Revista nº 811

Pediatric eating disorders for 10 years | Ramírez-Sánchez F, et al. Actual Med. 2020; 105(811): 182- 189 186 Psychiatric comorbidities were also investigated and detected; in 70-75%, depression and anxiety coinci- ded, finding an identifiable trigger in 40% of patients with these disorders. Behavioral alterations and ob- sessive-compulsive disorder appeared in 10%, family history of psychiatric illness in 20%, and bullying and traumatic events in 10-25% of the children. Concerning treatment, 100% of the patients need- ed personalized meal plans designed by a multidis- ciplinary group of professionals. In addition, 60% required nutritional supplements: 25% used micronu- trient supplements, 20% hypercaloric beverages, and 15% used both. 65% of patients were prescribed for one or more types of psychoactive drugs, being antidepres- sants and anxiolytics the most common. One-third of the patients required hospitalization in, at least, one occasion during their treatment, but only one patient received nasogastric tube feeding and another two chil- dren required serum or glucose intravenous therapy. The children in the present study have a particular profile with important differences, mainly regarding diagnosis, treatment objectives, approach and evolu- tion, respect to reported in adults with ED. The female-male sex ratio obtained is consistent with the bibliographic finding that these disorders mainly affect girls. Women have historically represented 90% of EDs and men only 10%, but studies in recent years show that this figure might already reach around 25% (11-13). These new findings are reflected in the lat- est updates to the DSM-V, which have accepted less sex-specific criteria, thus eliminating amenorrhea as a diagnostic criterion for AN (8,14). It should also be highlighted the fact that younger patients diagnosed with ED, especially ARFID(15) and in our study, childhood-onset anorexia, are more likely to be male (15) than older patients: the ratio in adults is esti- mated to be 10:1 at 15:1, while in the pediatric and adolescent population it ranges from 6 to 1(16-18). The mean age of onset of ED obtained through our data analysis was 11.3 years, which contrasts with other studies also carried out in children and adoles- cents, which states this age between 14 and 18 years (12,19). This reported average can be conditioned by the lack of studies exclusively focus to pediatric age. So, these conditions can contribute to increase the age of debut. Notwithstanding, in recent studies have been observed a trend in the coming decades to decrease the age of onset with more debuts in pedi- atric stages (15,20,21). On the other hand, the onset of BN is usually later, rarely being diagnosed in chil- dren under 14 years (15,22). According to the present study, the evolution time range before the first con- sultation is 6.6 months, without differences by sex. In other studies, concerning EDs in children, this time is shown to be at least 2 years (8), maybe by different access to the health system. Almost two-thirds of the patients were diagnosed with AN, being consistent with binge/purge behav- iors in studies with younger ED patients (6). Diagno- sis may present more difficulty in this age spectrum due to the higher prevalence of atypical or incomplete forms (13) and may not be accompanied by physical deterioration at first but of interrupted or selective eating behaviors and character changes, as occurred in 80% of our patients. One out of every four patients with AN developed a BN component throughout the disease, and in clinical practice it is noteworthy that this movement occurs in a higher percentage of males (5,16). 36% of pa- tients with severe restrictive disorders previously had a high and premorbid BMI. This suggests that obesi- ty and overweight may be risk factors for subsequent ED (23,24) with an increased risk of late diagnosis (10 months later in our study) and the development of complications with a worse prognosis(6,25,26). The initial nutritional evaluation is the basic pillar of the physical examination. However, anthropomet- ric data per se do not provide an accurate diagnosis as they may be normal in a patient with these dis- eases (i.e if the child showed obesity before) (27). In fact, the bioimpedanciometry offered data within the normal range in most of patients. It must be kept in mind that ED can present as a failure in weight gain rather than a loss of weight, so it can be misleading to evaluate patients only for their BMI (13). The BMI percentile was useful to classify the degree of sever- ity, with 57.2% of our sample being in an extreme percentile <15%. The average weight loss before the first evaluation was 10kg, with less involvement of the height percentile, which corroborates that the weight percentile is affected earlier and to a greater extent, making early evaluation necessary compared with previous data as well as with future comparisons to evaluate the evolution (12,28). Complications can occur in children with ED even at non-alarmingly low weights, with chronicity markers being important (2,8,19). At the first visit, most of the data was normal except for hormone levels and some biochemical markers, affected in approximately half of the patients. The most common alterations were hypercholesterolemia, reflecting the decrease in the elimination of bile acids in starvation conditions or by a greater reabsorption of endogenous cholesterol (8,29), and hypoglycemia due to restricted intake. In patients with altered hormonal levels, low levels of gonadotropin and sex hormones, testosterone in men, and estrogens in women were found, due to hypotha- lamic suppression (3,30,31). In fact, in 20% of the pa- tients, amenorrhea preceded weight loss. Hypoestro- genic status is a risk factor for the development of osteopenia, osteoporosis, and pathological fractures, DISCUSSION