Introduction to Anorexia Nervosa in Children

Anorexia Nervosa in children is a serious eating disorder characterized by self-starvation, excessive weight loss, distorted body image, and intense fear of gaining weight. While traditionally associated with adolescents and adults, the incidence in prepubertal children has been increasing significantly. Early-onset Anorexia Nervosa in children presents unique challenges for healthcare providers, requiring specialized nursing approaches for effective management.

Key Characteristics of Pediatric Anorexia

Deliberate restriction of caloric intake leading to significantly low body weight
Intense fear of gaining weight despite being underweight
Disturbance in self-perceived weight or shape
Developmental differences from adolescent presentation
Often accompanied by comorbid psychiatric conditions

Pediatric populations with Anorexia Nervosa in children require specialized nursing care tailored to their developmental needs. Early identification and intervention significantly improve prognosis and prevent long-term complications affecting growth and development.

Epidemiology and Risk Factors

Prevalence and Incidence

Rising incidence of Anorexia Nervosa in children under 12 years
Prevalence of 0.3-0.5% in pediatric populations
Female to male ratio approximately 10:1, though increasing in males
Mean age of onset decreasing over past decades
Significant variation by culture and geography

Risk Factors

Biological: Genetic predisposition, pubertal changes
Psychological: Perfectionism, anxiety disorders, OCD
Family: Family history of eating disorders, high parental expectations
Social: Peer pressure, exposure to idealized body images
Environmental: Participation in weight-sensitive activities (ballet, gymnastics)

Clinical Alert

Children with Anorexia Nervosa often present differently than adolescents. Look for subtle signs like food refusal without body image concerns, somatic complaints, or growth failure rather than explicit weight concerns.

Identification and Diagnosis

Early identification of Anorexia Nervosa in children is crucial for timely intervention and improved outcomes. Nurses play a vital role in recognizing warning signs and facilitating comprehensive assessment.

Diagnostic Criteria for Anorexia Nervosa in Children

According to DSM-5 criteria, adapted for pediatric populations:

Restriction of energy intake relative to requirements, leading to significantly low body weight in the context of age, sex, developmental trajectory, and physical health
Intense fear of gaining weight or becoming fat, or persistent behavior that interferes with weight gain, even though underweight
Disturbance in the way in which one’s body weight or shape is experienced, undue influence of body weight or shape on self-evaluation, or persistent lack of recognition of the seriousness of the current low body weight

Special considerations for children:

Weight loss may manifest as failure to make expected weight gain or growth
Body image distortion may be less verbalized in younger children
Assessment should consider age-adjusted BMI percentiles

Screening and Assessment Tools

Assessment Tool	Age Range	Key Components	Nursing Application
Children’s Eating Attitudes Test (ChEAT)	8-13 years	26-item self-report measuring disordered eating attitudes	Initial screening tool; scores ≥20 warrant further evaluation
SCOFF Questionnaire	All pediatric ages	5 simple questions on core features of eating disorders	Quick screening in primary care; ≥2 positive answers indicate risk
Eating Disorder Examination (EDE)	≥8 years (adapted)	Structured interview assessing eating disorder psychopathology	Comprehensive assessment tool for detailed evaluation
Growth Charts	All pediatric ages	Tracking height, weight, BMI percentiles over time	Essential for identifying growth deviations and weight loss patterns

Key Physical Assessment Findings in Pediatric Anorexia Nervosa

Cardiovascular

Bradycardia (HR <60 bpm)
Orthostatic hypotension
ECG abnormalities (prolonged QTc)
Acrocyanosis (bluish extremities)

Gastrointestinal

Abdominal pain/bloating
Constipation
Delayed gastric emptying
Liver enzyme abnormalities

Endocrine/Metabolic

Amenorrhea (in females post-menarche)
Delayed puberty
Growth stunting
Hypoglycemia
Hypothermia

Dermatological

Lanugo (fine, downy body hair)
Dry skin, brittle hair
Poor wound healing
Russell’s sign (calluses on knuckles)

Differential Diagnosis

Several conditions may mimic the presentation of Anorexia Nervosa in children and should be considered:

Medical conditions: Inflammatory bowel disease, celiac disease, hyperthyroidism, diabetes, malignancy
Other psychiatric disorders: Depression, anxiety disorders, OCD
Other eating disorders: Avoidant/Restrictive Food Intake Disorder (ARFID), food phobias
Substance use: Stimulant medications or illicit substances

Clinical Pearl

When evaluating a child with suspected Anorexia Nervosa, always perform comprehensive medical workup to rule out organic causes of weight loss or growth failure before confirming diagnosis.

Medical Complications

Anorexia Nervosa in children can lead to serious, sometimes life-threatening medical complications that require careful nursing monitoring and intervention.

System	Complications	Nursing Implications
Cardiovascular	Bradycardia Hypotension Arrhythmias QT prolongation Sudden cardiac death	Monitor vital signs q4h or more frequently if unstable 12-lead ECG on admission and regularly thereafter Telemetry monitoring for severe cases Monitor for orthostatic changes
Endocrine	Growth retardation Delayed/arrested puberty Low bone mineral density Euthyroid sick syndrome	Track growth parameters (height, weight) on appropriate growth charts Assess pubertal development using Tanner staging Monitor thyroid function tests Consider DEXA scanning for chronic cases
Gastrointestinal	Delayed gastric emptying Constipation Superior mesenteric artery syndrome Liver enzyme abnormalities	Monitor bowel movements Assess for abdominal pain/distention Monitor liver function tests Observe for refeeding intolerance
Neurological	Cerebral atrophy Cognitive impairment Seizures (with electrolyte abnormalities)	Monitor neurological status Perform cognitive assessments Seizure precautions if electrolytes abnormal
Renal/Electrolyte	Hypokalemia Hyponatremia Hypomagnesemia Hypophosphatemia (especially during refeeding)	Monitor electrolytes daily initially, then as clinically indicated Assess for signs of refeeding syndrome Strict input/output monitoring Daily weights

Critical Nursing Alert: Refeeding Syndrome

Children with severe Anorexia Nervosa are at high risk for refeeding syndrome, characterized by rapid electrolyte shifts (especially phosphate) when nutrition is reintroduced. Monitor for:

Severe hypophosphatemia
Cardiac arrhythmias
Seizures
Respiratory failure
Rhabdomyolysis

Nursing Management in Hospital Settings

Hospital-based care for Anorexia Nervosa in children requires a multidisciplinary approach with nursing playing a central role in the assessment, monitoring, and implementation of treatment plans.

Comprehensive Nursing Assessment

Initial Assessment Components

Physical assessment: Vital signs, weight, height, BMI percentile, orthostatic measurements
Nutritional assessment: Detailed diet history, food preferences/aversions, eating behaviors
Psychological assessment: Body image perception, anxiety levels, mood, comorbid conditions
Behavioral assessment: Exercise patterns, rituals around eating, compensatory behaviors
Family assessment: Family dynamics, knowledge level, support systems
Developmental assessment: Age-appropriate milestones, school performance

Ongoing Monitoring Parameters

Daily: Weight (same time, clothing, after voiding), vital signs q4-6h, strict I/O, meal supervision
Laboratory: Electrolytes, renal function, LFTs, glucose, phosphate (frequency based on severity)
Cardiac: ECG, telemetry if HR <45bpm or other cardiac abnormalities
Nutritional: Caloric intake monitoring, supplement intake, food/fluid refusal
Behavioral: Exercise attempts, water loading, purging behaviors
Psychological: Anxiety levels, cooperation with treatment plan, suicidal ideation

Nursing Care Plans for Anorexia Nervosa in Children

Nursing Diagnosis	Interventions	Expected Outcomes
Imbalanced Nutrition: Less than body requirements related to inadequate food intake, disturbed body image, and fear of weight gain	Implement structured meal plan with appropriate caloric intake for weight restoration (typically 30-40 kcal/kg/day initially) Supervise meals and snacks with time limits (typically 30 minutes for meals, 15 minutes for snacks) Monitor for 30-60 minutes post-meals to prevent purging Administer nutritional supplements as ordered Document accurate intake and provide feedback If needed, implement nasogastric feeding per protocol	Child will demonstrate weight gain of 0.5-1 kg/week in inpatient setting Child will consume ≥90% of prescribed diet consistently Child will demonstrate improving nutritional laboratory values Child will verbalize understanding of nutritional needs for growth and development
Disturbed Body Image related to altered perception, psychological factors, and unrealistic expectations	Establish therapeutic relationship through non-judgmental communication Limit body checking behaviors (frequent mirror use, pinching skin, etc.) Redirect conversations about weight, calories, and appearance Facilitate participation in therapeutic activities exploring self-concept Support child during therapeutic exposures to fear foods Encourage expression of feelings through art, writing, or other modalities	Child will demonstrate decreased anxiety around meals over time Child will engage in therapeutic activities addressing body image Child will express feelings about body image in therapy sessions Child will show reduced body checking behaviors
Risk for Decreased Cardiac Output related to electrolyte imbalances, malnutrition, and bradycardia	Monitor vital signs q4h and PRN Assess for orthostatic hypotension (lying, sitting, standing) Monitor ECG and telemetry results as ordered Implement activity restrictions based on cardiac status Administer electrolyte replacements as ordered Monitor for signs of refeeding syndrome Educate child and family about cardiac risks	Child will maintain heart rate >50 bpm Child will not exhibit orthostatic changes Child will maintain electrolytes within normal limits Child and family will verbalize understanding of cardiac risks
Anxiety related to treatment process, weight gain, and altered control	Assess anxiety levels using age-appropriate scales Teach and practice relaxation techniques (deep breathing, progressive muscle relaxation) Provide predictable routines and clear expectations Allow appropriate choices to give sense of control Use distraction techniques during meals and anxiety-provoking situations Administer anti-anxiety medications as ordered Provide calm, quiet environment	Child will demonstrate use of at least two coping techniques Child will report decreased anxiety on standardized measures Child will participate in treatment with decreasing resistance Child will demonstrate physiologic signs of decreasing anxiety

Monitoring and Intervention Protocols

RENOURISH Mnemonic for Anorexia Nervosa Monitoring

R – Regular vital signs and weight monitoring

E – Electrolyte balance assessment

N – Nutritional intake tracking

O – Orthostatic measurements

U – Urinary output monitoring

R – Refeeding syndrome prevention

I – Intake supervision

S – Supplementation as needed

H – Holistic psychological support

Meal Supervision Protocol

Prepare meal environment: minimize distractions, ensure adequate staffing, arrange appropriate seating
Present meal with neutral, matter-of-fact approach (avoid food-related discussions)
Set clear time expectations (typically 30 minutes for meals)
Provide supportive presence throughout meal
Use distraction techniques as needed (conversation, games, etc.)
Document consumption percentage and behaviors
Implement post-meal supervision period (30-60 minutes)
Provide positive reinforcement for completed meals
Implement consequences for incomplete meals according to treatment protocol (typically meal replacement)

Best Practice Tip

When working with children with Anorexia Nervosa, separate the child from the eating disorder in your communication. Use phrases like “the eating disorder thoughts are telling you…” rather than blaming the child directly. This helps reduce shame and resistance to treatment.

Home Management and Care

Transitioning a child with Anorexia Nervosa from hospital to home requires careful planning and preparation. Nursing care focuses on educating families, establishing sustainable routines, and providing ongoing support.

Family-Based Treatment (FBT) Support

FBT (also known as the Maudsley Approach) is the gold standard outpatient treatment for Anorexia Nervosa in children. Nurses support families by:

Educating parents on taking control of meals and nutrition
Teaching meal supervision techniques
Supporting parents through food refusal behaviors
Helping establish food hierarchies and exposure plans
Providing guidance on managing emotional outbursts
Teaching weight monitoring procedures
Supporting sibling adjustment and involvement

Home Environment Setup

Nurses should help families establish:

Structured meal and snack schedules
Appropriate food storage and preparation areas
Supervised bathroom access if purging is a concern
Removal of scales and body-checking tools
Safe physical activity guidelines
Distraction activities for meal times and post-meal periods
Calm spaces for anxiety management
Removal of triggering media (diet/fitness content)

Discharge Teaching Plan for Parents of Children with Anorexia Nervosa

Topic	Key Teaching Points	Evaluation Criteria
Nutritional Management	Meal plan implementation and caloric requirements Proper portion sizes and balanced nutrition Supplement use if prescribed Managing food rituals and restrictions Responding to food refusal Progressive exposure to feared foods	Parents demonstrate meal preparation according to meal plan Parents accurately describe caloric needs Parents demonstrate appropriate responses to food refusal Parents verbalize plan for introducing feared foods
Medical Monitoring	Home weight monitoring protocol (frequency, time of day, clothing) Vital sign monitoring if indicated Signs/symptoms requiring medical attention Medication administration if prescribed Follow-up appointment schedule	Parents demonstrate proper weight monitoring technique Parents identify at least 5 warning signs requiring medical attention Parents verbalize follow-up schedule Parents demonstrate medication administration if applicable
Behavioral Management	Recognizing compensatory behaviors (purging, exercise, laxative use) Setting appropriate limits on physical activity Managing bathroom access if needed Responding to distress and emotional outbursts De-escalation techniques Establishing appropriate rewards and consequences	Parents identify potential compensatory behaviors Parents demonstrate de-escalation techniques Parents articulate appropriate activity limits Parents develop behavior management plan
Family Dynamics	Separating child from illness (“It’s not your child, it’s the anorexia”) United parental front in treatment Sibling education and support Avoiding food/weight discussions and comparisons Self-care strategies for parents Support resources (groups, helplines)	Parents demonstrate externalizing language about the eating disorder Parents identify support resources Parents articulate plan for sibling support Parents identify self-care strategies

Home Monitoring Guidelines

Recommended monitoring schedule for home-based care of children with Anorexia Nervosa:

Weight: 1-2 times weekly, same time of day, after voiding, in light clothing
Vital signs: As directed by healthcare provider, typically pulse and orthostatic vitals initially
Laboratory tests: As scheduled by provider, initially more frequent then spacing out with stability
Clinical visits: Weekly initially, then biweekly as progress is made
Nutritional intake: Daily monitoring until stable, then periodic review
Behavioral symptoms: Daily log of concerning behaviors

Prevention and Control Strategies

Prevention and early intervention are crucial in addressing Anorexia Nervosa in children. Nurses play vital roles in education, screening, and implementing preventive interventions.

Primary Prevention

Strategies to prevent development of eating disorders:

Promoting positive body image in schools and communities
Education on healthy eating without diet focus
Media literacy training for children and parents
Anti-bullying programs addressing weight-based teasing
Promoting diverse body representation in educational materials
Educating coaches and physical activity leaders on healthy approaches
Parent education on avoiding weight talk and food restrictions

Secondary Prevention

Early identification and intervention:

Routine screening in primary care settings
Training healthcare providers in early warning signs
School nurse screening and education programs
Rapid referral pathways to specialized care
Brief interventions for concerning behaviors
Parent education on warning signs
School-based prevention programs for at-risk groups

Tertiary Prevention

Preventing relapse and complications:

Comprehensive discharge planning
Stepped care approaches
Long-term follow-up protocols
Relapse prevention planning
Ongoing family support and education
Monitoring for medical complications
School reintegration support

Warning Signs for Parents and Educators

Category	Warning Signs in Children
Physical Changes	Weight loss or failure to gain expected weight Growth stunting or delayed puberty Frequent complaints of feeling cold Dizziness, fainting, or weakness Dry skin, brittle nails, and hair loss Fine hair growth on body (lanugo) Dental problems (from purging)
Behavioral Changes	Refusing to eat certain food groups or specific foods Skipping meals or making excuses not to eat Excessive interest in cooking for others without eating Food rituals (cutting food into tiny pieces, eating foods in certain order) Withdrawing from social eating situations Frequent bathroom trips after meals Excessive exercise or physical activity Wearing baggy clothes to hide weight loss Collecting recipes or watching cooking shows obsessively
Psychological Signs	Preoccupation with weight, food, calories, or dieting Expressing fear of gaining weight Distorted body image comments Perfectionism and inflexible thinking Irritability, especially around mealtimes Decreased concentration and academic performance Social withdrawal from friends and activities Anxiety or depression symptoms Low self-esteem and negative self-talk

Communication Strategies for Prevention

When discussing food, weight, and body image with children:

DO:

Focus on health and nutrition rather than weight
Emphasize body functionality over appearance
Model positive relationship with food and body
Encourage intuitive eating and hunger awareness
Praise character, skills, and non-appearance attributes
Promote diversity in body shapes and sizes

DON’T:

Comment on child’s weight or body shape
Label foods as “good” or “bad”
Use food as reward or punishment
Engage in diet talk or weight criticism
Compare children’s bodies or eating habits
Make weight-based jokes or teasing

Clinical Resources and Mnemonics

Effective management of Anorexia Nervosa in children requires readily accessible tools and memory aids. Below are practical resources for nursing care.

SCALES Mnemonic for Anorexia Assessment

S – Starvation signs (physical manifestations)

C – Cognition about weight and body image

A – Activity level and exercise patterns

L – Loss of weight or failure to gain

E – Eating behaviors and rituals

S – Social withdrawal and psychological changes

WEIGHT Mnemonic for Red Flags

W – Weight loss exceeding expected growth parameters

E – Electrolyte imbalances or abnormal labs

I – Irregular heart rate or orthostatic changes

G – Growth failure or pubertal delay

H – Hypothermia or cold intolerance

T – Thoughts of self-harm or extreme body dissatisfaction

Criteria for Higher Level of Care

Parameter	Outpatient	Intensive Outpatient/Partial Hospitalization	Inpatient Hospitalization
% of Ideal Body Weight	>85%	75-85%	<75%
Heart Rate	>50 bpm	40-50 bpm	<40 bpm
Orthostatic Changes	Minimal	Significant (HR increase >20)	Severe (BP drop >20 mmHg)
Temperature	>36.1°C (97°F)	35.6-36.1°C (96-97°F)	<35.6°C (96°F)
Hydration Status	Normal	Mild dehydration	Moderate-severe dehydration
Electrolytes	Normal	Mildly abnormal	Significantly abnormal
Motivation/Engagement	Fair to good	Limited	Poor/Unable to participate
Family Support	Strong, able to monitor	Moderate, needs support	Limited or unable to supervise

Helpful Resources for Families and Clinicians

Books: “Help Your Teenager Beat an Eating Disorder” (Lock & Le Grange), “Brave Girl Eating” (Brown)
Organizations: National Eating Disorders Association (NEDA), Academy for Eating Disorders (AED), F.E.A.S.T. (Families Empowered and Supporting Treatment of Eating Disorders)
Clinical Guidelines: American Academy of Pediatrics (AAP) and Society for Adolescent Health and Medicine (SAHM) guidelines on eating disorders
Screening Tools: SCOFF Questionnaire, Eating Attitudes Test (EAT-26), Children’s Eating Attitudes Test (ChEAT)
Websites: maudsleyparents.org, nationaleatingdisorders.org, feast-ed.org

Conclusion

Anorexia Nervosa in children presents unique challenges requiring specialized nursing knowledge and skills. Through early identification, comprehensive assessment, and evidence-based interventions, nurses can significantly impact outcomes for these vulnerable patients. The multidisciplinary approach to care, with strong family involvement, offers the best chance for recovery and long-term health.

Nursing care across settings—from hospital to home to community—forms a crucial continuum in the treatment journey. By understanding the complex interplay of biological, psychological, and social factors in pediatric eating disorders, nurses can provide compassionate, effective care while supporting families through the recovery process.

Remember that recovery from Anorexia Nervosa in children is possible, and early intervention significantly improves prognosis. The knowledge and tools presented in these notes provide a foundation for evidence-based nursing practice in this challenging but rewarding area of pediatric care.

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