Managing and treating eating disorders

In this Contemporary Pediatrics interview, Kaitlin Borelli, CRNP, PMHS, MSN; Joanna Palac, MSN, CRNP-BC and Lindsay Levitz RD, LDN, CLC, of Children's Hospital of Philadelphia explained their session at the 2024 NAPNAP conference centered around eating disorders among youth in the outpatient setting.

Transcript:

Kaitlin Borelli, CRNP, PMHS, MSN:

We really focused on early identification of these patients and screening for medical instability. We know that the longer a child is underweight or living in malnutrition, the more likely they are to develop chronicity of symptoms. So with early identification and swift intervention of resources and treatment for these kids, we can actually help improve their outcomes.

Joanna Palac, MSN, CRNP-BC:

The aim of the presentation was to provide A less complicated roadmap for the primary care nurse practitioner, not only in identifying that their patient is potentially malnourished and later leading to an eating disorder diagnosis, but also, what does that follow up look like in the office? How often do we need to bring them back? What do we need to look at, what labs do we need to look at? Then recognizing that there is a behavioral health component, and that these resources in the community are often very challenging to connect a family with whether this is a psychological component of having the family buy in to the diagnosis, but also, it could just be simply location and insurance barriers. So describing the different levels of care, and what that looks like for families and patients so that the primary care practitioner can get the ball rolling with the conversations and what to expect after the initial diagnosis.

Borelli:

Primary Care plays such a crucial role in these patients trajectory through life. So we're very fortunate that we live in a very vast resource-dense area of the country, but we recognize that there are also very rural areas that don't have the services that we have. So I think, yes, we're starting the conversation, but in many cases, these primary care providers are the conversation and we just keep going with it. We do know that children and adolescents who are treated for malnutrition, impatient for eating disorders actually have higher suicide rates. So swift intervention and treatment in primary care and keeping these kids out of the hospital, when safe to do so, actually will lower the rates of suicide in this population.

Contemporary Pediatrics:

What are signs of an eating disorder that general providers can look for?

Palac:

So there are a few aspects that we look at from a clinician perspective, when your patients coming into the office for whatever reason. It may be a well visit, it may be a sick complaint, and you'll start by looking at your objective data and usually it would be your weight metric that is first cueing the clinician that something is going on. So this could be from a previous visit, telling the family that we need to have a healthier lifestyle to prevent further risk factors down the road to developing more chronic health conditions such as diabetes, this could be your athlete that you note now has a significant bradycardia and additional symptoms of syncope or visual changes, headaches. So it's not specifically that there is any 1 risk factor, it's more so what to look out for. Specific key points or key metrics, that should be cueing the clinician to start thinking a little bit broader in their differential that this may be more of a psychiatric component.

Contemporary Pediatrics:

What happens after diagnosis as far as treatment?

Borelli:

So this is very much a multidisciplinary approach. In our resource-dense area that includes a behavioral health clinician, your medical team, whether primary care or adolescent medicine, or a combination of both, and a dietitian. It's very important that all of these specialists and providers have experience treating kids and adolescents with malnutrition and eating disorders. Also, when available, a social worker is extremely helpful in figuring out insurance barriers and navigating other barriers to treatment in the home.

Palac:

So the follow up is not a very specific set number of follow ups. First, we need to determine is my patient medically stable to continue in the outpatient setting? Once the answer is yes, then you need to determine what resources you have and how long it's going to take to get that patient connected with this multidisciplinary team. So you may have your patient coming back every 48 hours or every week. And then, depending on continual checking of medical stabilization, some of the things we mentioned are orthostatic vital signs, what lab work you need to look at having, a 24 hour recall which our lovely dietitian will go into a little bit further with doing calculations to see if our patient is meeting the nutritional requirements that their body needs to remain stable. But again, it is a continuum depending on how their body and psychologically how the patient is responding to determine how often you're going to have the patient come back to your office for check in.

Lindsay Levitz RD, LDN, CLC:

So part of what the dietitian does is calculate goal calories using a resting energy expenditure and multiplying that by an activity factor, coming up with a calorie goal and also calculating goal weights based off of many different factors, including their historical growth curves, pubertal development, age, gender, so many different factors go into this but it's important to educate these primary care providers who are taking care of these kids outpatient.

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