Pediatric Primary Care (135 page)

1.  May require use of medications to reduce anxiety symptoms. Consider use of selective serotonin reuptake inhibitors (SSRIs). These may include:

a.  Fluoxetine (Prozac): starting dose of 5 mg/day; increase to 15-30 mg/ day for children; 10-40 mg/day for teens.

b.  Fluvoxamine (Luvox): starting dose of 25 mg/day; increase to 50-200 mg/day for children; 150-300 mg/day for teens.

c.  Sertraline (Zoloft): starting dose of 25 mg/day; increase to 50-100 mg/ day for children; 50-200 mg/day for teens.

2.  May also consider a tricyclic medication, such as clomipramine (Anafranil): starting dose of 10 mg/day; increase to 75-100 mg/day for children; 100-200 mg/day for teens.

3.  Cognitive behavioral therapy to help identify anxiety triggers, awareness of physiologic responses to anxiety. Develop plan for coping, evaluation of success of strategies.

4.  Family therapy to address ways family can support the child. Must allow 6-8 weeks before full benefit will be obtained. Follow black box warning regarding increase monitoring of SI.

I.  Follow up.

1.  Follow-up appointment to monitor effectiveness of medications, address side effects of medications, compliance issues.

2.  Collaboration with family, mental health treatment provider, school personnel to assess success of treatment approaches and medications.

J.  Complications.

1.  Poor school performance.

2.  Poor self-esteem, social skills, avoidance of peers.

3.  Potential for family stress and conflict.

4.  Development of comorbid diagnosis of substance abuse or major depression.

K.  Education.

1.  Parent/caregiver and child need education about nature of anxiety, ways to identify, evaluate, change anxious thoughts.

2.  Child needs to learn to recognize physiologic symptoms of anxiety, use of positive “self-talk.”

3.  Relaxation training may be beneficial.

II.  EATING DISORDERS

A.  Serious, sometimes life threatening; tend to be chronic, usually arise in adolescence.

B.  Etiology.

1.  Combination of genetic, neurochemical, psychodevelopmental, sociocultural factors.

a.  Increased risk among first-degree biological relatives of individuals with disorder. Often co-occurs with other mental health problems such as depression, anxiety, substance abuse, personality disorders.

C.  Occurrence.

1.  > 90% of all eating disorders occur in females.

2.  Estimated 0.5% of adolescent females have anorexia nervosa; 1-5% meet criteria for bulimia nervosa.

3.  Rarely begins before puberty, most common in ages 14-18 years.

4.  Onset may be associated with stressful life event.

D.  Clinical manifestations.

1.  Anorexia nervosa.

a.  Most severe consequence with mortality rate from starvation, suicide, electrolyte imbalance.

b.  Characterized by refusal to maintain minimally normal body weight for age and height (< 85% of expected weight).

c.  Intense fear of gaining weight or becoming fat.

d.  Significant disturbance in perception of shape or size of body; sees self as overweight even when dangerously thin.

e.  In postmenarchal females, presence of amenorrhea.

2.  Bulimia nervosa.

a.  Repeated episodes of binge eating characterized by:

•  Eating in discrete period of time (e.g., within 2 hours), amount of food larger than most people would eat during same period of time and under similar circumstances.

•  Sense of lack of control over eating during episode.

c.  Recurrent inappropriate compensatory behaviors to prevent weight gain such as self-induced vomiting, misuse of laxatives, diuretics, enemas, other medications, fasting, excessive exercise.

d.  Occurrence of
both
of above behaviors, on average at least twice a week for 3 months. Individuals place excessive emphasis on body shape, weight in self-evaluation.

E.  Physical findings.

1.  Anorexia nervosa.

a.  Reported by family members, individual presents with weight loss or failure to make expected weight gains.

b.  Leukopenia, mild anemia are common.

c.  May present with signs/symptoms of dehydration, sinus bradycardia, arrhythmias.

d.  May present with constipation, abdominal pain, cold intolerance, lethargy, hypotension, hypothermia, dry skin, dental enamel erosion.

2.  Bulimia nervosa.

a.  Typically presents within normal weight range to slightly overweight.

b.  May present with complaints of abdominal pain, nausea, hair loss, brittle nails, fatigue, insomnia, or weakness.

c.  Fluid and electrolyte imbalances: metabolic alkalosis from vomiting or metabolic acidosis from laxative abuse.

d.  Loss of dental enamel, increased frequency of dental caries.

e.  Enlarged parotid glands.

f.  Possible calluses/scars on dorsal surface of hand from repeated selfinduced vomiting.

F.  Diagnostic tests.

1.  Ask all preteens, adolescents screening questions about eating patterns, satisfaction with body appearance.

2.  Monitor height, weight, body mass index (BMI) on all visits.

3.  Laboratory studies: complete blood count (CBC), electrolyte measurement, liver function tests, urinalysis, thyroid-stimulating hormone (TSH) test.

4.  Electrocardiogram.

G.  Differential diagnosis.

1.  Rule out other possible medical causes for significant weight loss/failure to gain weight (GI disease, brain tumors, malignancies, AIDS, etc.), although these do not present with distorted body image.

2.  Comorbid diagnosis of substance abuse, major depression, anxiety disorder.

H.  Treatment.

1.  Anorexia nervosa.

a.  Requires comprehensive treatment plan including medical care, monitoring, psychotherapy, nutritional counseling, medication (when appropriate). Involves three phases:

•  Restoring weight loss due to severe dieting, purging.

•  Treating psychologic disturbances such as distorted body image, low self-esteem, interpersonal conflicts.

•  Achieving long-term remission, rehabilitation.

b.  Treatment with medication, such as SSRIs; consider
only
after weight gain established.

c.  Acute inpatient hospitalization may be required to restore weight, address fluid and electrolyte imbalance or cardiac disturbances. May require nutrition via nasogastric tube/IV therapy.

d.  Intensive treatment may be needed in specialized day treatment program or intensive outpatient program.

e.  Refer for cognitive behavioral therapy and family therapy.

2.  Bulimia nervosa.

a.  Requires comprehensive treatment plan including medical care, monitoring, psychotherapy, nutritional counseling, medication (when appropriate).

b.  Primary goal: reduce/eliminate binge eating, purging behavior.

•  Establish pattern of regular, nonbinging eating.