1. Anorexia Nervosa in Pediatrics
Eva Yuen
OHSU Dietetic Intern
NUTN 515
April 14th, 2008

2. Agenda What is Anorexia Nervosa? Treatment Case Study: Q & A
First Admission
Second Admission
Third Admission
Q & A

3. Anorexia Nervosa Eating Disorder Low Body Weight (85% or less of IBW)
Refusal to maintain normal body weight
Puberty is delayed
Denies the dangers of low weight
Fear of weight gain
Severe body image disturbance
Reports feeling fat even when emaciated
Excessive dieting, fasting, restricted diet

4. What is the treatment for anorexia nervosa?
Question
What is the treatment for anorexia nervosa?

5. Treatment Medical Monitoring: Psychological Treatment: Nutritional
Provider
Psychological
Treatment:
Mental Health Provider
Nutritional
Rehabilitation:
Dietitian

6. What is the female-to-male ratio in having anorexia nervosa?
Question
What is the female-to-male ratio in having anorexia nervosa?

7. Introducing Mr. Kid: Admission
Sex: M
Age: 15 ½ y.o.
Admission Diagnoses:
Anorexia nervosa
Bradycardia (slow heart rate)
Resting heart rate: ~40 bpm (normal: bpm)
Temperature: ۫C

8. Lab Values Normal Range Admission Na 135-145 mEq/L 139 K 3.5-5.3 mEq/L
4.1 Cl
mEq/L
104
CO2 content
mEq/L H Ca
mg/dL
9.4
Phosp.
mg/dL
3.5 Mg
mg/dL
2.5
Gluc.
mg/dL L
PAB
mg/dL 20
Total, Protein
g/dL
6.7
ALB
g/dL
4.4
Total, Bilirubin
mg/dL
0.9
Alk Phos
IU/L L
AST-(SGOT)
IU/L 24
BUN
mg/dL H
Creatinine
mg/dL
1.1

9. Diet history (Energy Input)
Breakfast:
English muffin / Bagel with cream cheese
Chocolate milk
Lunch:
½ Peanut butter and jelly sandwich
Snack:
Cereal
Dinner:
Soup / Spaghetti / Pasta
Fruit

10. Exercise (Energy Output)
Walking
Hip Hop class
Jump rope
Skateboard
Exercise video tape

11. Nutrition Assessment Height: 172cm Weight: 45.1 kg (99.5 lbs)
IBW: 69 kg (152 lbs) %IBW= 65%
BMI: (Underweight)
Unintentional weight change: ↓ 25 lbs
Est. Daily Caloric Needs: kcal/day
Kcal/kg needs: 45 kcal/kg
Est. Daily Protein Needs: 45+ g/day
Gm/kg needs: 1 g/kg
Nutrition Risk Status: High

12. Nutrition Diagnosis PES
Inadequate oral food/beverage intake related to disordered eating pattern as evidenced by significant weight loss in last 3 months.

13. Eating Disorder Protocol
Eating Disorder Diet
3 meals, 3 snacks
No non-caloric fluids
No fat-free or sugar-free products
Maintenance fluids (1cc/kcal minimum)
Start kcals at either:
Estimated daily intake prior to hospitalization OR
1000 kcals if they were eating less than this
↑ kcals/day until consistent weight gain of 0.2 kg/day
Plan:
1500 kcal diet kcal/day
3 meals a day
HS snack
Calorie counts

14. Menu Selection Breakfast: Lunch: Dinner: PM Snack: HS Snack:
Sausage Patty
Granola
Applesauce
2% Chocolate Milk
Apple Juice
Lunch:
Fruit & Cottage Cheese Salad Plate
Wheat Bagel with Cream Cheese
2% Milk
Dinner:
Macaroni and Cheese
Baby Carrots
Peaches
PM Snack:
Fresh Fruit Cup
½ Peanut Butter Monster Cookie
Milkshake
HS Snack:
Fruit Yogurt
Graham Crackers
2% Milk

15. Short-Term Goals Restoration of a healthful weight
Normalization of eating patterns
Adequate calorie & protein intake

16. Calorie Counts Day 1 Day 2 Day 3 Day 4 Day 5 Calories (kcal) 1665 1599
2453
1972
2297
Protein
(g) 69 67 96 58 88
Meals 3
Snacks 1 2

17. Daily Weight Change
Weight (kg)
Day

18. Long-Term Goals Self-care management ability
Maintain adequate calories intake
Maintain/gain weight
Increase self-efficacy
Positive self-image

19. Before Discharge Home plan 2500 kcal (3 meals + 2 snacks) Breakfast:
2 oz protein, 3 grains, 2 fruit, 2 fat, 1 cup milk
Lunch and Dinner:
3-4 oz protein, 3 grains, 1 vegetable, 2 fruit,
2 fat, 1 cup milk
Snack:
1 protein, 1 grain

20. 2nd Admission (2 weeks later)
Weight: 43.4 kg (↓ 3.2 kg)
Height: 172 cm
BMI: 15.8
Temperature: ۫C
Admitting diagnosis:
Anorexia nervosa
Severe weight loss
Bradycardia
Hypothermia

21. Lab Values Normal Range Admission Na 135-145 mEq/L 136 K 3.5-5.3 mEq/L
4.1 Cl
mEq/L
105
CO2 content
mEq/L 23 Ca
mg/dL
9.4
Phosp.
mg/dL
4.0 Mg
mg/dL
2.4
Gluc.
mg/dL 70
PAB
mg/dL 20
Total, Protein
g/dL
6.5
ALB
g/dL
4.4
Total, Bilirubin
mg/dL
1.0
Alk Phos
IU/L L
AST-(SGOT)
IU/L 21
BUN
mg/dL H
Creatinine
mg/dL
1.1

22. Nutrition Diagnosis PES Plan:
Inadequate oral food/beverage intake related to disordered eating pattern and food- and nutrition-related knowledge deficit as evidenced by significant weight loss.
Plan:
2000 kcal kcal/day 2500 kcal 3000 kcal
3 meals a day + 2 snacks
Calorie counts

23. Calorie Counts Day 1 Day 2 Day 3 Day 4 Day 5 Day 6 Day 7 Day 8 Day 9
Calories (kcal)
2160
2245
2435
2752
2563
2528
2815
2801
2670
Protein
(g) 95 75 86
112
120
101
110 92
Meals 3
Snacks 2

24. Daily Weight Change
Weight (kg)
Day

25. Before Discharge Home plan 3000 kcal (3 meals + 2 snacks) Breakfast:
2 oz protein, 3 grains, 2 fruit, 2 fat, 1 cup milk
Lunch and Dinner:
3-4 oz protein, 3 grains, 2 fruit, 2 fat,
1 vegetable with added fat, 1 cup milk
Snack:
1 protein, 1 grain, 1 fruit

26. 3rd Admission (10 days later)
Weight: 43.1 kg (↓ 3.9 kg)
Height: 172 cm
BMI: (Underweight)
Temperature: ۫C
Admitting diagnosis:
Anorexia nervosa
Severe weight loss
Bradycardia
Hypothermia

27. Lab Values Normal Range Admission Na 135-145 mEq/L 136 K 3.5-5.3 mEq/L
3.9 Cl
mEq/L
104
CO2 content
mEq/L 25 Ca
mg/dL
9.5
Phosp.
mg/dL
3.5 Mg
mg/dL
2.5
Gluc.
mg/dL 70
PAB
mg/dL 21
Total, Protein
g/dL
6.8
ALB
g/dL
4.5
Total, Bilirubin
mg/dL
0.9
Alk Phos
IU/L L
AST-(SGOT)
IU/L
BUN
mg/dL H
Creatinine
mg/dL
1.0

30. Nutrition Assessment Weight: 43.1 kg (↓ 3.9 kg) Height: 172 cm
BMI: (Underweight)
Est. Daily Caloric Needs: kcal/day
Kcal/kg needs: 45+ kcal/kg
Est. Daily Protein Needs: 45 g/day
Gm/kg needs: 1 g/kg
Est. Fluid Needs: ml/day
Nutrition Risk Status: High

31. Menu Selection Breakfast: Lunch: PM Snack: Dinner: Yogurt Parfaits
2% Milk
Orange Juice
Lunch:
Chicken Caesar with dressing
Wheat Roll
Margarine
Peaches
Peanut Butter Milkshake
Dinner:
Pasta Al Forno
Breadstick
Steamed Broccoli
Chocolate Chip Cookies
PM Snack:
Fresh Fruit
Yogurt Parfait

32. Am I dealing with disordered eating?
Do you spend time wishing parts of your body looked different?
Are you unhappy with your reflection in the mirror?
Do you skip meals?
Do you count the calories or fat grams in anything you eat?
Do you exercise so much that you are fatigued?
Do you weigh yourself often and find yourself obsessed with the number on the scale?
Are you afraid of gaining weight?

33. References
Escott-Stump S, Mahan LK. Krause’s Food, Nutrition, & Diet Therapy. 11th edition. Philadelphia: Elsevier, 2004.
ADA. Position of the ADA: Nutrition Intervention in the Treatment of Anorexia Nervosa, Bulimia Nervosa and other eating disorders. JADA 2006;106(12):
Melissa Eckstein-Harmon. Eating disorders: The changing role of nutrition intervention with anorexic and bulimic patients during psychiatric hospitalization. JADA 1993; 93(9):
Up To Date. Eating disorders: Treatment and outcome. (2007).
Up To Date. Eating disorders: Epidemiology, pathogenesis, and clinical features/ (2007).

34. Thank You! **Special Thanks to Jessie, Laurel, and June**
Questions?
Thank You!
**Special Thanks to Jessie, Laurel, and June**