tube feeding, when required, may be diurnal and/or nocturnal. Gastrointestinal .... Among these we can observe a) bradycardia, b). QRS reduced in 20% and ...
REVIEW
ARTICLE
Anorexia nervosa: nutritional treatment in pediatrics Sergio Miranda-Sánchez Abstract Prevalence and incidence of anorexia nervosa are both increasing. A younger age of onset is currently being observed, making this disease an important issue for general practice in pediatrics. Treatment must include a multidisciplinary team. Family participation in rehabilitation is currently encouraged. Detection of hospitalization criteria is the first task to accomplish during clinical evaluation. Once treatment is established, occurrence of refeeding syndrome consisting of life-threatening disorders of water and electrolyte metabolism (cardiac arrhythmias) must be ruled out. Oral route is the first choice for refeeding. Continuous tube feeding, when required, may be diurnal and/or nocturnal. Gastrointestinal disorders associated with anorexia nervosa may require drug therapy. Diagnosis and hospitalization criteria are discussed in this review as well as medical and dietary treatment options in hospitalized and ambulatory settings. Key words: anorexia nervosa, refeeding syndrome, continuous tube feeding, electrolyte metabolism.
Definition Currently, the most widely known criteria for diagnosing anorexia nervosa (AN) are included in the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV)1 and its European counterpart, International Classification of Diseases (ICD-10) (Tables 1 and 2).
disorder admit that anorexia is one of the unpleasant symptoms that cause suffering (egodystonic). Weight loss is a goal of AN, which differs from cases of anorexia associated with other physiological or mental disorders (during schizophrenia and paranoiac delirium dysfunctions, eating can be avoided because of fear of poisoning).
However, the term anorexia can be misleading because AN patients do not always experience loss of appetite. Also, a pronounced appetite loss can be observed in several gastrointestinal, renal or psychiatric disorders. It is essential to evaluate the relationship between patient self-perception and weight loss (with or without anxiety). Contrary to AN patients, those with appetite loss secondary to another
Diagnosis of secondary amenorrhea (SA), which has been included as a classic symptom according to different schools of thought, is still controversial. The relationship between severity of malnutrition (MN) and amenorrhea is variable: serious MN can present without amenorrhea in cases of long evolution of AN.2 Therefore, DSM-IV includes the nonspecific feeding disorders category and IDC-10 includes atypical AN (Tables 1 and 2).
Departamento de Gastroenterología y Nutrición Pediátrica, Hospital Infantil de México Federico Gómez, México, D.F., México.
The complexity of this disorder demands a multidisciplinary team for its diagnosis and management: psychiatry, psychology, family therapy, pediatrics, pediatric gastroenterology and nutrition, as well as social work.
Received for publication: 10-7-2008 Accepted for publication: 10-20-2008
Vol. 67, January-February 2010
3
Miranda Sánchez
Table 1. Diagnostic criteria for anorexia nervosa according to DSM-IV A. Rejection to maintain same body weight or above normal minimum value considering age and size (for example, loss of weight that results in weight
