Futility in adolescent anorexia nervosa and the question of withdrawal of care.

Anorexia nervosa is a chronic disorder of children, adolescents and young people typically characterised by self-starvation and resistance to interventions. Staff dealing with these young people frequently question patient motivations and the ethics of interventions that may be applied against the wishes of patients. The question of withdrawal of care in a subgroup of these patients has been raised. Futility is not an appropriate response to adolescent anorexia nervosa, and treatment withdrawal is not appropriate for a disorder in which most patients can be expected to recover, in which opposition to treatment is a characteristic of the disorder and in which brain dysfunction is precipitated by severe malnutrition.

Brief report: Correlates of inpatient psychiatric admission in children and adolescents with eating disorders.

OBJECTIVE: To examine the prevalence and importance of psychological, behavioural, and situational correlates of impending psychiatric inpatient admissions in children and adolescents with eating disorders. METHOD: The sample consisted of 285 patients (8-17 years, M = 14.4, SD = 1.49) with DSM-5 eating disorders assessed between 2006 and 2013 from the Helping to Outline Pediatric Eating Disorders (HOPE) Project. The sample was split into two groups, those with (n = 38) and without (n = 247) impending psychiatric admission; Discriminant function analysis was used to examine correlates. RESULTS: The prevalence of impending psychiatric admission was 13.3%. Suicidal ideation provided the greatest discriminating power, followed by eating pathology, depressive symptoms, anxiety, multiple methods of weight control, binge eating, and family functioning. CONCLUSIONS: Earlier recognition of comorbid symptoms in eating disorders in the community may reduce the number of young people with eating disorders who present needing critical psychiatric care.

Comparative study of children and adolescents referred for eating disorder treatment at a specialist tertiary setting.

OBJECTIVE: To examine child and adolescent differences in the clinical presentation of eating disorders (EDs) at referral to a specialist pediatric program. METHOD: This study compared cognitive, behavioral, and physical and medical features of children (≤ 12 years) and adolescents (13-18 years) with EDs presenting to a state-wide specialist pediatric ED service over two decades (N = 656; 8-18 years; 94% female). RESULTS: Significant differences were found between the groups. Children were more commonly male (p < .001), had lower eating pathology scores (p < .001), were less likely to binge eat (p = .02), purge (p < .001) or exercise for shape and weight control (p < .001), and lost weight at a faster rate than adolescents (p = .009), whereas adolescents were more likely to present with bulimia nervosa spectrum disorders (p = .004). Children and adolescents did not differ significantly on mean body mass index z-score, percentage of body weight lost, or indicators of medical compromise (p > .05). DISCUSSION: The clinical presentation of EDs differs among children and adolescents, with eating pathology and behavioral symptoms less prominent among children. Frontline health professionals require knowledge of these differences to assist with early detection, diagnosis, and prognosis.

Parent-child concordance in reporting of child eating disorder pathology as assessed by the eating disorder examination.

OBJECTIVE: The aim of this study was to examine parent-youth concordance in reporting of eating disorder pathology, as assessed by the Eating Disorder Examination (EDE) in a clinical pediatric sample. METHOD: The sample comprised 619 parent-youth dyads of youth (8-18 years) presenting for treatment at a specialist eating disorder clinic. A cross-sectional correlational design was used to examine the association between parent and youth symptom reports. RESULTS: On the whole, parent-youth inter-rater agreement was poor to moderate. Agreement was acceptable for the presence of behavioral symptoms, with the exception of excessive exercise (PAK = 0.48-0.98). There was poor inter-rater agreement on frequency of behavioral symptoms, with parents providing lower estimates than youth (ICC = 0.07-0.52). Although we predicted that inter-rater agreement on cognitive symptoms would by higher with adolescents than children, both groups were discordant with parent reports. Younger children identified less severe eating disorder cognitions than parents and the opposite occurred for adolescents. An anorexia nervosa presentation and lower malnutrition were not associated with lower inter-rater agreement, as might have been expected through ego syntonicity. Youth with bulimia nervosa presentations reported significantly higher severity of cognitive symptoms and more frequent disordered eating behaviors compared with their parents. DISCUSSION: Results support the utility of parent-youth assessment via the EDE to obtain a wider clinical picture of eating disorder psychopathology in children and adolescents, particularly for younger children. Clinical implications pertinent to administration of the EDE and parent literacy regarding eating disorder symptoms are discussed.

Familial hypercholesterolaemia in children and adolescents: a new paediatric model of care.

Familial hypercholesterolaemia (FH) is a common genetic disorder affecting more than 8000 children and adolescents throughout Australia. It results in marked elevation in plasma low-density lipoprotein cholesterol levels from birth that predisposes individuals to premature coronary heart disease in adult life. The majority of children and adolescents with FH are undiagnosed, as symptoms and signs only develop after decades of hypercholesterolaemia. Cascade screening of family members after detecting FH in an index case is an effective approach that allows the diagnosis of FH to be made in the young, before significant atherosclerosis develops. With the availability of effective therapies, mainly statins, paediatricians are ideally placed to improve the outcomes of this disorder by detecting and managing hypercholesterolaemia in childhood, thereby preventing premature coronary artery disease. We describe a new paediatric model of care for FH.

Monitoring nutritional status accurately and reliably in adolescents with anorexia nervosa.

AIM: Accurate assessment of nutritional status is a vital aspect of caring for individuals with anorexia nervosa (AN) and body mass index (BMI) is considered an appropriate and easy to use tool. Because of the intense fear of weight gain, some individuals may attempt to mislead the physician. Mid-upper arm circumference (MUAC) is a simple, objective method of assessing nutritional status. The setting is an eating disorders clinic in a tertiary paediatric hospital in Western Australia. The aim of this study is to evaluate how well MUAC correlates with BMI in adolescents with AN. METHODS: Prospective observational study to evaluate nutritional status in adolescents with AN. RESULTS: Fifty-five adolescents aged 12-17 years with AN were assessed between January 1, 2004 and January 1, 2006. MUAC was highly correlated with BMI (r = 0.79, P < 0.001) and individuals with MUAC >or=20 cm rarely required hospitalisation (negative predictive value 93%). CONCLUSIONS: MUAC reflects nutritional status as defined by BMI in adolescents with AN. Lack of consistency between longitudinal measurements of BMI and MUAC should be viewed suspiciously and prompt a more detailed nutritional assessment.

Diagnosis of Helicobacter pylori infection in a high-prevalence pediatric population: a comparison of 2 fecal antigen testing methods and serology.

OBJECTIVES: Accurate methods for diagnosing active Helicobacter pylori infection in children have been limited to invasive or time-consuming techniques. Recently, fecal antigen testing has been used successfully for the diagnosis of H pylori infection in the pediatric population. We compared 2 monoclonal fecal antigen diagnostic methods in a population of children with a suspected high prevalence of H pylori infection. We also assessed the diagnostic performance of H pylori immunoglobulin G serology. MATERIALS AND METHODS: In a cross-sectional study of African refugee children (<16 years) we compared an immunochromatographic technique (ICT) and serology with a monoclonal fecal antigen enzyme immunoassay (MFAT) method for the detection of active H pylori infection. Following the manufacturer's instructions, an optical density of >or=0.190 was used as a cutoff for MFAT. Sensitivity, specificity, and positive and negative predictive values were calculated. RESULTS: Of the 193 eligible children enrolled, active H pylori infection was detected in 149 of 182 (81.9%) in whom MFAT was performed. The prevalence of active infection increased with age; children with active infection were significantly older, and there were no sex differences. ICT and serology underperformed in comparison with MFAT (ICT sensitivity 74.6%, specificity 63.6%, positive predictive value 89.8%, negative predictive value 36.8%; and serology sensitivity 57.9%, specificity 77.4%, positive predictive value 92.0%, negative predictive value 29.9%). CONCLUSIONS: Monoclonal enzyme immunoassay fecal antigen testing is a practical and feasible alternative to traditional invasive diagnostic methods in high-prevalence pediatric populations. Neither immunochromatography nor serology is useful for the diagnosis of active H pylori infection in these children.

A decade of data from a specialist statewide child and adolescent eating disorder service: does local service access correspond with the severity of medical and eating disorder symptoms at presentation?

BACKGROUND: Eating disorders affect up to 3% of children and adolescents, with recovery often requiring specialist treatment. A substantial literature has accrued suggesting that lower access to health care services, experienced by rural populations, has a staggering effect on health-related morbidity and mortality. The aim of this study was to evaluate whether lower service access foreshadowed a more severe medical and symptom presentation among children and adolescents presenting to a specialist eating disorders program. METHOD: The data source was the Helping to Outline Paediatric Eating Disorders (HOPE) Project registry (N ~1000), a prospective ongoing registry study comprising consecutive paediatric tertiary eating disorder referrals. The sample consisted of 399 children and adolescents aged 8 to 16 years (M =14.49, 92% female) meeting criteria for a DSM-5 eating disorder. RESULTS: Consistent with the hypotheses, lower service access was associated with a lower body mass index z-score and a higher likelihood of medical complications at intake assessment. Contrary to our hypothesis, eating pathology assessed at intake was associated with higher service access. No relationship was observed between service access and duration of illness or percentage of body weight lost. CONCLUSIONS: Lower service access is associated with more severe malnutrition and medical complications at referral to a specialist eating disorder program. These findings have implications for service planning and provision for rural communities to equalize health outcomes.

Acute and persistent diarrhea.

Socially disadvantaged Indigenous infants and children living in western industrialized countries experience high rates of infectious diarrhea, no more so than Aboriginal children from remote and rural regions of Northern Australia. Diarrheal disease, poor nutrition, and intestinal enteropathy reflect household crowding, inadequate water and poor sanitation and hygiene. Acute episodes of watery diarrhea are often best managed by oral glucose-electrolyte solutions with continuation of breastfeeding and early reintroduction of feeding. Selective use of lactose-free milk formula, short-term zinc supplementation and antibiotics may be necessary for ill children with poor nutrition, persistent symptoms, or dysentery. Education, high standards of environmental hygiene, breastfeeding, and immunization with newly licensed rotavirus vaccines are all needed to reduce the unacceptably high burden of diarrheal disease encountered in young children from Indigenous communities.

An insight into the relationships between hepcidin, anemia, infections and inflammatory cytokines in pediatric refugees: a cross-sectional study.

BACKGROUND: Hepcidin, a key regulator of iron homeostasis, is increased in response to inflammation and some infections, but the in vivo role of hepcidin, particularly in children with iron deficiency anemia (IDA) is unclear. We investigated the relationships between hepcidin, cytokines and iron status in a pediatric population with a high prevalence of both anemia and co-morbid infections. METHODOLOGY/PRINCIPAL FINDINGS: African refugee children <16 years were consecutively recruited at the initial post-resettlement health check with 181 children meeting inclusion criteria. Data on hematological parameters, cytokine levels and co-morbid infections (Helicobacter pylori, helminth and malaria) were obtained and urinary hepcidin assays performed. The primary outcome measure was urinary hepcidin levels in children with and without iron deficiency (ID) and/or ID anaemia (IDA). The secondary outcome measures included were the relationship between co-morbid infections and (i) ID and IDA, (ii) urinary hepcidin levels and (iii) cytokine levels. IDA was present in 25/181 (13.8%). Children with IDA had significantly lower hepcidin levels (IDA median hepcidin 0.14 nmol/mmol Cr (interquartile range 0.05-0.061) versus non-IDA 2.96 nmol/mmol Cr, (IQR 0.95-6.72), p<0.001). Hemoglobin, log-ferritin, iron, mean cell volume (MCV) and transferrin saturation were positively associated with log-hepcidin levels (log-ferritin beta coefficient (beta): 1.30, 95% CI 1.02 to 1.57) and transferrin was inversely associated (beta: -0.12, 95% CI -0.15 to -0.08). Cytokine levels (including IL-6) and co-morbid infections were not associated with IDA or hepcidin levels. CONCLUSIONS/SIGNIFICANCE: This is the largest pediatric study of the in vivo associations between hepcidin, iron status and cytokines. Gastro-intestinal infections (H. pylori and helminths) did not elevate urinary hepcidin or IL-6 levels in refugee children, nor were they associated with IDA. Longitudinal and mechanistic studies of IDA will further elucidate the role of hepcidin in paediatric iron regulation.