approach and had an insufficient amount of subjects.

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Behavior Therapy/Psychotherapy

Various psychologic therapies have proven helpful in treating patients with anorexia nervosa, including the following[35, 72, 73] :

  • Individual therapy (insight-oriented)
  • Cognitive analytic therapy
  • Cognitive behavior therapy (CBT)
  • Interpersonal therapy (IPT)
  • Motivational enhancement therapy
  • Dynamically informed therapies
  • Group therapy
  • Family therapy
  • Conjoint therapy
  • Separated family therapy
  • Multifamily groups
  • Relatives and caregiver support groups

Psychodynamic psychotherapy in combination with behavioral strategies is indispensable in patients with anorexia nervosa. Randomized controlled trials show that CBT is very effective, especially in the setting of tube feeding.[74]

A flexible approach to the use of CBT or IPT is important and should be tailored to the individual, whenever possible, especially taking into account expressed emotion.[34, 75] Successful CBT can yield better results than community-based treatment, especially in the presence of specific issues (eg, sexual abuse, traumatic events) more likely to respond to specific subtypes of CBT, such as trauma-focused CBT or exposure therapy with response prevention.[19, 76, 77]

Psychopharmacologic therapy is generally unhelpful, although fluoxetine may stabilize recovery in patients who have already attained 85% of their weight. See Medications.

Evidence-based studies show that pharmacotherapy is more effective when combined with CBT and should not be used alone; if selective serotonin reuptake inhibitors (SSRIs) (eg, fluoxetine) are used, they should be used with careful monitoring for hypomanic or manic adverse effects.

Comparisons of psychotherapies

In a study by McIntosh et al that compared 3 psychotherapies, IPT and family therapy were also reported to be effective when the expressed emotion was not negative.[78] Some patients who received nonspecific management appeared to have as good or better an outcome as those who received the other therapies; IPT was the least effective and CBT outcomes were not as effective because of the large amount of psychoeducational material, large skills acquisition, and "the inability to generate alternatives to fixed cognition stemming from the cognitive rigidity of anorexia nervosa patients."[78]

Nonspecific management may be more successful, because the therapy is provided by experienced clinicians, is practiced according to a detailed treatment manual, and institutes psychoeducation with a strong focus on normalizing eating with approaches such as smart food selection and quantities needed to gain weight.[78] The rest of the sessions in the McIntosh et al study were based on issues presented by the patient. Key features of this type of therapy may include the nonspecific factor of empathy and therapeutic alliance. Because this is the first time this nonspecific management was studied, a replication of this study may be necessary.[78]

Family group psychotherapy versus family-based therapy

Family involvement is a vital part of the process in the treatment of anorexia nervosa. Family group psychotherapy has been shown to be more cost-effective than family therapy and equally useful (weight gain measurements).[79]

Robin et al found that although the effect of family relations on behavioral family systems therapy (BFST) versus ego-oriented individual therapy (EOIT) as treatment modalities for adolescents with anorexia nervosa was not statistically disparate,[80] the results demonstrated a greater improvement in body mass index (BMI) in the BFST group. In addition, in this group, the mothers showed a decrease in negative communication and an increase in positive communication, whereas the mothers in the EOIT group did not.[80]

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Activity Restrictions

Limited physical activity (eg, sports, exercise classes) is recommended. By limiting activity, energy expenditure is limited, thus assuring a balanced weight. Limitation of activity may also motivate the patient to maintain healthy eating habits in order to ensure a rapid return to favorite activities. Note that the disadvantage of curtailing activity is the removal of the patient's coping mechanism to deal with stress.

Anorexia nervosa is based on caloric restriction and increased caloric expenditure that leads to excess exercise to control weight. Previous studies have described the use of exercise programs for hospitalized inpatients in which exercise was exchanged for weight gain and compliance. However, no guidelines were set forth in terms of type, intensity, and duration of exercise.

Thien et al looked at a standard program designed for outpatient use, graduated in type of exercise, duration, and level of activity and demonstrated that both the exercise and the control groups increased in body mass index (BMI) and body fat percentage.[81] However, quality of life was increased in the exercise group, whereas the control group showed a decrease in all aspects of quality-of-life measures, although the difference was not statistically significant.[81] Without structure, patients could be exercising in potentially harmful ways and at very high intensities.

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Consultations

The approach to the treatment of individuals with anorexia nervosa is multidisciplinary. Consultations with specialists in adolescent medicine, nutrition, psychiatry or behavioral-developmental pediatrics, and psychology may be required.

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Long-Term Monitoring

Patients with anorexia nervosa may respond best to family therapy. Psychodynamic psychotherapy in combination with behavioral strategies is indispensable. Remember that anorexia nervosa is associated with suicide.

For patients with the mild stage of anorexia nervosa, reevaluate in 1-2 months to check that the weight is not decreasing, that health is maintained, and that the patients have not developed bad eating habits. Surveillance is required to ensure that the patient has not progressed to the moderate stage.

Complications of weight control habits include the inability to break the cycle of disordered eating as an outpatient and the inability to initiate effective outpatient psychotherapy.[13]

See Hospitalization for indications to admit an individual with anorexia nervosa for inpatient management. Also see Patient Education for important points to discuss with the patient and/or the family.

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Proceed to Medication
 
 
Contributor Information and Disclosures
Author

Bettina E Bernstein, DO  Clinical Assistant Professor, Department of Psychiatry, Philadelphia College of Osteopathic Medicine; Private Practice at the Wynnewood House; Outpatient Consultant, Clinical Affiliate, Department of Child and Adolescent Psychiatry, Children's Hospital of Philadelphia; Court Appointed Evaluator, Family Court of Philadelphia; Psychiatric Consultant, Intercommunity Action, Inc, Easttown Tredyffrin School District

Bettina E Bernstein, DO is a member of the following medical societies: American Academy of Child and Adolescent Psychiatry and American Psychiatric Association

Disclosure: Nothing to disclose.

Specialty Editor Board

Angelo P Giardino, MD, PhD, MPH  Associate Professor, Baylor College of Medicine; Chief Medical Officer, Texas Children's Health Plan; Chief Quality Officer, Medicine, Texas Children's Hospital

Angelo P Giardino, MD, PhD, MPH is a member of the following medical societies: Academic Pediatric Association, American Academy of Pediatrics, American Professional Society on the Abuse of Children, Harris County Medical Society, Helfer Society, and International Society for Prevention of Child Abuse and Neglect

Disclosure: Bayer Honoraria Review panel membership; Pfizer Grant/research funds Independent contractor; MedImmune Honoraria Review panel membership; Teva Pharmacutical travel & honoraria Managed Care Advisory Panel; CIGNA Honoraria Physician Advisory Council

Mary L Windle, PharmD  Adjunct Associate Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Nothing to disclose.

Chief Editor

Caroly Pataki, MD  Professor of Clinical Psychiatry and Behavioral Sciences, Department of Psychiatry, Division Chair, Child and Adolescent Psychiatry, Keck School of Medicine of the University of Southern California

Caroly Pataki, MD is a member of the following medical societies: American Academy of Child and Adolescent Psychiatry, New York Academy of Sciences, and Physicians for Social Responsibility

Disclosure: Nothing to disclose.

Additional Contributors

The authors and editors of Medscape Reference gratefully acknowledge the contributions of previous author Jennifer DA Liburd, MD, to the development and writing of the source article.

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