Revista nº 811

Ramírez-Sánchez F, et al. | Pediatric eating disorders for 10 years Actual Med. 2020; 105(811): 182- 189 187 the main therapy being weight gain (12,19). In this sample of children, no alterations were found in the count of blood or electrolytic cells, described above all in patients with purgative behaviors (3,5,19). Clin- ical symptoms such as lanugo, dry and scaly skin, brittle hair and nails, bradycardia and hypotension and delayed pubertal development of secondary sexu- al characteristics were also observed in these patients (12,21,31). A family history of psychiatric illness was found in more than half of the patients, consistently to oth- er studies (8,16,17). Those with a family history of AN are 11.4 times more risk, while in BN they are 3.7 times (18). It seems that there is a positive rela- tionship between excessive control, the application of strict dietary rules, and the individualization of food with the appearance of ED(4) with an influence of the genetic load (heritability of AN around 48-74%) that condition the beginning before puberty or during adolescence(11,14). Other risk factors found in the sample and reported, are the medium-high socio-eco- nomic level, insecure personality with low self-es- teem, dependency, obsessive-compulsive tendencies, and identity problems (19). It is also worth noting the effects of cultural aspects related to the search for perfection and an ideal of beauty-focused on thin- ness, as well as the membership in certain groups where the key to success is related to weight control: social, modeling or sport clubs (4,32). Results of psychiatric comorbidity in our study are in harmony with the pre-existing findings (11,18). The prevalence of, at least one comorbidity varies between 40-90% (8). Depression is a common comorbid diag- nosis with rates of up to 63% (8,21) (70% in our sam- ple) and between 25-75% of adult patients with ED have anxiety disorders (13,21), affecting 75% of the children in the study. Obsessive-compulsive disorder appeared in 10% of our patients and has been de- scribed especially associated with AN (18). Severe life stress, as well as traumatic events in childhood, have been implicated in the development of ED (9); in fact, they were detected in 70% of children. It has been re- ported that people who have experienced some form of child abuse are three times more likely to develop an ED than the general population. Both emotional dysregulation and abuse are related (32,33). Howev- er, those who had a traumatic event as an identifi- able trigger (almost half of the patients in our sample) were more likely to recover (20). Treatment was multidisciplinary (21), being the cor- nerstone of it nutritional recovery. A fundamental pillar is the individual psychotherapy programs (cog- nitive behavioral therapy) and therapy that actively involves the family (family-based treatment, FBT) finding the latter more effective. A systematic review from 2015 concluded that there is clear and growing evidence supporting the efficacy of FBTs in children and adolescents with AN and other restrictive disor- ders (6,17,34). A large part of the patients with de- pression received drugs as a complement to the main treatment, resulting in a significant decrease in binge eating and purging. However, there is no solid evi- dence to support pharmacological treatment (16,19). From 10 to 15% of the patients in our sample with a comorbid psychiatric disorder did not receive such treatment and yet did not perform worse; paradoxi- cally, there is no evidence that pharmacological treat- ment has statistical significance in weight gain (34) or the reduction of EDs symptoms in people receiving multifaceted treatment, yet a meta-analysis conclud- ed that depressive symptoms improved at the cost of increased anxiety (5,8,18,21). In our study, 58% of the children received oral nutri- tional supplementation (enteral hypercaloric and/or hyper-proteic formulas, vitamins...). Literature sup- ports the use of these formulas and supplements, given they obtain a greater weight gain with the additional advantage of using small volumes, therefore avoid- ing the early appearance of satiety. Also, the fact that these supplements are considered as a “treatment” by the patient has been observed to reduce anxiety levels towards getting nutrients. However, as soon as nutri- tional status and reasonable intake allow, they should be replaced by food progressively (19). Patients with AN experience more serious complications than pa- tients with BN, with hospitalization being rare in the latter case (3,5). Although our sample is formed of children with severe disease, only 35% required hos- pital admission at some point in their treatment, the proportion in adults being much higher (8). There is no consensus on a precise definition of re- covery. Most agree that it includes normalizing eating patterns, improving psychosocial, interpersonal, and occupational functioning, and in children and adoles- cents, restoring normal growth and pubertal patterns, and reversing most damage to the organs. The main difference in treatment in children is the difficulty of setting a weight goal, as the goals change as they grow. Reaching the minimum weight to restart growth and physical development (15) or a BMI percentile (ac- cording to sex and age) between 13 and 30 is reported (19). In some studies, 50% of children (up to 70-80% in adolescents) recover completely, 25% improve, 10- 20% develop a chronic ED (19) and 5% die from com- plications (8) (mainly suicide and associated medical complications, with a death rate from AN for 10-12 times greater than in general population) (18,19,21). In this sample, a half of children responded to treat- ment with a very good evolution since the initial as- sessment, while the other half had a first period of non-response to treatment, maintaining the changes and even worsening during the first 1-5 visits, but af- ter that, there was a great improvement and a good evolution. Although there are still some follow-up patients, in those who achieved recovery, the aver- age follow-up time varied from 2 to 42 months, com- pared to the duration of the disease in adults, which often exceeds 10 years, indicating a better prognosis and shorter duration of illness in children (3,35). The