Eating disorder hospitalizations among children and youth in Canada from 2010 to 2022: a population-based surveillance study using administrative data.

BACKGROUND: Eating disorders (EDs) are severe mental illnesses associated with significant morbidity and mortality. EDs are more prevalent among females and adolescents. Limited research has investigated Canadian trends of ED hospitalizations prior to the COVID-19 pandemic, however during the pandemic, rates of ED hospitalizations have increased. This study examined rates of ED hospitalizations among children and youth in Canada from 2010 to 2022, by sex, age, province/territory, length of stay, discharge disposition and ED diagnosis. METHODS: Cases of ED hospitalizations among children and youth, ages 5 to 17 years, were identified using available ICD-10 codes in the Discharge Abstract Database from the 2010/11 to 2022/23 fiscal years. The EDs examined in this study were anorexia nervosa (F50.0), atypical anorexia nervosa (F50.1), bulimia nervosa (F50.2), other EDs (F50.3, F50.8) and unspecified EDs (F50.9). Both cases of total and first-time ED hospitalizations were examined. Descriptive statistics and trend analyses were performed. RESULTS: Between 2010/11 and 2022/23, 18,740 children and youth were hospitalized for an ED, 65.9% of which were first-time hospitalizations. The most frequent diagnosis was anorexia nervosa (51.3%). Females had significantly higher rates of ED hospitalization compared to males (66.7/100,000 vs. 5.9/100,000). Youth had significantly higher rates compared to children. The average age of ED hospitalization was 14.7 years. Rates of ED hospitalizations were relatively stable pre-pandemic, however during the pandemic (2020-2021), rates increased. INTERPRETATION: Rates of pediatric ED hospitalizations in Canada increased significantly during the pandemic, suggesting that there may have been limited access to alternative care for EDs or that ED cases became more severe and required hospitalization. This emphasizes the need for continued surveillance to monitor how rates of ED hospitalizations evolve post-pandemic.

Eating disorders disproportionally affect children and youth, however, literature investigating long-term trends of eating disorder hospitalizations among children and youth in Canada is limited. We conducted a retrospective surveillance study, examining eating disorder hospitalizations among children and youth in Canada, from 2010 to 2022, by sex, age group, geography and eating disorder diagnosis. More than half of eating disorder hospitalizations examined during our study period were first-time hospitalizations. The most common eating disorder diagnoses were anorexia nervosa, followed by unspecified eating disorders. Youth had higher rates of eating disorders compared to younger children and females had higher rates compared to males. In Canada, rates of pediatric eating disorder hospitalizations increased during the pandemic. These results emphasize the need for continued surveillance to monitor how ED hospitalizations evolve post-pandemic, as well as prioritizing early intervention and treatment to help reduce the number of children and youth requiring hospitalization.

The COVID-19 Pandemic and Canadian Pediatric Tertiary Care Hospitalizations for Anorexia Nervosa.

PURPOSE: Global studies show an increase in hospitalizations for pediatric eating disorders (EDs). No published Canadian studies have confirmed these findings in pediatric ED programs for one-year post onset of the COVID-19 pandemic. The primary objective was to examine health administrative data from two pediatric tertiary care ED programs: Alberta Children's Hospital (ACH) and Hospital for Sick Children (SickKids) to determine the number of pediatric hospitalizations with the most responsible discharge diagnosis of anorexia nervosa (AN). METHODS: This hospital-based design explored monthly pediatric hospitalizations in seven-year-olds to 18-year-olds between March 11, 2014 and March 11, 2021 using the Discharge Abstract databases. The analysis used negative binomial regression with robust standard errors to compare hospitalization counts in the months preceding and following the World Health Organization pandemic declaration (March 11, 2020). RESULTS: Hospitalizations due to pediatric AN increased by 63% and 132% at SickKids (p < .001) and ACH (p < .001), respectively, in the first year of the pandemic compared to the previous six years. The total number of non-ED hospitalizations decreased by 29.3% and 2.4% at SickKids and ACH, respectively. DISCUSSION: This is the first Canadian study to show a rise in pediatric hospitalizations over one year due to AN in two tertiary care hospitals following the onset of the pandemic, confirming the impact that the pandemic has had on children and adolescents with AN in Canada.

The impact of the COVID-19 pandemic on eating disorders: A systematic review.

OBJECTIVE: A growing body of evidence suggests that individuals with eating disorders (EDs) have experienced deteriorating symptoms, increased isolation, and an increase in hospital admissions as a result of the COVID-19 pandemic. Despite this, no systematic reviews have been conducted examining the COVID-19 and ED peer-reviewed literature. Therefore, this systematic review aimed to synthesize the impact of the COVID-19 pandemic on individuals with EDs. METHOD: Database searches of the peer-reviewed literature were completed in the subsequent databases: CINAHL, Embase, MEDLINE, and PsycINFO (from November 2019 to October 20, 2021). All research reporting on the relationship between the COVID-19 pandemic on individuals with EDs were included. RESULTS: Fifty-three studies met the inclusion criteria, including 36,485 individuals with EDs. The pooled hospital admissions across the studies demonstrated on average a 48% (pre = 591, post = 876, n = 10 studies) increase in admissions during the pandemic compared to previous pre-pandemic timepoints. In this review, 36% of studies (n = 19) documented increases in eating disorder symptoms during the pandemic, this increase in eating disorder symptoms were documented in AN, BED, BN, and OFSED patients. Studies also demonstrated increases in anxiety (n = 9) and depression (n = 8), however patterns of change appeared to be diagnostic and timing specific (e.g., lockdowns). DISCUSSION: We found a large increase in the number of hospitalizations and an increase in ED symptoms, anxiety, depression, and changes to BMI in ED patients during the pandemic. However, these changes appeared to be diagnostic and timing specific. Many qualitative studies described deterioration in ED symptomatology due to decreased access to care and treatment, changes to routine and loss of structure, negative influence of the media, and social isolation. Future studies are needed to focus on pediatric populations, new ED diagnoses, and severity of illness at presentation. PUBLIC SIGNIFICANCE: The scientific literature suggests that individuals with eating disorders have experienced deteriorating symptoms, increased isolation, and an increase in hospital admissions as a result of the COVID-19 pandemic. This study synthesized 53 articles and explored the impact of the COVID-19 pandemic on patients with eating disorders. We found increases in eating disorder symptoms during the pandemic; this increase in eating disorder symptoms was documented in patients with common eating disorders including anorexia nervosa, binge-eating disorder, bulimia nervosa, and other specified feeding and eating disorders. This review also demonstrated changes in body mass index (an index used to classify underweight, overweight, and obesity in adults) and increases in anxiety and depression during the pandemic compared to previous timepoints; patterns of change appeared to be related to timing of lockdowns. This review provides important information on the impact of COVID-19 on the physical and mental health of individuals with eating disorders.

OBJETIVO: Un creciente conjunto de evidencia sugiere que las personas con trastornos de la conducta alimentaria (TCA) han experimentado síntomas de deterioro, mayor aislamiento y un aumento en los ingresos hospitalarios como resultado de la pandemia de COVID-19. A pesar de esto, no se han realizado revisiones sistemáticas que examinen la literatura revisada por pares de COVID-19 y TCA. Por lo tanto, esta revisión sistemática tuvo como objetivo sintetizar el impacto de la pandemia de COVID-19 en las personas con TCA. MÉTODO: Las búsquedas en las bases de datos de la literatura revisada por pares se completaron en las bases de datos posteriores: CINAHL, Embase, MEDLINE y PsycINFO (de noviembre de 2019 al 20 de octubre de 2021). Se incluyeron todos los informes de investigación sobre la relación entre la pandemia de COVID-19 en individuos con TCA. RESULTADOS: Cincuenta y tres estudios cumplieron los criterios de inclusión, incluyendo 36,485 individuos con TCA. Los ingresos hospitalarios agrupados en los estudios demostraron en promedio un aumento del 48% (antes = 591, después = 876, n = 10 estudios) en los ingresos durante la pandemia en comparación con los puntos de tiempo previos a la pandemia. En esta revisión, el 36% de los estudios (n = 19) documentaron aumentos en los síntomas del trastorno alimentario durante la pandemia, este aumento en los síntomas del trastorno de la conducta alimentaria se documentó en pacientes con AN, TpA, BN y OSFED. Los estudios también demostraron aumentos en la ansiedad (n = 9) y la depresión (n = 8), sin embargo, los patrones de cambio parecían ser diagnósticos y específicos del momento (por ejemplo, encierros). DISCUSIÓN: Encontramos un gran aumento en el número de hospitalizaciones y un aumento en los síntomas de TCA, ansiedad, depresión y los cambios en el IMC en pacientes con TCA durante la pandemia. Sin embargo, estos cambios parecían ser diagnósticos y específicos del momento. Muchos estudios cualitativos describieron un deterioro en la sintomatología del trastorno de la conducta alimentaria (TCA) debido a la disminución del acceso a la atención y el tratamiento, los cambios en la rutina y la pérdida de estructura, la influencia negativa de los medios de comunicación y el aislamiento social. Se necesitan estudios futuros para centrarse en las poblaciones pediátricas, los nuevos diagnósticos de TCA y la gravedad de la enfermedad al momento de la presentación. PALABRAS CLAVE: trastornos de la conducta alimentaria, pandemia, COVID-19.

Trends in the Incidence of New-Onset Anorexia Nervosa and Atypical Anorexia Nervosa Among Youth During the COVID-19 Pandemic in Canada.

Importance: The COVID-19 pandemic has had considerable mental health consequences for children and adolescents, including the exacerbation of previously diagnosed eating disorders. Whether the pandemic is a factor associated with the concomitant increase in new-onset anorexia nervosa or atypical anorexia nervosa remains unknown. Objective: To assess the incidence and severity of newly diagnosed anorexia nervosa or atypical anorexia nervosa in a national sample of youth before and during the first wave of the COVID-19 pandemic. Design, Setting, and Participants: This repeated cross-sectional study analyzed new eating disorder assessments that were conducted at 6 pediatric tertiary-care hospitals in Canada between January 1, 2015, and November 30, 2020. Patients aged 9 to 18 years with a new anorexia nervosa or atypical anorexia nervosa diagnosis at the index assessment were included. Exposures: COVID-19-associated public health confinement measures during the first wave of the pandemic (March 1 to November 30, 2020). Main Outcomes and Measures: Primary outcomes were the incidence and hospitalization rates within 7 days of de novo anorexia nervosa or atypical anorexia nervosa diagnosis. Event rate trends during the first wave were compared with trends in the 5-year prepandemic period (January 1, 2015, to February 28, 2020) using an interrupted time series with linear regression models. Demographic and clinical variables were compared using a χ2 test for categorical data and t tests for continuous data. Results: Overall, 1883 children and adolescents with newly diagnosed anorexia nervosa or atypical anorexia nervosa (median [IQR] age, 15.9 [13.8-16.9] years; 1713 female patients [91.0%]) were included. Prepandemic anorexia nervosa or atypical anorexia nervosa diagnoses were stable over time (mean [SD], 24.5 [1.6] cases per month; ß coefficient, 0.043; P = .33). New diagnoses increased during the first wave of the pandemic to a mean (SD) of 40.6 (20.1) cases per month with a steep upward trend (ß coefficient, 5.97; P < .001). Similarly, hospitalizations for newly diagnosed patients increased from a mean (SD) of 7.5 (2.8) to 20.0 (9.8) cases per month, with a significant increase in linear trend (ß coefficient, -0.008 vs 3.23; P < .001). These trends were more pronounced in Canadian provinces with higher rates of COVID-19 infections. Markers of disease severity were worse among patients who were diagnosed during the first wave rather than before the pandemic, including more rapid progression (mean [SD], 7.0 [4.2] months vs 9.8 [7.4] months; P < .001), greater mean (SD) weight loss (19.2% [9.4%] vs 17.5% [9.6%]; P = .01), and more profound bradycardia (mean [SD] heart rate, 57 [15.8] beats per minute vs 63 [15.9] beats per minute; P < .001). Conclusions and Relevance: This cross-sectional study found a higher number of new diagnoses of and hospitalizations for anorexia nervosa or atypical anorexia nervosa in children and adolescents during the first wave of the COVID-19 pandemic in Canada. Research is needed to better understand the drivers and prognosis for these patients and to prepare for their mental health needs in the event of future pandemics or prolonged social isolation.

Incidence and Age- and Sex-Specific Differences in the Clinical Presentation of Children and Adolescents With Avoidant Restrictive Food Intake Disorder.

Importance: To our knowledge, this is the first pediatric surveillance study of children and adolescents with avoidant restrictive food intake disorder (ARFID). Objectives: To examine the incidence and age- and sex-specific differences in the clinical presentation of ARFID in children and adolescents in Canada. Design, Setting, and Participants: In this cross-sectional study, patients with ARFID were identified through the Canadian Paediatric Surveillance Program by surveying 2700 Canadian pediatricians monthly from January 1, 2016, to December 31, 2017. Main Outcomes and Measures: The incidence of ARFID in Canadian children (5-18 years of age) and age- and sex-specific clinical characteristics at presentation. Results: In total, 207 children and adolescents (mean [SD] age, 13.1 [3.2] years; 127 [61.4%] female) were included in this study. The incidence of ARFID in children 5 to 18 years of age was 2.02 (95% CI, 1.76-2.31) per 100 000 patients. Older children and adolescents were more likely to endorse eating too little (5-9 years of age: 76.7%; 95% CI, 58%-88.6; 10-14 years of age: 90.9%; 95% CI, 84.6%-94.8%; 15-18 years of age: 95.6%; 95% CI, 83.6%-98.9%; P = .02), have a loss of appetite (5-9 years of age: 53.3%; 95% CI, 35.4%-70.4%; 10-14 years of age: 74.2%; 95% CI, 66.0%-81.0%; 15-18 years of age: 80.0%; 95% CI, 65.5%-89.4%; P = .03), be medically compromised (mean body mass index z score: 10-14 vs 5-9 years of age: -1.31; 95% CI, -2.0 to -0.6; 15-18 vs 5-9 years of age: -1.35; 95% CI, -2.2 to -0.5; 15-18 vs 10-14 years of age: -0.04; 95% CI, -0.6 to 0.5; P < .001; mean percentage of treatment goal weight: 10-14 vs 5-9 years of age: -8.6; 95% CI, -14.3 to -2.9; 15-18 vs 5-9 years of age: -9.8; 95% CI, -16.3 to -3.3; 15-18 vs 10-14 years of age: -1.2; 95% CI, -5.8 to 3.4; P < .001; mean heart rate (beats per min): 10-14 vs 5-9 years of age: -10; 95% CI, -21.9 to 1.9; 15-18 vs 5-9 years of age: -19.7; 95% CI, -33.1 to -6.2; 15-18 vs 10-14 years of age: -9.7; 95% CI, -18.7 to -0.7; P = .002), have higher rates of anxiety (5-9 years of age: 26.7%; 95% CI, 13.7-45.4; 10-14 years of age: 52.3%; 95% CI, 43.7%-60.7%; 15-18 years of age: 53.3%; 95% CI, 38.6%-67.5%; P = .03) and depression (5-9 years of age: 0%; 10-14 years of age: 6.8%; 95% CI, 3.6%-12.7%; 15-18 years of age: 26.7%; 95% CI, 15.7%-41.6%; P < .001), and be more likely to be hospitalized (5-9 years of age: 13.3%; 95% CI, 5.0%-31.1%; 10-14 years of age: 41.7%; 95% CI, 33.5%-50.3%; 15-18 years of age: 55.6%; 95% CI, 40.7%-69.5%; P = .001). Younger children were more likely to endorse lack of interest in food (5-9 years of age: 56.7%; 95% CI, 38.4%-73.2%; 10-14 years of age: 75.0%; 95% CI, 66.8%-81.7%; 15-18 years of age: 57.8%; 95% CI, 42.8%-71.4%; P = .03), avoidance of certain foods (5-9 years of age: 90.0%; 95% CI, 72.6%-96.8%; 10-14 years of age: 69.7%; 95% CI, 61.3%-77.0%; 15-18 years of age: 62.2%; 95% CI, 47.2%-75.3%; P = .03), and refusal based on sensory characteristics (5-9 years of age: 66.7%; 95% CI, 47.9%-81.3%; 10-14 years of age: 38.6%; 95% CI, 30.7%-47.3%; 15-18 years of age: 22.2%; 95% CI, 12.3%-36.9%; P < .001). Eating but not enough was more common in girls (75.0%; 95% CI, 64.1%-83.4%) vs boys (68.5%; 95% CI, 59.8%-76.1; P = .04), and boys had a higher rate of refusal based on sensory characteristics (51.2%; 95% CI, 40.2%-62.2%) compared with girls (31.5%; 95% CI, 23.9%-40.2%; P = .007). Conclusions and Relevance: This study suggests that ARFID is a relatively common eating disorder and is associated with important age- and sex- specific clinical characteristics that may help in early recognition and timely treatment of the presenting symptoms.

Protecting children and adolescents against the risks of vaping.

Youth vaping presents significant risks for the health and safety of Canadian children and adolescents. This statement provides background information about vaping, vaping products, and related devices, discusses the short- and long-term harms known to be associated with their use, and offers prevention and cessation strategies for youth who vape or are at risk for starting. Youth vaping is associated with increased risk for tobacco and other substance use, mental health problems, pulmonary and cardiovascular disease, and unintentional injuries. Vaping should not be used as a smoking cessation tool for youth, due to lack of effectiveness and evidence of harm. Many preventive and treatment strategies used for tobacco cessation, including behavioural and pharmacological options, can be adapted to help youth quit vaping. Recommendations for community stakeholders and policy makers are included.

La protection des enfants et des adolescents contre les risques du vapotage.

Le vapotage chez les jeunes comporte des risques importants pour la santé et la sécurité des enfants et des adolescents canadiens. Le présent document de principes fournit de l'information générale sur le vapotage et les produits et dispositifs qui y sont liés, traite des méfaits à court et à long terme associés à leur utilisation et propose des stratégies de prévention et d'abandon pour les jeunes vapoteurs ou ceux qui sont à risque de commencer à vapoter. Le vapotage chez les jeunes est associé à un risque accru d'usage de tabac et de substances psychoactives, de troubles de santé mentale, de pneumopathie, de cardiopathie et de blessures accidentelles. Le vapotage ne doit pas servir d'outil d'abandon du tabac chez les jeunes, en raison de son manque d'efficacité et des données probantes sur les méfaits qu'il occasionne. De nombreuses stratégies préventives et thérapeutiques utilisées pour l'abandon du tabac, y compris les stratégies comportementales et pharmacologiques, peuvent être adaptées pour aider les jeunes à arrêter de vapoter. Des recommandations sont formulées pour les intervenants communautaires et les décideurs.

A paediatric perspective on hormonal contraception and breast cancer risk: New literature about a recurring question.

The New England Journal of Medicine recently featured an original research article, 'Contemporary Hormonal Contraception and the Risk of Breast Cancer'. (Source: Mørch LS, Skovlund CW, Hannaford PC, Iversen L, Fielding S, Lidegaard Ø. Contemporary hormonal contraception and the risk of breast cancer. N Engl J Med 2017;377(23):2228-39). This study of 1.8 million women ages 15 to 49 years in Denmark found that women who were currently or recently using any type of hormonal contraception had an increased risk of breast cancer and this risk increased with longer duration of use. To date, the implications of this study have focused on older female populations. In this commentary, the authors summarize the key findings of the study and discuss its unique implications for adolescents. The authors emphasize that health care providers need not change their practice as a result of this 'old but new again' controversy and should continue to support the prevention of unintended pregnancy by promoting access to ALL forms of contraception.

Stay the course: practitioner reflections on implementing family-based treatment with adolescents with atypical anorexia.

BACKGROUND: Atypical anorexia nervosa (AN) has received minimal empirical attention regarding effective diagnosis and treatment. Family-based treatment (FBT) might be a promising treatment for atypical AN, yet it is unclear as to what adaptations are needed to the current manualized FBT for AN model. The objective of the current study was to identify how FBT practitioners applied FBT for atypical AN for adolescents in their clinical practice, and if there were any implementation challenges and adaptations to the model for this population. METHODS: The current study employed fundamental qualitative description, with the aim of capturing practitioners' reflections on working with adolescents with atypical AN in clinical practice. A purposeful sample of practitioners with training in FBT were recruited and each participant completed an individual, semi-structured interview. Data was analyzed using conventional content analysis. RESULTS: A total of 23 practitioners participated in this study. The results indicate that practitioners maintained some fidelity to manualized FBT in treating atypical AN, but they differed in their discussions around target weights, what constitutes weight restoration, and the dosage for FBT phases. Salient practice challenges included operationalizing the Diagnostic and Statistical Manual of Mental Disorders - 5th Edition (DSM-5) definition of atypical AN, identifying a 'goal weight' for adolescents and activating parents to take charge of the re-nourishment process. CONCLUSIONS: The results of this qualitative study demonstrate practitioner reflections on the delivery and adaptations of FBT for adolescents with atypical AN. These reflections highlight the need to establish the delivery of coherent and consistent treatment and messaging with patients and families. Further, practitioners' reflections highlight common strategies to increase the sense of urgency in parents to support their child with atypical AN.

Tackling mixed messages: Practitioner reflections on working with adolescents with atypical anorexia and their families.

The treatment of atypical anorexia nervosa (AN) poses new research and practice challenges for the field of eating disorders. The objective of this study was to describe frontline practitioners' perceptions of differences between adolescents living with atypical versus typical AN, as well as the intervention challenges they experience when working with these adolescents and their families. We followed the principles of fundamental qualitative description and recruited a purposeful sample of practitioners treating adolescent eating disorders to complete a one-on-one semi-structured interview. Conventional content analysis and the constant comparison technique were used for data analysis. A total of 23 practitioners from four countries participated in this study. Practitioners described that adolescents with atypical AN present with higher pre-morbid weights and rates of weight-based teasing compared to their AN peers. Clinical challenges perceived by practitioners to be specific to working with adolescents with atypical AN included: addressing conflicting messages about eating disorders and weight loss, empathizing with a justified fear of weight gain, and increased risk for parental and therapist collusion with the eating disorder. Findings have implications for delivering interventions to adolescents seeking care for atypical AN.

Eating disorders and menstrual dysfunction in adolescents.

Menstrual dysfunction is a common feature of all eating disorders and results in significant medical complications. The etiology of menstrual dysfunction is multifaceted and the result of a complex interplay of many factors including weight loss, decreased body fat, hypoleptinemia, abnormal eating attitudes and behaviors, exercise, and psychological stressors. This chapter will review the prevalence of menstrual dysfunction in adolescents with eating disorders, its multifactorial etiology, the evidence-based pathophysiology, and the resulting complications to linear growth, pubertal development, bone mineral accretion, and cognitive function. Future research directions are identified that suggest opportunities to gain new insights into our understanding of the mechanisms and treatment of menstrual dysfunction in adolescents with eating disorders.