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## Complete Summary

#### GUIDELINE TITLE

Eating disorders among children and adolescents.

#### BIBLIOGRAPHIC SOURCE(S)

Finnish Medical Society Duodecim. Eating disorders among children and
adolescents. In: EBM Guidelines. Evidence-Based Medicine \[Internet\].
Helsinki, Finland: Wiley Interscience. John Wiley & Sons; 2007 Mar
28 \[Various\].

#### GUIDELINE STATUS

This is the current release of the guideline.

This guideline updates a previous version: Finnish Medical Society
Duodecim. Eating disorders among children and adolescents. In: EBM
Guidelines. Evidence-Based Medicine \[Internet\]. Helsinki, Finland:
Wiley Interscience. John Wiley & Sons; 2005 Feb 8 \[Various\].

### \*\* REGULATORY ALERT \*\*

#### FDA WARNING/REGULATORY ALERT

**Note from the National Guideline Clearinghouse**: This guideline
references a drug(s) for which important revised regulatory and/or
warning information has been released.

-   [May 2, 2007, Antidepressant
    drugs](http://www.fda.gov/medwatch/safety/2007/safety07.htm#Antidepressant):
    Update to the existing black box warning on the prescribing
    information on all antidepressant medications to include warnings
    about the increased risks of suicidal thinking and behavior in young
    adults ages 18 to 24 years old during the first one to two months of
    treatment.

### COMPLETE SUMMARY CONTENT

 \*\* REGULATORY ALERT \*\*\
 SCOPE\
 METHODOLOGY - including Rating Scheme and Cost Analysis\
 RECOMMENDATIONS\
 EVIDENCE SUPPORTING THE RECOMMENDATIONS\
 BENEFITS/HARMS OF IMPLEMENTING THE GUIDELINE RECOMMENDATIONS\
 IMPLEMENTATION OF THE GUIDELINE\
 INSTITUTE OF MEDICINE (IOM) NATIONAL HEALTHCARE QUALITY REPORT
CATEGORIES\
 IDENTIFYING INFORMATION AND AVAILABILITY\
 DISCLAIMER

### SCOPE

#### DISEASE/CONDITION(S)

Eating disorders including anorexia and bulimia nervosa

#### GUIDELINE CATEGORY

Counseling\
Diagnosis\
Evaluation\
Management\
Treatment

#### CLINICAL SPECIALTY

Family Practice\
Nutrition\
Pediatrics\
Psychiatry\
Psychology

#### INTENDED USERS

Health Care Providers\
Physicians\
Psychologists/Non-physician Behavioral Health Clinicians

#### GUIDELINE OBJECTIVE(S)

Evidence-Based Medicine Guidelines collect, summarize, and update the
core clinical knowledge essential in general practice. The guidelines
also describe the scientific evidence underlying the given
recommendations.

#### TARGET POPULATION

Children and adolescents with known or suspected eating disorders, such
as anorexia nervosa or bulimia nervosa

#### INTERVENTIONS AND PRACTICES CONSIDERED

**Diagnosis/Evaluation**

1.  Screening questionnaire

2.  Evaluation for signs and symptoms of eating disorders

3.  Laboratory tests to evaluate for anemia and low blood glucose levels
    (anorexia nervosa) or for hypokalaemia and increased serum amylase
    (bulimia nervosa)

**Treatment/Management/Counseling**

1.  Treatment of severe malnutrition in a somatic ward

2.  Psychotherapy (individual and family)

3.  Cognitive therapy and medication (bulimia nervosa)

4.  Psychopharmaceuticals (e.g., neuroleptics and antidepressants)

**Note**: Guideline developers considered several other prevention and
treatment options. For a list of these, see the \"Major
Recommendations\" field below.

#### MAJOR OUTCOMES CONSIDERED

-   Eating disorder symptomatology

-   Weight gain

-   Efficacy of treatment at reducing symptoms of eating disorders and
    improving prognosis

-   Mortality

### METHODOLOGY

#### METHODS USED TO COLLECT/SELECT EVIDENCE

Hand-searches of Published Literature (Primary Sources)\
Hand-searches of Published Literature (Secondary Sources)\
Searches of Electronic Databases

#### DESCRIPTION OF METHODS USED TO COLLECT/SELECT THE EVIDENCE

The evidence reviewed was collected from the Cochrane database of
systematic reviews and the Database of Abstracts of Reviews of
Effectiveness (DARE). In addition, the Cochrane Library and medical
journals were searched specifically for original publications.

#### NUMBER OF SOURCE DOCUMENTS

Not stated

#### METHODS USED TO ASSESS THE QUALITY AND STRENGTH OF THE EVIDENCE

Weighting According to a Rating Scheme (Scheme Given)

#### RATING SCHEME FOR THE STRENGTH OF THE EVIDENCE

**Levels of Evidence**

A.  **Quality of Evidence: High**

> Further research is very unlikely to change confidence in the estimate
> of effect

-   Several high-quality studies with consistent results

-   In special cases: one large, high-quality multi-centre trial

B.  **Quality of Evidence: Moderate**

> Further research is likely to have an important impact on confidence
> in the estimate of effect and may change the estimate.

-   One high-quality study

-   Several studies with some limitations

C.  **Quality of Evidence: Low**

> Further research is very likely to have an important impact on
> confidence in the estimate of effect and is likely to change the
> estimate.

-   One or more studies with severe limitations

D.  **Quality of Evidence: Very Low**

> Any estimate of effect is very uncertain.

-   Expert opinion

-   No direct research evidence

-   One or more studies with very severe limitations

#### METHODS USED TO ANALYZE THE EVIDENCE

Review of Published Meta-Analyses\
Systematic Review

#### DESCRIPTION OF THE METHODS USED TO ANALYZE THE EVIDENCE

Not stated

#### METHODS USED TO FORMULATE THE RECOMMENDATIONS

Not stated

#### RATING SCHEME FOR THE STRENGTH OF THE RECOMMENDATIONS

Not applicable

#### COST ANALYSIS

A formal cost analysis was not performed and published cost analyses
were not reviewed.

#### METHOD OF GUIDELINE VALIDATION

Peer Review

#### DESCRIPTION OF METHOD OF GUIDELINE VALIDATION

Not stated

### RECOMMENDATIONS

#### MAJOR RECOMMENDATIONS

The levels of evidence \[A-D\] supporting the recommendations are
defined at the end of the \"Major Recommendations\" field.

**Objectives**

-   Remember that eating disorders are very common among adolescent
    girls and especially bulimic disorders are encountered in boys as
    well.

-   One must remember to look for signs of an eating disorder; patients
    seldom report it themselves.

-   The diagnosis and planning of treatment are the responsibility of
    special personnel.

**Basic Rules**

-   An eating disorder refers to states in which food and nourishment
    have an instrumental and manipulative role: food has become a way to
    regulate the appearance of the body.

-   The spectrum of eating disorders is vast. The most common disorders
    are anorexia nervosa and bulimia nervosa. In addition, incomplete
    clinical pictures and simple binge eating have become more general.

-   Recently the international trend has been to put more emphasis on
    early reaction to the symptoms.

-   Even small children can have different kinds of eating disorders
    that relate to difficulties in the relationships between the child
    and his/her caretaker.

**Aetiology**

-   Currently eating disorders are considered to be multifarious.
    Genetic and sociocultural factors and also individual dynamics all
    affect eating disorders.

-   The typical age of onset is adolescence, when the body changes and
    grows.

-   Anorexia nervosa typically emerges between 14 and 16 years of age or
    around the age of 18 years. Bulimia appears typically at the age of
    19-20 years.

-   Eating disorders are 10-15 times more common among girls than boys.

-   Every 150th girl between the ages of 14 and 16 years suffers from
    anorexia nervosa.

-   There is no epidemiological data on the occurrence of bulimia, but
    it is considered to be more common than anorexia nervosa.

**Diagnostic Criteria for Anorexia Nervosa**

-   The patient does not want to maintain his or her normal body weight.

-   The patient\'s weight is at least 15% below that expected for age
    and height.

-   The patient\'s body image is distorted.

-   The patient is afraid of gaining weight.

-   There is no other sickness that would explain the loss of weight.

**Diagnostic Criteria of Bulimia Nervosa**

-   Desire to be thin, phobic fear of gaining weight

-   Persistent preoccupation with eating and an irresistible urge or
    compulsive need to eat.

-   Episodes of binge eating (at least twice a week); control over
    eating is lost.

-   After the episode of binge eating, the person attempts to eliminate
    the ingested food (e.g., by self-induced vomiting and by abuse of
    purgatives and diuretics).

**Symptoms**

-   Anorexia nervosa generally starts gradually.

-   Losing weight can either be very rapid or very slow. Generally the
    patients continue to go to school; they go on with their hobbies and
    feel great about themselves. Therefore the families are usually
    surprised to find that their child suffers from malnutrition.

-   A screening questionnaire is helpful in the assessment of patients
    with suspected eating disorder (each positive answer gives one
    point; 2 or more points suggest an eating disorder).

    1.  Do you try to vomit if you feel unpleasantly satiated?

    2.  Are you anxious with the thought that you cannot control the
        amount of food you eat?

    3.  Have you lost more than 6 kg of weight during the last 3 months?

    4.  Do you consider yourself obese although others say you are
        underweight?

    5.  Does food/thinking of food dominate your life?

-   Anorectic adolescents deny their symptoms, and it takes time and
    patience to motivate them to accept treatment.

-   Somatic symptoms include:

    -   Disappearance of menstruation

    -   The slowing of metabolism, constipation

    -   Slow pulse, low blood pressure

    -   Flushed and cold limbs

    -   Reduction of subcutaneous fat

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-   Bulimic adolescents are aware that their eating habits are not
    normal, but the habit causes so much guilt and shame that seeking
    treatment is not easy.

-   Bulimia also causes physical symptoms

    -   Disturbances of menstruation

    -   Disturbances in electrolyte and acid-alkali balances created by
        frequent vomiting and damage of the enamel of teeth (see the
        Finnish Medical Society Duodecim guideline \"Dental Caries and
        Other Diseases of the Hard Tissues of the Teeth and Dental
        Pulp\")

**Laboratory Findings**

-   In anorexia nervosa

    -   Slight anaemia

    -   Blood glucose levels on the lower border of normal

-   In bulimia

    -   Hypokalaemia

    -   Increased serum amylase

**Differential Diagnosis**

-   Severe somatic diseases, for example, brain tumours

-   Psychiatric diseases\--severe depression, psychosis, use of drugs

**Treatment**

-   If the symptoms correspond to the diagnostic criteria of anorexia
    nervosa, the situation should be discussed with the family before
    treatment is arranged.

-   The adolescent and his or her family should be made aware of the
    seriousness of the disorder.

-   Sometimes it takes time to motivate the patient to participate in
    the treatment.

-   The treatment is divided into

    -   Restoring the state of nutrition

    -   Psychotherapeutic treatment

-   If the state of malnutrition is life threatening, the patient is
    first treated in a somatic ward, and thereafter the adolescent is
    guided into therapy if possible.

-   The forms of psychotherapy vary: both individual and family therapy
    have brought results; in cases of bulimia cognitive therapy and
    medication (Lewandowski et al., 1997; Whittal, Agras, & Gould, 1999)
    \[**C**\] have been successful.

-   With adolescents between the ages of 14 and 16 years, positive
    results have been obtained by treating the entire family, because
    the adolescent\'s symptoms are often connected with difficulties to
    \"cut loose\" from the family.

-   With older patients, individual, supportive, and long-lasting
    treatment has been the best way to promote recovery.

-   A prolonged state of malnutrition and insufficient outpatient care
    are reasons to direct a patient into forced treatment.

**Medical Treatment**

-   A specialist should start all drug treatment.

-   Different psychopharmaceuticals, for example, neuroleptics and
    antidepressants, have been tried in the treatment of anorexia
    nervosa. Controlled studies have proved them indisputably useful
    only if the disorder is linked to clear depression.

-   Most research on the medical treatment of bulimia has concentrated
    on antidepressants (Bacaltchuk & Hay, 2003) \[**A**\], particularly
    fluoxetine, which has been found to decrease binge eating and
    vomiting for about two-thirds of bulimic patients.

**Prognosis**

-   Early intervention improves prognosis.

-   Eating disorders comprise a severe group of diseases that are
    difficult to treat. The prognosis for the near future of anorectic
    patients is good, but for the long term the prognosis is worse. The
    percentage of mortality is still 5 to 16%.

-   Not enough follow-up research has been carried out on the prognosis
    of bulimia, but the disease is thought to last years.

-   Bulimia can be associated with depression, self-destructiveness,
    abuse of alcohol or drugs, and other psychological problems.

**Related Resources**

**Cochrane Reviews**

-   A combination of antidepressants and psychotherapy may be more
    effective than psychotherapy alone, but psychotherapy appeared to be
    more acceptable to subjects. There was a non-significant trend
    favouring single psychotherapy over single antidepressants
    (Bacaltchuk, Hay, & Trefiglio, 2001) \[**C**\].

-   Antidepressants appear to be ineffective in the treatment of
    anorexia nervosa (Claudino et al, 2006; Walsh et al., 2006; Treasure
    & Schmid, 2005) \[**B**\].

**Other Evidence Summaries**

-   There is no evidence from controlled trials to assess whether early
    intervention is beneficial in anorexia nervosa (Shoemaker, 1997)
    \[**D**\].

-   Evidence on inpatient versus outpatient care for eating disorders is
    insufficient for firm conclusions (Meads et al., 1999) \[**D**\].

**Definitions**:

**Levels of Evidence**

A.  **Quality of Evidence: High**

> Further research is very unlikely to change confidence in the estimate
> of effect

-   Several high-quality studies with consistent results

-   In special cases: one large, high-quality multi-centre trial

B.  **Quality of Evidence: Moderate**

> Further research is likely to have an important impact on confidence
> in the estimate of effect and may change the estimate.

-   One high-quality study

-   Several studies with some limitations

C.  **Quality of Evidence: Low**

> Further research is very likely to have an important impact on
> confidence in the estimate of effect and is likely to change the
> estimate.

-   One or more studies with severe limitations

D.  **Quality of Evidence: Very Low**

> Any estimate of effect is very uncertain.

-   Expert opinion

-   No direct research evidence

-   One or more studies with very severe limitations

#### CLINICAL ALGORITHM(S)

None provided

### EVIDENCE SUPPORTING THE RECOMMENDATIONS

#### REFERENCES SUPPORTING THE RECOMMENDATIONS

[References open in a new
window](http://www.guideline.gov/summary/select_ref.aspx?doc_id=11035)

#### TYPE OF EVIDENCE SUPPORTING THE RECOMMENDATIONS

Concise summaries of scientific evidence attached to the individual
guidelines are the unique feature of the Evidence-Based Medicine
Guidelines. The evidence summaries allow the clinician to judge how
well-founded the treatment recommendations are. The type of supporting
evidence is identified and graded for select recommendations (see the
\"Major Recommendations\" field).

### BENEFITS/HARMS OF IMPLEMENTING THE GUIDELINE RECOMMENDATIONS

#### POTENTIAL BENEFITS

-   Appropriate diagnosis and treatment of eating disorders among
    children and adolescents

-   Early intervention improves prognosis.

#### POTENTIAL HARMS

Not stated

### IMPLEMENTATION OF THE GUIDELINE

#### DESCRIPTION OF IMPLEMENTATION STRATEGY

An implementation strategy was not provided.

### INSTITUTE OF MEDICINE (IOM) NATIONAL HEALTHCARE QUALITY REPORT CATEGORIES

#### IOM CARE NEED

Getting Better\
Living with Illness

#### IOM DOMAIN

Effectiveness

### IDENTIFYING INFORMATION AND AVAILABILITY

#### BIBLIOGRAPHIC SOURCE(S)

Finnish Medical Society Duodecim. Eating disorders among children and
adolescents. In: EBM Guidelines. Evidence-Based Medicine \[Internet\].
Helsinki, Finland: Wiley Interscience. John Wiley & Sons; 2007 Mar
28 \[Various\].

#### ADAPTATION

Not applicable: The guideline was not adapted from another source.

#### DATE RELEASED

2004 Jun (revised 2007 Mar 28)

#### GUIDELINE DEVELOPER(S)

Finnish Medical Society Duodecim - Professional Association

#### SOURCE(S) OF FUNDING

Finnish Medical Society Duodecim

#### GUIDELINE COMMITTEE

Editorial Team of EBM Guidelines

#### COMPOSITION OF GROUP THAT AUTHORED THE GUIDELINE

*Primary Author*: Päivi Rantanen

#### FINANCIAL DISCLOSURES/CONFLICTS OF INTEREST

Not stated

#### GUIDELINE STATUS

This is the current release of the guideline.

This guideline updates a previous version: Finnish Medical Society
Duodecim. Eating disorders among children and adolescents. In: EBM
Guidelines. Evidence-Based Medicine \[Internet\]. Helsinki, Finland:
Wiley Interscience. John Wiley & Sons; 2005 Feb 8 \[Various\].

#### GUIDELINE AVAILABILITY

This guideline is included in a CD-ROM titled \"EBM Guidelines.
Evidence-Based Medicine\" available from Duodecim Medical Publications,
Ltd, PO Box 713, 00101 Helsinki, Finland; e-mail:
<info@ebm-guidelines.com>; Web site:
[www.ebm-guidelines.com](http://www.ebm-guidelines.com/).

#### AVAILABILITY OF COMPANION DOCUMENTS

None available

#### PATIENT RESOURCES

None available

#### NGC STATUS

This NGC summary was completed by ECRI on August 29, 2005. This NGC
summary was updated by ECRI on December 22, 2006, and December 31, 2007.

#### COPYRIGHT STATEMENT

This NGC summary is based on the original guideline, which is subject to
the guideline developer\'s copyright restrictions.

### DISCLAIMER

#### NGC DISCLAIMER

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Date Modified: 11/3/2008