Feeding DTW

  1. Normal development of eating
  2. Breastfeeding
    1. Key Points
    2. Management
  3. Vegetarianism
    1. Key Points
    2. Management
  4. Irregular Feeding/Eating Disorders (Mostly 0-5 years)
    1. Key Points
  5. Definitions
    3. Diet/Body Image/Eating Disorders
      1. Key Points
      2. Definition of Eating Problems
        1. Variations
        2. Problems
        3. Disorders
      3. Clinical Guides for Anorexia and/or Bulimia (See Also: Clinical Guide Algorithm
      4. Differential Diagnosis of Anorexia Nervosa
      5. Management of Anorexia Nervosa
      6. Co-Morbid Conditions of Anorexia
      7. Symptoms and Signs:
    4. Purging/Binge Eating/Eating Disorders
      1. KEY POINTS
      2. Definitions
        1. Variations
        2. Problems
        3. Disorders
      3. Clinical Guides for Anorexia and/or Bulimia See: Clinical Guide Algorithm
      4. Differential Diagnosis of Bulimia
      5. Management of Bulimia
      6. Co-Morbid Conditions With Bulimia
  6. Tools
  7. Problem Oriented Screening Instrument for Teenagers (POSIT, 1991) E. Rahdert, Editor, National Institute on Drug Abuse
  8. Citations
  9. Organizations and Resources for Eating Disorders

Normal development of eating

Breastfeeding

Key Points

Latest research on Breastfeeding

Management

Vegetarianism

Key Points

Latest research on Vegetarianism

Management

Irregular Feeding/Eating Disorders (Mostly 0-5 years)

Key Points

Definitions

According to the Diagnostic Classification of Mental Health and Developmental Disorders of Infancy and Early Childhood (DC:0-3) (Zero to Three, 1994), the following is the definition for Eating Behavior Disorder for infants and toddlers ages 0-3.

600 Eating Behavior Disorder

The diagnosis of eating behavior disorder, which may become evident at different stages of infancy and early childhood should be considered when an infant or young child shows difficulties in establishing regular feeding pattern with adequate or appropriate food intake (e.g., nonorganic failure to thrive). The child does not regulate his or her eating in accordance with physiological feelings of hunger or fullness. In the absence of general regulatory difficulties, interpersonal precipitants such as separation, negativism, trauma, etc., one should consider a primary eating disorder. Specific feeding disorders of infancy and early childhood such as pica and rumination can be found in the DSM-IV.

If difficulties are accompanied by notable sensory reactivity, processing problems, sensory-motor problems or organic/structural problems (e.g., cleft palate, reflux), then this diagnosis should not be used, nor should it be used if the eating behavior problem is part of a larger symptom picture or associated with other affective or behavioral disturbances.

  • Variation: the child demonstrates moderate difficulty establishing feeding routines or maintaining adequate/appropriate food intake, with no significant disruption to infant/family function.
  • Problem: the child demonstrates moderate difficulty establishing feeding routines or maintaining adequate/appropriate food intake, with moderate effects on infant/family functioning.
  • Eating Behavior Disorder: significant difficulties with feeding routines or amount/appropriateness of food intake cause marked disturbance of infant/family function.
Information for Parents:

Parent text, Infancy

Differential Diagnosis of Irregular Feeding/Eating Disorders

Management of Irregular Feeding/Eating Disorders

Co-Morbid Conditions and Differential Diagnosis of Irregular Feeding Disorders

  • Gastrointestinal disorders[note]
  • Specific food intolerance (e.g., lactose)
  • Specific food allergy (e.g., celiac)
  • Sandifer syndrome
  • Electrolyte abnormalities
  • Oral health problems such as dental erosions or halitosis
  • Obesity
  • Lead poisoning
  • Malnutrition
  • Failure to thrive
  • Attachment disorders
  • Emotional deprivation
  • Mental retardation
  • Prepubertal anorexia nervosa
  • Child physical, emotional or sexual abuse
  • Mood disorders

Diet/Body Image/Eating Disorders

Key Points

Prevalence of Anorexia Nervosa

Etiology of Anorexia Nervosa

Laboratory Findings in Anorexia Nervosa

  • Chemical[note]
    • Elevated BUN from dehydration (renal - nitrogen in urine)
    • Hypercarotenemia (elevated carotene in the blood)
    • Elevated cholesterol early - may decrease late
    • Decreased transferrin, low complement C3, fibrinogen and prealbumin
    • Elevated LDH, alk phos
    • Depressed phosphorus late (ominous), Mg, Ca
    • Possible depressed Zn plasma, urinary Zn, urinary Cu
  • Endocrine[note]
    • Normal prolactin
    • Elevated circulating cortisol, low normal fasting glucose
    • low normal T4, reduced T3, elevated Rt3, normal TSH
    • Possible elevation of PTH, elevated resting GH
  • Hematologic[note]

Physical Findings in Anorexia Nervosa (American Academy of Pediatrics 2003)

  • Bradycardia
  • Orthostatic by pulse or blood pressure
  • Hypothermia
  • Cardiac murmur (one third with mitral valve prolapse)
  • Dull, thinning scalp hair
  • Sunken cheeks, sallow skin
  • Lanugo
  • Atrophic breasts (postpubertal)
  • Atrophic vaginitis (postpubertal)
  • Pitting edema of extremities
  • Emaciated, may wear oversized clothes
  • Flat affect
  • Cold extremities, acrocyanosis

Prognosis of Anorexia Nervosa

  • 70% recover short term, >40% long term. 30% improve, 20% do not improve; 9% die.
  • Better if: female; early motivation for change; early intervention
  • Worse if: male; late onset; extreme weight loss, long duration, multiple hospitalizations; bulimic; persistently distorted body image; severe personality disorders or major family pathology.
  • Anorexia has the highest mortality rate[note] of any mental health disorder (Pomeroy, C 2004) .

Latest research on Anorexia

Definition of Eating Problems

Variations

V65.49 Dieting/Body Image Variation

Dieting may occur if the child is overweight but it should be a realistic program.

The child does not completely eliminate any food group, but generally decreases intake of food, especially of sweets and fats or is on an appropriate diet.

The child favors a thin appearance but has a realistic image.

The individual can stop dieting voluntarily.

Information for Parents:

Parent text, School Age

Problems

V69.19 Dieting/Body Image Problem

Dieting and voluntary food restrictions are more restrictive and result in weight loss or failure to gain weight as expected during growth but these behaviors are not sufficiently intense to qualify for the diagnosis of anorexia nervosa or eating disorder, NOS.

The individual begins to become obsessed with the pursuit of thinness and develops systematic fears of gaining weight.

The individual also begins to develop consistent disturbance in body perception and starts to deny that weight loss or dieting is a problem.

Information for Parents:

Parent text, School Age

Disorders

According to the Diagnostic and Statistical Manual of Mental Disorder-Fourth Edition (DSM-IV) (Wolraich, M. (Ed.) 1996) , the following are the definitions for the Anorexia Nervosa, Bulimia Nervosa, and Eating NOS Disorders:

307.1 Anorexia Nervosa

  • Refusal to maintain body weight at or above minimally normal weight for age and height (e.g., weight loss leading to maintenance of body weight less than 85% of that expected; or failure to make expected weight gain during period of growth, leading to body weight less than 85% of that expected).
  • Intense fear of gaining weight or becoming fat, even though underweight.
  • Disturbance in the way in which one's body weight or shape is experienced, undue influence of body weight or shape on self-evaluation, or denial of the seriousness of the current low body weight.
  • In postmenarcheal females, amenorrhea, i.e., the absence of at least three consecutive menstrual cycles. (A woman is considered to have amenorrhea if her periods occur only following hormone; e.g., estrogen administration).

Specify type:

Restricting Type: during the current episode of Anorexia Nervosa, the person has not regularly engaged in binge-eating or purging behavior (i.e., self-induced vomiting or the misuse of laxatives, diuretics, or enemas)

Binge-Eating/Purging Type: during the current episode of Anorexia Nervosa, the person has regularly engaged in binge-eating or purging behavior (i.e., self-induced vomiting or the misuse of laxatives, diuretics, or enemas).

Information for Parents:

Parent text, School Age

Management of Anorexia Nervosa

  • Primary care management
  • Treatment for more severe cases

    • Co-Morbid Conditions of Anorexia

    Symptoms and Signs:

    Anorexia Nervosa Bulimia Nervosa
    General Underweight; hyperactivity (mental & motor); lethargy; Irritability; sleep problems; confusion; Weight loss, amenorrhea; aberrant behavior; Hypothermia (rectal temp <96.6); dizziness; Hyperacusis or hyperaesthesia; Syncope; low self esteem; depressed mood; feelings of ineffectiveness; isolation-withdrawal Cachexia; emaciation; debilitation; Dehydration; bradypnea; signs of shock; Covert infectious processes; anergy May be normal, overweight or underweight; hyperactivity - mental & motor; Bloating; diarrhea; puffy face; swelling; constant and extreme thirst and urination (hypokalemic nephropathy-hypovolemia); usually well groomed; swelling of parotid and salivary glands; weakness, paralysis; muscle cramping; signs of hypokalemia
    Skin & Hair Subcutaneous fat loss; Yellow skin, palms and soles; Dry, peeling skin and dirty appearance; Lanugo; brittle or loss of scalp and pubic hair Ulcerations, scars, or calluses on back of hand (over knuckles); lesions of hands, fingernails, fingers
    Oral Dental caries; Enamel erosion or discoloration of teeth (posterior surface), palatal injuries
    Pyorrhea of gums
    Cardiovascular Hypotension (<70/50);
    Bradycardia (<60) Heart murmur    		 Arrhythmias
    Gastrointestinal Constipation; decreased bowel sounds Epigastric tenderness; Ileus; Abdominal tenderness
    Neuromuscular Muscle weakness/wasting, Decreased deep tendon reflexes Muscle weakness/wasting/cramping, Decreased deep tendon reflexes
    Extremities Cold, mottled hands and feet, edema of lower extremities Edema of feet (and perhaps hands)
    Genitourinary Thin, pale, dry, atrophic vaginal mucosa
    Musculoskeletal Osteopenia/fractures
    Hormonal Estrogen deficiency & androgen, deficiency (no acne, no oily skin)

    Purging/Binge Eating/Eating Disorders

    KEY POINTS

    Prevalence of Bulimia

    Etiology of Bulimia

    Laboratory Findings in Bulimia

    Physical Findings in Bulimia (American Academy of Pediatrics 2003)

    • Sinus bradycardia
    • Orthostatic by pulse or blood pressure
    • Hypothermia
    • Cardiac murmur (mitral valve prolapse)
    • Hair without shine
    • Dry skin
    • Parotitis
    • Russell's sign (callous on knuckles from self-induced emesis)
    • Mouth sores
    • Palatal scratches
    • Dental enamel erosions
    • Affect may appear normal
    • Other cardiac arrhythmias

    Latest research on Bulimia

    Definitions

    Variations

    V65.49 Purging/ Binge-Eating Variation

    Occasional overeating or perception of overeating, either objective or subjective binges, occurs.

    Intermittent concern about body image or getting fat is present in specific situations during which too much food was eaten. Concerns are not pervasive or cross-situational and do not change eating behaviors.

    Normal weight gain is typically present.

    Information for Parents:

    Parent text, School Age

    Problems

    V69.19 Purging/Binge-Eating Problem

    Includes experimentation with vomiting, laxatives, fasting, or exercises to prevent weight gain. Isolated episodes are far apart in time. Individual has increased episodes of uncontrolled eating. The individual's perceptions of body shape or size become more systematically distorted. Negative self-evaluation is often influenced by weight and body shape. The behaviors are not sufficiently intense to qualify for a diagnosis of bulimia nervosa or eating disorder, NOS.

    Information for Parents:

    Parent text, School Age

    Disorders

    According to the Diagnostic and Statistical Manual of Mental Disorder-Fourth Edition (DSM-IV) (American Psychiatric Association 1994) , the following are the definitions for the Bulimia Nervosa:

    307.51 Bulimia Nervosa

    • Recurrent episodes of binge eating. An episode of binge eating is characterized by both of the following:
      1. eating, in a discrete period of time (e.g., within any 2-hour period), an amount of food that is definitely larger than most people would eat during a similar period of time and under similar circumstances.
      2. A sense of lack of control over eating during the episode (e.g., a feeling that one cannot stop eating or control what or how much one is eating).
    • Current inappropriate compensatory behavior in order to prevent weight gain, such as self-induced vomiting; misuse of laxatives, diuretics, enemas, or other medications; fasting or excessive exercise.
    • The binge eating and inappropriate compensatory behaviors both occur, on average, at least twice a week for 3 months.
    • Self-evaluation is unduly influenced by body shape and weight.
    • The disturbance does not occur exclusively during episodes of Anorexia Nervosa.

    Specify type:

    Purging Type: during the current episode of Bulimia Nervosa, the person has regularly engaged in self-induced vomiting or the misuse of laxatives, diuretics, or enemas.

    Nonpurging Type: during the current episode of Bulimia Nervosa, the person has used other inappropriate compensatory behaviors, such as fasting or excessive exercise, but has not regularly engaged in self-induced vomiting or the misuse of laxatives, diuretics, or enemas.

    Information for Parents:

    Parent text, School Age

    Clinical Guides for Anorexia and/or Bulimia

    See: Clinical Guide Algorithm

    1. Assure reliable reporting usually without parents present and with assurance of confidentiality[note]
    2. General adolescent interview e.g., "Heads First" Interview[note] (Goldenring JM, Cohen G, 1988) (Fuller, PG, Cavanough, RM, 1995)
    3. Assess:
      • Stage of illness at diagnosis
      • Whether patient has anorexia, bulimia, or both together: restrictive or not
      • Family dynamics and probable level of support
      • Presence of a concomitant affective disorder and or substance abuse problem. (Comerci, GD 1999) .
      • Trigger Questions[note] (Comerci, GD 1999)
    4. Hospitalization Criteria[note] (American Psychiatric Association Work Group on Eating Disorders 2000)
    5. Define: Stages/DSM-PC diagnoses[note]
    6. Screening tests[note] (Comerci, GD 1999)
    7. Recommendations[note] (Healthy Steps Interactive Multimedia Training and Resource Kit 2000)

    Management of Bulimia

  • Treatment for more severe cases
  • Prognosis of Bulimia
    • Five to ten years after diagnosis 50% show full recovery; 20% still meet criteria; 30% experience relapse (Keel, PK 1997) .
    • Some data indicate that childhood obesity, low self-esteem and personality problems are related to worse outcomes (Fairburn, CG 2003) .

    Co-Morbid Conditions With Bulimia

    • Endocrine disorders[note]
    • Gastrointestinal problems[note]
    • GI disease (i.e., ulcer, Crohn, IBD, achalasia esp. if dysphagia)
    • Immunologic[note]
    • Psychiatric Disorders[note] (e.g., Depression or Bipolar disorder; See Sadness DTW)
    • Thought disorders (i.e., body dysmorphic disorder, conversion reactions)
    • Personality disorders
    • Anxiety disorders (especially OCD; See Anxiety DTW)
    • Chronic Infections (i.e, CMV, EBV, HIV)
    • Renal disease
    • Collagen Vascular disease
    • Drug use (especially cocaine and other stimulants)

    Tools

    Problem Oriented Screening Instrument for Teenagers (POSIT, 1991) E. Rahdert, Editor, National Institute on Drug Abuse

    Circle one
    1. Do you have so much energy you don't know what to do with it? Yes No
    2. Do you brag? Yes No
    3. Do you get into trouble because you use drugs or alcohol at school? Yes No
    4. Do your friends get-bored at parties when there is no alcohol served? Yes No
    5. Is it hard for you to ask for help from others? Yes No
    6. Has there been adult supervision at the parties you have gone to recently? Yes No
    7. Do your parents or guardians argue a lot? Yes No
    8. Do you usually think about how your actions will affect others? Yes No
    9. Have you recently either lost or gained more than 10 pounds? Yes No
    10. Have you ever been intimate with someone who shot up drugs? Yes No
    11. Do you often feel tired? Yes No
    12. Have you had trouble with stomach pain or nausea? Yes No
    13. Do you get easily frightened? Yes No
    14. Have any of your best friends dated regularly during the past year? Yes No
    15. Have you dated regularly in the past year? Yes No
    16. Do you have a skill, craft, trade or work experience? Yes No
    17. Are most of your friends older than you are? Yes No
    18. Do you have less energy than you think you should? Yes No
    19. Do you get frustrated easily? Yes No
    20. Do you threaten to hurt people? Yes No
    21. Do you feel alone most of the time? Yes No
    22. Do you sleep either too much or too little? Yes No
    23. Do you swear or use dirty language? Yes No
    24. Are you a good listener? Yes No
    25. Do your parents or guardians approve of your friends? Yes No
    26. Have you lied to anyone in the past week? Yes No
    27. Do your parents or guardians refuse to talk with you when they are mad at you? Yes No
    28. Do you rush into things without thinking about what could happen? Yes No
    29. Did you have a paying job last summer? Yes No
    30. Is your free time spent just hanging out with friends? Yes No
    31. Have you accidentally hurt yourself or someone else while high on alcohol or drugs? Yes No
    32. Have you had any accidents or injuries that still bother you? Yes No
    33. Are you a good speller? Yes No
    34. Do you have friends who damage or destroy things on purpose? Yes No
    35. Have the whites of your eyes ever turned yellow? Yes No
    36. Do your parents or guardians usually know where you are and what you are doing? Yes No
    37. Do you miss out on activities because you spend too much money on drugs or alcohol? Yes No
    38. Do people pick on you because of the way you look? Yes No
    39. Do you know how to get a job if you want one? Yes No
    40. Do your parents or guardians and you do lots of things together? Yes No
    41. Do you get A's and B's in some classes and fail others? Yes No
    42. Do you feel nervous most of the time? Yes No
    43. Have you stolen things? Yes No
    44. Have you ever been told you are hyperactive? Yes No
    45. Do you ever feel you are addicted to alcohol or drugs? Yes No
    46. Are you a good reader? Yes No
    47. Do you have a hobby you are really interested in? Yes No
    48. Do you plan to get a diploma (or already have one)? Yes No
    49. Have you been frequently absent or late for work? Yes No
    50. Do you feel people are against you? Yes No
    51. Do you participate in team sports which have regular practices? Yes No
    52. Have you ever read a book cover to cover for your own enjoyment? Yes No
    53. Do you have chores that you must regularly do a at home? Yes No
    54. Do your friends bring drugs to parties? Yes No
    55. Do you get into fights a lot? Yes No
    56. Do you have a hot temper? Yes No
    57. Do your parents or guardians pay attention when you talk to them? Yes No
    58. Have you started using more and more drugs or alcohol to get the effect you want? Yes No
    59. Do your parents or guardians have rules about what you can and cannot do? Yes No
    60. Do people tell you that you are careless? Yes No
    61. Are you stubborn? Yes No
    62. Do any of your best friends go out on school nights without permission from their parents or guardians? Yes No
    63. Have you ever had or do you now have a job? Yes No
    64. Do you have trouble getting your mind off things? Yes No
    65. Have you ever threatened anyone with a weapon? Yes No
    66. Do you have a way to get to a job? Yes No
    67. Do you ever leave a party because there is no alcohol or drugs? Yes No
    68. Do your parents or guardians know what you really think or feel? Yes No
    69. Do you often act on the spur of the moment? Yes No
    70. Do you usually exercise for a half hour or more at least once a week? Yes No
    71. Do you have a constant desire for alcohol or drugs? Yes No
    72. Is it easy to learn new things? Yes No
    73. Do you have trouble with your breathing or with coughing? Yes No
    74. Do people your own age like and respect you? Yes No
    75. Does your mind wander a lot? Yes No
    76. Do you hear things no one else around you hears? Yes No
    77. Do you have trouble concentrating? Yes No
    78. Do you have a valid driver's license? Yes No
    79. Have you ever had a paying job that lasted at least one month? Yes No
    80. Do you and your parents or guardians have frequent arguments which involve yelling and screaming? Yes No
    81. Have you had a car accident while high on alcohol or drugs? Yes No
    82. Do you forget things you did while drinking or using drugs? Yes No
    83. During the past month have you driven a car while you were drunk or high? Yes No
    84. Are you louder than other kids? Yes No
    85. Are most of your friends younger than you are? Yes No
    86. Have you ever intentionally damaged someone else's property? Yes No
    87. Have you ever stopped working at a job because you just didn't care? Yes No
    88. Do your parents or guardians like talking with you and being with you? Yes No
    89. Have you ever spent the night away from home when your parents didn't know where you were? Yes No
    90. Have any of your best friends participated in team sports which require regular practices? Yes No
    91. Are you suspicious of other people? Yes No
    92. Are you already too busy with school and other adult supervised activities to be interested in a job? Yes No
    93. Have you cut school at least 5 days in the past year? Yes No
    94. Are you usually pleased with how well you do in activities with your friends? Yes No
    95. Does alcohol or drug use cause your moods to change quickly like from happy to sad or vice versa? Yes No
    96. Do you feel sad most of the time? Yes No
    97. Do you miss school or arrive late for school because of your alcohol or drug use? Yes No
    98. Is it important to you now to get or keep a satisfactory job? Yes No
    99. Do your family or friends ever tell you that you should cut down on your drinking or drug use? Yes No
    100. Do you have serious arguments with friends or family members because of your drinking or drug use? Yes No
    101. Do you tease others a lot? Yes No
    102. Do you have trouble sleeping? Yes No
    103. Do you have trouble with written work? Yes No
    104. Does your alcohol or drug use ever make you do something you would not normally do like breaking rules, missing curfew, or breaking the law? Yes No
    105. Do you feel you lose control and get into fights? Yes No
    106. Have you ever been fired from a job? Yes No
    107. During the past month, have you skipped school? Yes No
    108. Do you have trouble getting along with any of your friends because of your alcohol or drug use? Yes No
    109. Do you have a hard time following directions? Yes No
    110. Are you good at talking your way out of trouble? Yes No
    111. Do you have friends who have hit or threatened to hit someone without any real reason? Yes No
    112. Do you ever feel you can't control your alcohol or drug use? Yes No
    113. Do you have a good memory? Yes No
    114. Do your parents or guardians have a pretty good idea of your interests? Yes No
    115. Do your parents or guardians usually agree about how to handle you? Yes No
    116. Do you have a hard time planning and organizing? Yes No
    117. Do you have trouble with math? Yes No
    118. Do your friends cut school a lot? Yes No
    119. Do you worry a lot? Yes No
    120. Do you find it difficult to complete class projects or work tasks? Yes No
    121. Does school sometimes make you feel stupid? Yes No
    122. Are you able to make friends easily in a new group? Yes No
    123. Do you often feel like you want to cry? Yes No
    124. Are you afraid to be around people? Yes No
    125. Do you have friends who have stolen things? Yes No
    126. Do you want to be a member of any organized group, team, or club? Yes No
    127. Does one of your parents or guardians have a steady job? Yes No
    128. Do you think it's a bad idea to trust other people? Yes No
    129. Do you enjoy doing things with people your own age? Yes No
    130. Do you feel you study longer than your classmates and still get poorer grades? Yes No
    131. Have you ever failed a grade in school? Yes No
    132. Do you go out for fun on school nights without your parents' permission? Yes No
    133. Is school hard for you? Yes No
    134. Do you have an idea about the type of job or career that you want to have? Yes No
    135. On a typical day, do you watch more than two hours of TV? Yes No
    136. Are you restless and can't sit still? Yes No
    137. Do you have trouble finding the right words to express what you are thinking? Yes No
    138. Do you scream a lot? Yes No
    139. Have you ever had sexual intercourse without using a condom? Yes No

    To obtain a free copy of the manual scoring template go to: http://eib.emcdda.eu.int/index.cfm

    To obtain the computerized POSIT and POSIT followup, contact the following for pricing information on the currently available computer software: PowerTrain, Inc.
    8201 Corporate Drive
    Suite 1080. Landover, MD 20785
    (301) 731-0900
    http://powertrain.com.posit
    posit@powertrain.com

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    Organizations and Resources for Eating Disorders

    Organizations

    American Anorexia/Bulimia Assoc., 418 East 76th Street, New York, NY 10021, FAX: (212) 734-1114.

    National Eating Disorders Association, 603 Stewart St., Suite 803, Seattle, WA 98101, 206-382-3587, toll-free information and referral helpline at 1-800-931-2237, http://www.nationaleatingdisorders.org.

    Anorexia Nervosa and Related Eating Disorders, Inc. Accessed at: http://www.anred.com/welcome.html.

    Resources

    Eating disorders : A handbook for teens, families, and teachers, by Tania Heller, 2003.

    The American Academy of Pediatrics Guide to your Child's Nutrition, edited by William H. Deitz, and Loraine Stern, 1999.

    When Your Child Has An Eating Disorder, A Step-by-Step Workbook For Parents And Other Caregivers, by Abigail H. Natenshon, 1999.

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