Recovery Trajectories in Adolescent Girls with Anorexia Nervosa.

Background: This study aimed to document recovery trajectories among adolescents with anorexia nervosa (AN) based on three markers of remission, namely changes in body weight, food restriction, and excessive exercise, and to identify predictors of these trajectories. Methods: One hundred twenty-six adolescent girls (14.7 ± 1.3 years) were recruited during initial assessment visits at specialized eating disorder (ED) programs in five University Health Centers across the province of Quebec, Canada. z-BMI and AN symptom severity (food restriction and excessive exercise) were assessed at initial assessment visits and subsequently reassessed at each quarterly follow-up over a 12-month period to identify recovery trajectories. Results: Considering the three markers of remission, three distinct trajectories emerged: Group 1, rapid responders; Group 2, gradual responders; and Group 3, unstable responders. At initial visits, a difference between groups was found regarding the type of treatment (p = 0.01) and weight suppression (p = 0.02). Group 1 had a higher number of youths hospitalized than Group 2 and Group 3, and a greater weight suppression than Group 3. Furthermore, individuals with atypical AN were more likely to belong to Group 2 than to Group 1 and Group 3 (p < 0.0001). Conclusions: This study contributes to a better understanding of the heterogeneity of recovery trajectories in adolescent girls with AN.

Perceived barriers to the provision of adolescent confidential care in a tertiary care setting.

Objective: Adolescents are more likely to seek care and disclose sensitive health information if confidentiality is assured. Little is known regarding the provision of confidential care to adolescents in the hospital setting. We sought to understand confidentiality practices and barriers for adolescents cared for in a tertiary hospital setting. Methods: This was a cross-sectional survey of all Emergency Department (ED), hospitalist, and resident physicians at a tertiary paediatric hospital from May/2019 to July/2019. Participants were asked multiple choice questions regarding practices, comfort, and barriers to confidential care. Results: Response rate was 91% (n = 72/79; 26 ED, 14 hospitalists, 32 residents). Overall, 47% of respondents doubted that confidential care was being consistently provided to adolescents. Fifty-eight per cent of attendings and 31% of residents reported usually/always offering confidential care. Factors most reported to influence the provision of confidential care were chief complaint (75%), time of visit (45%), and patient age (25%). Barriers to the quantity or quality of confidential care were identified by 89%, most commonly including time constraints (21%), perceived parental resistance (26%), lack of private space (26%), and the belief that confidentiality is not necessary for all adolescent encounters (34%). Forty per cent of respondents reported breaching confidentially and discussing sensitive topics with adolescents in front of family members. Overall, only 45% felt they had received adequate training on how best to deliver confidential care, and 75% reported a desire for additional training. Conclusion: Results suggest inadequate provision of confidential care in a tertiary teaching hospital, with several potentially modifiable barriers.

Considerations for privacy and confidentiality in adolescent health care service delivery.

A hallmark of delivering quality adolescent health care services is the provision of confidential care. Key tenets when providing confidential care for adolescents include time alone with a health care provider, maintaining the privacy of health information, and securing informed consent for services without permission from a parent, guardian, or caregiver. While confidentiality is a basic principle for all health care encounters regardless of age, the unique considerations for capable adolescent patients are not always realized or appreciated. By ensuring appropriate quantity and quality of confidential care for adolescents, clinicians are better equipped to elicit a comprehensive history and physical examination, while empowering the adolescent involved to develop agency, autonomy, trust, and responsibility for their own health care decision-making and management.

Classification of Children and Adolescents With Avoidant/Restrictive Food Intake Disorder.

BACKGROUND AND OBJECTIVES: Evidence suggests that children and adolescents with avoidant/restrictive food intake disorder (ARFID) have heterogeneous clinical presentations. To use latent class analysis (LCA) and determine the frequency of various classes in pediatric patients with ARFID drawn from a 2-year surveillance study. METHODS: Cases were ascertained using the Canadian Pediatric Surveillance Program methodology from January 1, 2016, to December 31, 2017. An exploratory LCA was undertaken with latent class models ranging from 1 to 5 classes. RESULTS: Based on fit statistics and class interpretability, a 3-class model had the best fit: Acute Medical (AM), Lack of Appetite (LOA), and Sensory (S). The probability of being classified as AM, LOA, and S was 52%, 40.7%, and 6.9%, respectively. The AM class was distinct for increased likelihood of weight loss (92%), a shorter length of illness (<12 months) (66%), medical hospitalization (56%), and heart rate <60 beats per minute (31%). The LOA class was distinct for failure to gain weight (97%) and faltering growth (68%). The S class was distinct for avoiding certain foods (100%) and refusing to eat because of sensory characteristics of the food (100%). Using posterior probability assignments, a mixed group AM/LOA (n = 30; 14.5%) had characteristics of both AM and LOA classes. CONCLUSIONS: This LCA suggests that ARFID is a heterogeneous diagnosis with 3 distinct classes corresponding to the 3 subtypes described in the literature: AM, LOA, and S. The AM/LOA group had a mixed clinical presentation. Clinicians need to be aware of these different ARFID presentations because clinical and treatment needs will vary.

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.

Prophylactic Phosphate Supplementation for the Inpatient Treatment of Restrictive Eating Disorders.

PURPOSE: The medical stabilization of adolescent patients with restrictive eating disorders can be associated with refeeding syndrome, a potentially fatal complication preceded by refeeding hypophosphatemia (RH). Whether RH can be prevented by routine prophylactic phosphate supplementation has not been previously examined. This study sought to determine the safety and efficacy of a refeeding strategy that incorporates prophylactic phosphate supplementation to prevent RH. METHODS: Retrospective chart data were collected for patients aged younger than 18 years with restrictive eating disorders admitted to a tertiary pediatric inpatient ward between January 2011 and December 2014. All patients were refed with a standardized protocol that included prophylactic oral phosphate supplementation (1.0 ± .2 mmol/kg/day). RESULTS: During the 4-year study period, 75 admissions (70 patients) were included for analysis. The mean age and percent median body mass index of included patients were 15.3 years and 83.5%, respectively. Seven out of 75 (9%) had percent median body mass index of <70% and 26 out of 75 (35%) had percent body weight loss >20%. All patients were normophosphatemic at the time of admission (mean serum phosphate 1.24 ± .2 mmol/L). Serial laboratory evaluation revealed that all supplemented patients maintained serum phosphate levels >1.0 mmol/L during the initial 7 days of refeeding. Eleven patients became mildly hyperphosphatemic (range 1.81-2.17 mmol/L) with no associated clinical consequences. Additional analysis of 11 patients presenting with hypophosphatemia before refeeding revealed that with supplementation, phosphate values normalized by Day 1, and this group experienced no further RH episodes during initial refeeding. CONCLUSIONS: Prophylactic oral phosphate supplementation appears safe, and no episodes of RH occurred in patients with restrictive eating disorders undergoing inpatient refeeding.

Shifting paradigms: continuous nasogastric feeding with high caloric intakes in anorexia nervosa.

PURPOSE: The initial goal of admission for a patient with anorexia nervosa is physiologic stabilization through nutritional rehabilitation balanced against the risk of refeeding syndrome. Recent alternative approaches emphasize meal composition, limiting carbohydrates, to reduce risk. The Montreal Children's Hospital has instituted a standardized high-calorie continuous nasogastric (NG) refeeding protocol for the initial management of inpatient adolescents with restrictive eating disorders. This study aims to confirm that this protocol results in a shorter admission duration and faster rate of weight gain without increased incidence of complications. METHODS: Retrospective chart review of patients with restrictive eating disorders admitted to the Montreal Children's Hospital during December 2003 to December 2011. Those treated with higher calorie NG refeeding protocol (N = 31) were compared with those managed with a standard bolus meal treatment (N = 134). RESULTS: Length of stay was significantly reduced in the NG-fed cohort (NG cohort 33.8 days; bolus-fed cohort 50.9 days; p = .0002). Mean rate of weight gain in the NG group was significantly improved for both the first and second week when compared with the bolus-fed cohort (1.22 kg/week (1), p = .01; 1.06 kg/week (.9), p = .04). No significant difference was found in the rate of complications or electrolyte abnormalities with 90% of the NG-fed cohort receiving prophylactic phosphate supplementation from admission. CONCLUSIONS: This study provides further evidence to support the treatment of undernourished inpatients with restrictive type eating disorders with a higher initial caloric intake to achieve rapid and safe nutritional rehabilitation.