Feeding, Eating, and Elimination Disorders

Anorexia Nervosa (AN)

• Physical findings on severe underweight:
  • Extremely low body weight where visible tendons, prominent ribs, and lack of bulk are evident; breast tissue can be absent due to low fat stores; marked muscle wasting.
  • Lanugo: downy hair growth (reminiscent of infancy) as a thermoregulatory adaptation; body attempts to insulate itself after fat stores are depleted.
  • Cold intolerance with mottled skin; dressed in multiple layers (bulky sweatshirts, sweatpants, socks; may tuck hands inside clothing to preserve warmth).
• Vital signs and thermoregulation:
  • Hypotension, bradycardia, and hypothermia due to impaired thermoregulation and energy conservation.
  • Orders may include provider notification if temperature, blood pressure, or heart rate are abnormal; bradycardia can be significant (HR may be < 40 in severe cases).
• Body composition and hormonal effects:
  • Underdeveloped secondary sexual characteristics (female); fat-driven hormones needed for menses; many AN patients are amenorrheic.
  • Hyperactivity observed as a behavioral/compensatory mechanism to burn calories; energy conservation drives behavior.
• Neurologic and systemic effects:
  • Peripheral neuropathy; decreased circulation; low white blood cell count; elevated carotene levels; metabolic alkalosis and other electrolyte imbalances.
  • Osteoporosis; fatty degeneration of the liver; abnormal thyroid function tests; proteinuria.
• Gastrointestinal and nutritional issues:
  • Constipation from reduced intake and slowed gut motility.
  • Refeeding must be cautious to avoid refeeding syndrome; patients may require enteral or oral nutrition support when tolerable.
• Hospital admission and monitoring specifics:
  • Admitted patients may have strict controls: weight-based restrictions, timing and duration of meals, and companionship; out-of-room time is limited (e.g., ~20 minutes).
  • One-on-one observation initially to prevent pacing and excessive caloric expenditure.
  • Orthostatic vital signs are monitored; daily weight checks at the same time (laminated card on admission).
  • Feeding and activity restrictions (e.g., reduced pacing) to minimize caloric burn.
• Psychological profile and behavior:
  • History of dieting; use of laxatives or OTC drugs; strong weight- and shape- related beliefs; distorted body image with a moving target weight (e.g., “If I weigh 120 pounds, I’ll be better”; often never satisfied).
  • Social withdrawal and isolation; excessive preoccupation with appearance and weight.
• Treatment goals and approach:
  • Refrain from praise for weight gain; patients may interpret praise as incentive to lose more weight.
  • Involve psychology and family; outpatient therapy often precedes hospitalization; inpatient care focuses on medical stabilization and nutrition restoration.
  • Multidisciplinary approach: dietitians, psychologists, nurses; advanced practice nurses may work in this area.
• Long-term prognosis and risks:
  • High risk of long-term complications and mortality; early death can result from cardiac arrhythmias due to electrolyte disturbances (e.g., hypokalemia).
  • Cardiac remodeling and reduced heart function may occur; distinctive heart sounds can reflect loss of fat and myocardial changes.
• Medical complications and systems at risk:
  • Cardiac: low heart rate, orthostatic changes, arrhythmias related to electrolyte imbalances; possible cardiac arrest with severe imbalances.
  • Neuromuscular: peripheral neuropathy; reduced circulation; cold intolerance.
  • Hepatic: fatty degeneration; liver function may be affected.
  • Endocrine: hypoestrogenism; osteoporosis; amenorrhea.
  • Renal/urinary: proteinuria; electrolyte disturbances.
• Hospitalization criteria (general for eating disorders):
  • Weight loss of $30 ext{ extperthousand}$ over six months; rapid decline in weight.
  • Severe hypothermia; bradycardia with HR $< 40$; systolic BP $< 70$ mmHg.
  • Electrolyte imbalances; significant EKG changes; possible suicidality or self-harm behaviors.
  • Out-of-control laxative/diet pill use; failure to comply with outpatient treatment contracts.

- Diagnosis crosses outpatient to inpatient care when medical instability is present.

Bulimia Nervosa (BN)

• Typical presentation:
  • Often not visibly ill; patients may appear close to their ideal body weight.
  • Oral and dental complications: enlarged parotid glands; dental erosion; chronic sore throats from frequent vomiting.
  • Bradycardia and orthostatic changes can occur; better outwardly than AN, but medically complex.
• Complications of purging:
  • Esophageal tears and electrolyte disturbances (e.g., hypokalemia) due to recurrent vomiting.
  • Russell's sign: calloused knuckles from self-induced vomiting; dental calculus from enamel erosion.
  • Cardiac risks similar to AN but often less dramatic until complications arise.
• Mechanisms and substances used:
  • Use of purgatives and vomiting; ipecac syrup (epicac) may be misused; electrolyte disturbances contribute to arrhythmias.
• Treatment approach:
  • Cognitive-behavioral therapy (CBT) is commonly used to normalize eating habits and address triggers.
  • Antidepressants combined with CBT can improve outcomes; careful selection to avoid weight gain or increases in appetite that could worsen BN.
  • Family involvement and education, with careful monitoring of safety and relapse prevention.
• Hospitalization and management considerations:
  • BN is less often hospitalized solely for BN symptoms; admission reserved for complications such as electrolyte disturbances, severe dehydration, or suicidality.
• Key clinical signs and signs to monitor:
  • Bradycardia, possible orthostatic intolerance; dental and salivary gland changes; esophagitis and throat pain.

Binge Eating Disorder (BED)

• Diagnostic criteria (as described):
  • Recurrent episodes of binge eating, defined as large quantities of food in a short period without compensatory behaviors; occurs at least once a week for at least $3 ext{ months}$.
  • Eating to the point of discomfort, rapid eating, or a sense of loss of control; followed by significant distress.
  • Weight gain and associated medical risks due to overweight/obesity.
• Health implications:
  • Higher risk for type 2 diabetes, hypertension, cancer, and other conditions related to obesity.
  • Severity depends on frequency (e.g., once a week vs. multiple times per week).
• Treatment considerations:
  • CBT and behavioral therapy; appetite suppressants or medications that promote satiety may be used carefully to avoid excess weight gain.
  • Choice of antidepressants should consider weight impact; together with therapy they yield better outcomes.
  • Bariatric surgery is considered for obesity; however, active binge eating can jeopardize surgical outcomes and patient safety (e.g., risk of rupture at the surgical site after binge episodes).
• Hospitalization:
  • Not commonly hospitalized for BED alone; may occur if comorbid complications (mobility issues, wounds, or other medical concerns) arise.
• Lifestyle and management strategies:
  • Coping strategies, healthy eating patterns, and regular exercise.
  • Long-term commitment and robust support systems are essential.

Avoidant/Restrictive Food Intake Disorder (ARFID)

• Core features:
  • Avoidance or restriction of food intake starting in childhood; not primarily driven by body image concerns.
  • Can be severe with significant low BMI and nutritional deficiencies; may require enteral feeding via gastrostomy tube (G-tube).
  • Often associated with autism spectrum or other neurodevelopmental conditions.
• Practical examples and challenges:
  • Safe foods lists may be very limited; texture, flavor, and smell can influence intake; patients may resist new foods after traumatic triggers.
  • Hospitalization lengthy and multidisciplinary (pediatricians, dietitians, psychologists, and family involvement).
  • Family dynamics can be a contributing factor; parents may unintentionally reinforce restrictive patterns.
• Treatment approach:
  • Gradual exposure to new foods; structured therapy; nutrition support via G-tube when necessary.
  • Inpatient care may involve gradual reintroduction of foods, weight restoration, and home discharge planning with dietitian support.
• Real-world considerations:
  • In the notes from the clinical setting, ARFID care was described as highly resource-intensive, with long hospital stays and significant family involvement.

Pica

• Definition:
  • Eating nonfood items beyond toddler years; not culturally sanctioned; not a simple curiosity.
• Relevance:
  • Could appear in NCLEX-type questions; requires evaluation for nutritional deficiencies or developmental disorders.

Rumination Disorder

• Definition:
  • Regurgitation with rechewing or reswallowing or spitting; not explained by GI or medical condition.
• Metaphor/analogy:
  • Compared to a mama bird regurgitating food to feed the young; no underlying GI pathology.

Enuresis and Ankopresis (Constipation)

• Enuresis (bedwetting):
  • Developmental concern in children older than ~five years; involuntary or intentional urination into clothing or bed at least twice weekly for over three months.
  • Rule out physiological causes first; vasopressin therapy may be discussed by endocrine colleagues.
• Encopresis/Ankopresis (chronic constipation):
  • Chronic constipation in children older than four with involuntary or intentional fecal leakage; can be months-long retention.
  • Management often includes NG tube hydration, bowel-cleanout regimens, and disimpaction under anesthesia when needed.
  • Rectal Botox injections have been used to relax the anal sphincter and aid stool passage in severe cases.
  • Large volume cleanouts may be performed; Rankin Jordan program may follow discharge for behavioral modification and family involvement.
• Hospitalization and family dynamics:
  • Recurrent admissions may occur; some families develop contracts to attend multiple meals per day to ensure adherence to nutrition plans.
• Special considerations on a GI floor:
  • On pediatric GI floors (e.g., at Saint Louis Children’s Hospital), data may be skewed due to specialized care; this setting may see more feeding/GI-related cases than general pediatric units.
• Practical notes from care teams:
  • Use of GoLYTELY/go-litely‑type preparations for cleanouts; monitoring stool consistency and passage visually (e.g., attempting to see through stool using hats/urinals as containment visuals).
  • Transitioning from inpatient to outpatient care often involves home-based feeding plans (e.g., NG feeding and coordination with dietitians).
  • Behavioral contracts often require parental involvement (e.g., being on-site for two meals per day during inpatient care) to ensure adherence.

General themes and clinical takeaways

• Multidisciplinary nature:
  • Successful management relies on nutrition, psychology, family involvement, and medical stabilization.
  • Teams may include pediatricians, dietitians, psychologists, and advanced practice nurses.
• Early recognition and stabilization are crucial:
  • Medical instability (e.g., electrolyte disturbances, bradycardia, hypotension) can be severe even when outward appearance does not suggest critical illness.
• Cautions in treatment planning:
  • Refeeding must be carefully managed to avoid refeeding syndrome.
  • Some medications can affect weight and appetite; selection should consider the patient’s primary disorder and risk of weight gain.
• Ethical and practical considerations:
  • Balancing patient autonomy with safety; family dynamics often influence treatment adherence and outcomes.
• Real-world context and resources:
  • Specialized centers (e.g., Rankin Jordan, GI-focused pediatric services) play a key role in complex cases but may introduce access and family-burden considerations.
• Key cross-links to foundational knowledge:
  • Energy balance, caloric intake vs. expenditure; body image distortion in anorexia and bulimia; the role of CBT in modifying maladaptive eating behaviors.
  • Electrolyte homeostasis and cardiac function as core concerns in eating disorders; the importance of recognizing silent or non-obvious medical deterioration.
• Formulas and numeric references (LaTeX):
  • Weight loss criterion: $30\%\text{ over }6\text{ months}$
  • Binge eating disorder frequency: $\geq 1\ \text{episode/week for }\geq 3\text{ months}$
  • Critical vitals in hospitalization criteria: $\text{HR} < 40; \text{SBP} < 70\ \text{mmHg}$
• Ethical considerations and patient-centered care:
  • Avoid praising weight gain without addressing underlying cognitive distortions; focus on health and safety rather than appearance.
  • Counseling and therapy aim to reframe distorted beliefs and build healthier attitudes toward body image and food.

Quick reference checklist (study-friendly)

• AN: severe underweight; lanugo; bradycardia; hypothermia; onditional hospital admission; moving target weights; avoidance of praise for weight gain.
• BN: purging signs; parotid enlargement; dental erosion; esophageal tears; Epiac use; CBT + antidepressants; outpatient-heavy management.
• BED: recurrent weekly binge for 3 months; obesity-related risks; CBT; cautious pharmacotherapy; rarely inpatient.
• ARFID: childhood onset; low BMI; G-tube reliance; neurodevelopmental associations; long, multidisciplinary treatment.
• Pica: non-food ingestion; non-illuminated pathology.
• Rumination Disorder: regurgitation with rechewing; not GI-driven.
• Enuresis: bedwetting in >5 years; rule out organic causes; vasopressin as a potential management option.
• Encopresis/Constipation: chronic stool retention; disimpaction; rectal Botox; Rankin Jordan program; family contracts.