Eating Disorders

Updated March 22, 2022 by Leah Alexander, M.D. F.A.A.P.

An eating disorder is a condition in which abnormal eating behaviors have detrimental effects on a child’s health. When most parents hear the phrase “eating disorder,” they think of an adolescent girl who is hospitalized for severe weight loss due to refusing to eat.

However, there is more than one type of eating disorder, and symptoms can begin during early childhood. Both boys and girls can develop them. Children with these conditions present unique challenges for both parents and medical providers.

Several factors distinguish eating disorders from typical childhood picky eating behaviors.  Despite consuming a limited diet, picky eaters typically maintain normal weights and growth patterns.

In contrast, children with an eating disorder may experience weight fluctuations, and often suffer from nutritional deficiencies.

Common Causes Of Eating Disorders In Children

Stress

Psychological stress is the most common trigger of childhood eating disorders. Discord or issues at home, school, or other settings become upsetting enough to manifest as problematic eating.

Instead of the more common complaint of headaches or stomach aches, the child responds to stress by altering his or her eating habits.

The role of stress has been further revealed during the CoVID-19 pandemic. The CDC reports that an increased number of children and adolescents have required treatment for eating disorders in emergency rooms since the spring of 2020.

Food Allergies

Eight percent of children in the U.S. are allergic to at least one type of food. The initial experience of an allergic reaction can be quite traumatic for a child, especially when it results in a trip to the emergency room.

Afterward, some children become not only afraid of a future allergic reaction, but also change their eating habits. They may refuse to eat at a restaurant, or closely observe food preparation at home to make sure none of the offending food has been added to the meal.

The gold standard of food allergy management is strict avoidance of the allergenic food.  However, some children begin to restrict other foods despite no reaction to them. This “fear of food” can progress to anxiety, depression and nutritional deficiencies.

Fear of Vomiting

Gastroenteritis, typically known as “stomach virus,” is a common pediatric illness. Vomiting often occurs after an attempt to eat or drink. Although most children are minimally distressed by this, others develop an intense fear of future vomiting.

After the illness has resolved, these children believe that eating will again once trigger symptoms. In mild cases, this fear is situational, for example, a child refusing to eat at school because a vomiting episode occurred there.

In more severe cases, the child refuses to eat select foods because he or she feels they were the cause of illness.  Over time, such food restrictions can result in poor weight gain .

Body Image Concerns

Body awareness develops during the early childhood years. Parental opinions of their own bodies, along with societal, peer, and cultural pressures, influence how children view themselves.

The desire to have a certain body type can influence food choices, and the amount a child eats.   When body dissatisfaction develops at a young age, it can persist throughout adolescence and adulthood.

A Possible Biochemical Link

The hormone leptin is released into the bloodstream from body fat. Leptin has a direct effect on the hypothalamus in regulating food intake. It also helps the body metabolize fat.

Research shows that leptin levels are altered by a decreased caloric intake which impairs the functioning of the brain’s “satiety center.”

Low leptin levels also promote loss of body fat which can exacerbate unhealthy weight loss in children with some types of eating disorders.

Types Of Eating Disorders

The most common eating disorders include anorexia nervosa, avoidant-restrictive food disorder, bulimia, binge eating disorder, and “other specified” eating and feeding disorder.

A 2019 study of emergency room visits for nine to 10 years olds showed that all five types are possible in kids, but bulimia is less common.

Anorexia Nervosa

This form of eating disorder is characterized by a purposeful restriction of food intake.  Without intervention, it results in progressive weight loss, muscle wasting, and electrolyte imbalances.  In cases where a child has an unhealthy body image, there is often a fear of gaining weight.

Avoidant-Restrictive Food Disorder

With this type of eating disorder, children restrict their intake of certain foods due to fear of an adverse reaction.

The child worries that he or she will vomit, choke, or have an allergic reaction if the avoided foods are eaten. As the list of such foods increases, weight loss and nutritional deficiencies become evident.

Bulimia

Children with bulimia eat an excessive amount of food, then compensate for it in some way afterward. Vomiting is the commonly chosen behavior, but older children may instead compensate with more frequent and intense exercise.

There is also an attempt to hide the binging and purging. Bulimia can be more difficult to detect because the child’s weight can be normal or slightly increased.

Binge Eating Disorder

Although it is less common in children, those with a binge eating disorder feel a compulsion to eat an excessive amount of food over a short period of time.

These children are typically overweight, and at risk for obesity-related medical conditions such as hypertension, diabetes, and high cholesterol.

Other Specified Eating And Feeding Disorder

This classification includes eating disorders that negatively impact health and social functioning, but do not meet the criteria of the other types.

What Are Signs That Indicate A Child Has An Eating Disorder?

The first sign is often a change a child’s interest in food.  Such signs may be evident before any physical symptoms develop.  Here are some worrisome behaviors.

Regularly Refusing To Eat Meals

This goes beyond typical picky eating behavior. For example, it is normal for a child who has eaten breakfast, lunch, and several snacks throughout the day to have minimal interest in eating dinner.

These children gain weight and grow well. Children with anorexia and avoidant-restrictive food disorders, however, will regularly refuse most of foods offered.

Leaving Most Of Meals Uneaten

These children will eat a “few bites,” then leave most of the food on their plates. They neither snack nor drink lots of milk and other beverages throughout the day. Weight gain is often suboptimal.

Pushing Food Around A Plate To Mimic Eating

Savvy children with anorexia may use utensils to simulate eating, but don’t actually put much of the food into their mouths. If the family dog is nearby, it may be fed instead of the child.

Finding Uneaten Food That Has Been Hidden Or Discarded

These children may chew food, then spit it into a napkin to be discarded later. Uneaten school lunches may be brought home and hidden in bedroom drawers or closets. Older children may refuse to eat with the family, requesting to eat separately in order to discard or hide the food.

Progressively Limiting The Number And Types Of Foods Eaten

Children with food allergies may begin to restrict even non-allergenic foods. They may also avoid situations that they believe are a risk for an allergic reaction.

With anorexia or avoidant-restrictive food disorder, children randomly select foods they no longer want to eat. This list of foods increases over time.

Finding Food Wrappers Or Packaging That Has Been Hidden

Those with bulimia and binge eating disorders may attempt to hide their excessive eating. They may refuse to eat meals with the family in order to avoid comments about the amount of food eaten.

Parents may find evidence of a binge hidden in the child’s room, garbage cans, or other locations.

Clothing Size Changes

As disordered eating begins to affect a child’s weight, clothing may no longer fit properly.  Children whose eating disorder is associated with an unhealthy body image may choose baggier clothing to hide their appearance.

Additional Warning Signs

Over time, the affects on mental and physical health may become evident.

These include:

• Reduced interest in friends or social interactions
• Less energy or motivation to do normal daily activities
• Sudden concentration difficulties that affect school performance
• Constipation
• Irregular or absent periods (girls who have begun menstruating)
• Hair thinning
• Sleeping difficulties
• Dental caries
• Feeling cold even in warm environments
• Rapid and excessive weight gain or loss

Diagnosis And Management Of Eating Disorders

Because eating disorders include both psychological and physical symptoms, the involvement of a multidisciplinary team is necessary. The initial diagnosis is often made by a pediatrician or primary care provider.

If the child receives care from mental health providers for conditions such as anxiety or depression, they may discover the eating disorder.

Once an eating disorder is suspected, the initial diagnostic work up includes a physical exam, blood work to rule out other medical conditions, and a psychological screening.

Eating disorder management depends on the severity of symptoms at the time of diagnosis.  Children who appear dehydrated, have elevated heart rates, or blood pressure fluctuations require stabilization in a hospital setting.

During the hospital stay, they will be evaluated by a psychologist, nutritionist, and any other necessary specialists. Together, this team can address the acute issues, and develop a long-term treatment plan.

Children who are clinically stable can receive outpatient treatment. This involves regular weight checks, psychotherapy, and nutrition management. For children who frequently purge, a dental referral may be necessary.

Unfortunately, some children resist these interventions, making treatment very difficult.  Despite these challenges, persistence is important to prevent irreversible effects on growth, bone mineralization, and brain structure.

What Parents Should Do When They Suspect An Eating Disorder

The first step parents should take is to call their pediatrician or primary care provider. He or she can determine whether or not the child should be assessed in an emergency room or an office setting.

In addition, this provider can assist with referrals to nutritionists, psychologists, and others. Eating disorder treatment centers provide multidisciplinary care in a single location, and offer inpatient and outpatient care options.

Unfortunately, many of have age requirements, and do not offer care to children under the age of 13.

There Is Hope

Although having a child with an eating disorder is upsetting and presents treatment challenges, help is available. The most important thing to know is that early recognition and intervention is essential to successful treatment and positive outcomes.