Dr. Sarah Gubara (Host): Welcome to Pediatrics in Practice, a CME podcast. I'm Dr. Sarah Gubara. and I'm joined by Dr. Sara Gould, a board-certified Clinical Child and Adolescent psychologist and certified eating disorders specialist at Children's Mercy Kansas City. Today, we'll be talking about the diagnosis and treatment of eating disorders. Dr. Gould, thank you so much for taking the time to join us this morning

Sara Gould, PhD: I appreciate being here.

Host: Wonderful to have you. Now, Dr. Gould, what are some of the early signs of eating disorders that pediatricians should watch out for, especially those that can be missed in routine visits?

Sara Gould, PhD: Two primary areas include those physical symptoms, and then the second is the behavioral symptoms. So in terms of physical presentation, looking for changes in growth trajectory, particularly in weight, whether it is up or down, either one. Sometimes changes up are missed or overlooked a little bit in terms of potential eating disorder. And also looking for potential micronutrient deficiencies can be another area of concern.

And in terms of behaviorally, sometimes the earliest changes that we see are things that look very positive, very mature, kids eating more healthfully, as we tend to look at it, things like decreasing the number of sweets or higher calorie foods, increasing the amount of fruits and vegetables, things like that. And those can be positive changes, but perhaps warrant a few more followup questions to understand the motivation and reasons for them.

Another thing that can be overlooked is kids who have been historically lower weight on the growth curve. And so, it's not a marked change, but has been where they've just kinda hung out all the time. We do see some kids, particularly with an ARFID or a really picky eating presentation, who simply have a neurological difference that they don't sense hunger cues as commonly as others do, and they're therefore just fairly disinterested in food. But even though they're responding to their cues, that can underestimate their body's needs.

Finally, in terms of weighing, vitals and exam, looking for kids who get nervous before getting on the scale. Looking for kids who tense up with physical exam, particularly when they haven't done so historically, can be a sign of body image concerns.

Host: Those are wonderful early signs to look for. How else can pediatricians distinguish between typical picky eating, disordered eating, and conditions like anorexia, bulimia, or ARFID?

Sara Gould, PhD: In terms of picky eating, one consideration is developmental stage. We all know those toddlers who were eating mixed foods, gloppy foods, whatever, fine, and then suddenly they're pushing it off their plate. So, that would be developmentally typical. But if an eight-year-old is doing that, if those changes have hung around for an extended period of time, that might be worth another look.

Picky eaters usually, generally speaking, are eating a less variety than their peers may be, but it's not hitting them physically or socially. So, they're able to navigate their world just fine with the limited foods that they're comfortable with, and their bodies are getting all of the things that they need to grow and develop just fine.

Disordered eating often is a change from previous presentation and, in some way, is a mismatch between what food is coming in or how it's coming in and what the body needs. So for example, with overeating, emotional eating, then the nutrition is beyond what the body is utilizing. And then, obviously, the reverse, if there's some restriction or more heightened selectivity, the body is not getting enough.

Chaotic eating can also fall into that category. So perhaps, overall, the energy balance is in place, but there's large periods of the day in which kids are not eating or not eating much, and then short periods in which they're eating more than you would usually think in that timeframe.

Another consideration finally is what are caregivers seeing and what are they thinking about what's going on, how are they changing their lives to meet their kids' needs. For example, we have enough fortified foods in our food environment that kids with ARFID and that really selective eating pattern can be fine nutritionally, but parents are jumping through hoops praying that a certain specific kind of chicken nugget stays on the shelves, things like that. Having difficulty with travel or environments where their preferred foods are harder to have available. Things like that are really good distinguishing characteristics between the three.

Host: That makes a lot of sense. Dr. Gould, when an eating disorder is suspected, what initial medical evaluation and monitoring should occur in primary care?

Sara Gould, PhD: Absolutely. Primary care is very well-situated in terms of the length of time that they've followed kids, and they have the historical data right at their fingertips to be able to see how things are progressing over time. And in addition, that trust that has been built with caregivers really opens the door for them to ask questions that maybe they're not quite comfortable asking in those settings. And so, that's a really positive place to start.

We've already touched on growth and looking for changes or differences in that respect. If there seems to be a mismatch between the energy coming in and that is undershooting what the body needs, checking out cardiac health through even just the simple pulse heart rate that's taken in office and looking potentially at an EKG to sort that out. And also, screening out other potential explanations for changes in weight or growth, such as celiac disease, thyroid conditions, things like that.

Another really helpful tool can be to gain a 24-hour recall. It's very brief. I know time is short in these visits, but just asking kids, "What was the last thing you ate? How about before that? How about before that?" until you have about a day's worth. And asking a bit about amounts as well and fluid intake. Sometimes that can get a lot of information pretty quickly. And all kids, I would say ages 10 and up, are, just by nature of their developmental period, at increased risk for disordered eating and eating disorders. So, there aren't any physical markers, demographic markers that would exclude a child from benefiting from being screened.

In addition to those pieces for ongoing monitoring, keeping an eye on that growth. And then, if you have recommended changes to the family to correct some difficulties that you've noticed, are those changes happening? So for example, sometimes athletes, just due to their high energy expenditure and increased time in their schedule that's sucked up by their sport, can accidentally undernourish themselves. But with those recommendations, the explanation that it will help their sports performance implement the changes without blinking an eye. But if those recommendations have been made and change is not occurring or parents are sharing with you that their child is really resistant to those changes, that is a marker of increased concern

Host: In terms of collaboration, what does evidence-based multidisciplinary treatment for pediatric eating disorders look like today?

Sara Gould, PhD: We are at a really exciting point in our field because the tools continue to grow, which means that we can really understand which components of interventions are most effective and pull those out, and we can really tailor interventions to a child's unique presentation in terms both of eating disorder symptoms, of other medical or psychiatric comorbidities, family context, local resources, all kinds of things. And that's really different from when I started in this field just 15 years ago.

Across the board, however, one common component is critical and should take priority to proceed with that nutritional rehabilitation or normalization. Authors who conducted a scoping review likened it to neurological recalibration. That is because our nutrition, particularly that energy balance, has a huge impact on how our brain uses information, processes information, and how effectively it can do its work. And so, what we know is being malnourished for any reason really increases mental health concerns just itself, including and especially anxiety and depressive symptoms. But it can also really impact the body's ability to become renourished.

We have slew of adaptations that equip us to survive famines. And those same things, slowing the motility of the gut, the decrease of digestive enzyme production to save resources that aren't being used, can make the refeeding progress more challenging and painful with some bloating, abdominal pain, symptoms like that. And so, coming alongside families to push through those challenges and get that nutrition right back on track, very often we see all the other symptoms that were present decrease or fully resolve without other intervention. And that is very promising because it means we can streamline treatment for families.

Traditionally, it has involved multiple disciplines for every patient. And now, we're able to use a step care model. For example, we have started utilizing medical providers for some patients as the sole interventionist who are pushing forward that behavioral work. And then, we're seeing what else children need as they progress in that realm.

For other kids, they need medical nutrition and therapy. For others, they're doing great medically. This can be particularly the case in conditions such as binge eating disorder or ARFID where there are no medical complications. Those kids sometimes can work solely with a dietician, solely with a therapist, or solely with an occupational therapist. And so, we have really prioritized comprehensive and solid assessment of patients at the get-go of treatment so that we can select the pieces that will make the most difference from them and not overburden the family with perhaps extras unless we have an indication that those are needed for progress and healing.

Host: Those sound like really intentional interventions. When it's time to refer to a specialized eating disorder center, what information typically helps ensure that families have timely access to care?

Sara Gould, PhD: So, some of the pieces that are really helpful are related to that historical data and the current look that pediatricians are getting now. So, those growth records are invaluable in helping us plan treatment and estimate where we need to help families land over time. Recent labs can be very helpful. And if you've run an EKG, those results are very helpful as well. That helps us get a more comprehensive look at families right away and prevents us from asking them to perhaps redo lab work or procedures because we don't have those data at our fingertips.

Right now, we are triaging briefly. Usually, families are offered an appointment with us within about a week. Sometimes families need longer than that to make arrangements with work or pieces. And so, we see them when they can come in. We are moving in just a couple of weeks to eliminating that first triage piece and simply scheduling families with a medical provider with the intention to have that turnaround as fast as possible.

In the meantime, between families, call us or you refer to us. And when they're actually seen in clinic, we will continue to try to get those records so that we can be the most prepared to serve them as we can. But they will have it on the books and be able to move forward seamlessly. And from that medical visit and that evaluation, that will help us select the other interventions potentially that would be of benefit for that family.

Host: Wonderful. Well, Dr. Gould, last question for you. What common misconceptions do you see among pediatric providers, and how can better education and collaboration address them?

Sara Gould, PhD: I'll start with the second part of that. I think collaboration always teaches us as we go along. And we know whatever we discussed for this patient when we're evaluating the next patient with similar concerns. And so, that ongoing two-way communication, I think, is really valuable, both in effective patient care but in helping us have a growing shared understanding over time.

Returning to some of the common misconceptions, I would say these are similar to those held by the larger community. And so, one of them we've already touched on is the perception that because these are mental health concerns, the psychological aspects of the condition need to be addressed first, and then the physical complications will resolve after that. And as I said, we really know the biological changes related to malnutrition necessitate that physical healing come first, and that facilitates the behavioral and psychological progress over time.

Another misconception is that eating disorders are a lifelong condition that can only be managed. And the research and our experience is very, very clear. With early consistent quality intervention, these can be conditions that are in kids' rearview mirror, that they may be at increased risk of relapse, similar to a patient who has had cancer will always be at increased relapse risk. But that doesn't mean it will happen again. And it means that full remission is absolutely possible.

 There's also a perception that eating disorders require a patient being low weight or lower than their historical weight. And we know that most individuals with eating disorder are actually in the average BMI range or higher, so not being falsely reassured by weight status.

And then, we also know there continues to be a perception, although I think we're making headway with this one, that this is a young middle class or rich white girl's condition. And we know that there are no demographic variables that decrease the risk for eating disorders. Presentations are somewhat different across some ethnic groups or pieces like that, but eating disorders occur with equal prevalence, and so having them on the differential for every patient that presents.

Host: Thank you for educating us on the diagnosis and treatment of eating disorders, Dr. Gould. And as a reminder to our audience, claim your CME credits after listening to this fascinating episode today. You could do so by visiting cmkc.link/cmepodcast and then click the Claim CME button. If you enjoyed this podcast, please share it on your social channels and check out the entire podcast library for topics of interest to you. I'm Dr. Sarah Gubara. And this has been Pediatrics in Practice, a CME podcast