Eating disorders (EDs) are complex and serious mental health disorders that manifest with persistent disturbances in eating-related behavior, thoughts and emotions. These disturbances have a substantial impact on dietary intake, significantly impairing physical health and psychosocial functioning.1

They include, among others, anorexia nervosa (AN), bulimia nervosa (BN), binge-eating disorder (BED), atypical anorexia nervosa (AAN) and avoidant/restrictive food intake disorder (ARFID) (Table 1).1 Due to the particular manifestations and specific approach to the management of ARFID, which differ from those of other EDs, we will not address it in this article.

The prevalence of EDs varies considerably depending on the country and the methodology used in epidemiological studies, resulting in heterogeneous estimates. At the global level, it is estimated that 5.5% to 17.9% of women and 0.6% to 2.4% of men will have an ED during their lifetime. In Europe, the estimated prevalence in women is 1% to 4% for AN, 1% to 2% for BN and 1% to 4% for BED. In men, the prevalence of EDs is estimated at 0.3 to 0.7%.2 Data from various European countries have evinced an alarming increase in the incidence of EDs in the population aged 6 to 18 years since the beginning of the coronavirus disease 2019 (COVID-19) pandemic, in addition to an increase in severity and earlier onset of these disorders.3–5

Although they are most common in female adolescents, they can affect people of any age, sex, race, socioeconomic status, body build or weight. The average age of onset is 12.5 years. Adolescents who participate in sports that emphasize thinness or impose weight requirements (eg, gymnastics, horseback riding, dance, athletics or boxing) are at increased risk of developing an ED.6–8

Patients with early onset of EDs (before adolescence) are more likely to have a previous history of psychiatric disorders, such as depression, obsessive-compulsive disorder or anxiety. In this subset of patients, binge-eating episodes and purging behaviors are less frequent. In addition, there is a more uniform sex distribution and weight loss tends to be quicker, which could facilitate earlier detection in many cases.6

The high prevalence and early onset of EDs highlight the importance of the role played by pediatricians in their prevention, detection and early diagnosis. Given their complexity, these disorders require multidisciplinary management led by mental health professionals. However, the high demand for care usually delays access to specialized treatment. In this context, it is important for pediatricians to be proactive, implementing early interventions to stabilize patients, making sure that they are not left unattended during this critical period and coordinating multidisciplinary care.

The development of EDs involves a complex interaction of biological, genetic, psychological and social factors. Some of the most relevant modifiable risk factors are the energy intake deficit associated with the pursuit of restrictive diets and the low self-esteem associated with body dissatisfaction. In this regard, pediatricians play a key role in implementing strategies aimed at promoting a healthy relationship with food and the body, thus contributing to primary prevention. These strategies include9–12:

• 1

  Discouraging restrictive diets, meal skipping or prolonged fasting. Extreme calorie restriction is the main risk factor for the development of EDs. In adolescents, following a very strict diet is associated with an 18-fold increase in the risk of developing an ED, while following a moderate diet is associated with a five-fold increase. Therefore, it is essential to promote balanced and sustainable dietary habits instead of to focusing on weight loss, with a family-centered approach to intervention.

• 2

  Promoting family meals. A higher frequency of family meals is associated with improved diet quality and has a protective effect against the development of unhealthy eating behaviors in adolescents. It also facilitates early detection of changes in dietary habits.

• 3

  Advising families to refrain from talking about weight or body image at home. The focus should be on promoting balanced nutrition and physical activity habits rather than on physical appearance.

• 4

  Discouraging any form of teasing or negative comments about weight. Criticism or jokes related to body weight, especially within the family, are associated with an increased risk of excess weight, binge-eating and unhealthy weight-control behaviors in girls as well as excess weight in boys.

• 5

  Promoting a positive body image. Fostering the acceptance of body diversity and self-care is important. Efforts should be made to avoid reinforcing body dissatisfaction as a motivation for changing dietary habits or body weight.

• 6

  Inquiring about any past history of mistreatment or bullying. In adolescents with overweight or obesity, it is essential to assess for potential experiences of victimization, and these issues should be addressed with the patient and the family.

• 7

  Carefully monitoring weight loss in adolescents who need to lose weight, prioritizing the establishment of a varied and flexible diet rather than focusing on weight changes. The weight loss process should always be closely monitored by a medical provider.

In conclusion, by promoting an environment that fosters healthy habits, a positive body image and emotional support in the home, pediatricians can contribute significantly to reducing the risk of EDs.

The best strategy for the early detection and diagnosis of an ED is for the pediatrician to maintain a high index of suspicion, being particularly watchful for the signs and symptoms that may indicate its presence (Tables 1 and 2).13,14 The presenting complaint is frequently a somatic symptom, such as abdominal pain (which is presented as the reason for the low intake), constipation, dizziness, amenorrhea or a “food intolerance” typically involving calorie-dense foods. Any of these, especially if associated with weight loss, should prompt the pediatrician to explore the possibility of an ED.

It is also essential to consider the possibility of atypical presentations. Some patients, especially the youngest, may not explicitly express a desire to lose weight, a fear of gaining weight or a distorted body image. In the case of prepubertal patients, the weight loss may not be apparent, but there may be other noticeable manifestations, such as failure to reach the expected weight or deceleration of linear growth. In boys, the symptoms may be less evident and present under the guise of wanting to “be healthy” or “improve athletic performance”, with an emphasis on increasing muscle mass and excessive exercise.

Any red flag should prompt a focused history taking (Table 3) in addition to an exhaustive physical examination (Table 4) and measurement of vital signs (standing and supine blood pressure, heart rate), weight, height and body mass index (BMI).6 It is important to compare current and premorbid anthropometric measurements, recording them in the growth chart, and monitoring weight loss and the pace at which it occurs.

The degree of malnutrition must be assessed (Table 5),15 always remembering that a BMI in the normal range does not rule out EDs or the possibility of serious complications. Patients may maintain a normal weight or even be overweight, yet exhibit behaviors typical of EDs, such as binge eating or vomiting. In particular, patients who are overweight at the outset may experience severe malnutrition despite maintaining a normal BMI, which underscores the importance of a comprehensive assessment beyond the BMI.

Laboratory tests can be useful for identification of certain complications associated with EDs (Table 6). However, it is important to keep in mind that results within the normal range do not exclude the presence of an ED.

An electrocardiogram (ECG) is indicated in patients with clinically significant abnormalities (bradycardia with heart rate < 50 bpm, tachycardia, hypotension, syncope, dizziness, palpitations or chest pain), electrolyte disturbances, severe undernutrition and/or use of diuretics, laxatives or medication that prolongs the QT interval.16

It is important to consider and rule out other causes of weight loss or vomiting, although this should not result in delaying intervention. Once the diagnosis is confirmed, patients should be followed up with assessments at regular intervals to detect medical complications. These can be severe, may involve any organ or system, and usually result from weight loss, malnutrition and/or recurrent purging behaviors (Table 7).16–18

Early and appropriate treatment of EDs is crucial to modify the course of disease and improve patient outcomes. A multidisciplinary approach, led by mental health specialists and with participation of pediatricians or other health care professionals (family physicians, endocrinologists, nutritionists…) enables the effective management of both the physical and psychological aspects of the disease. Referral to mental health specialists, including psychiatrists and psychologists, cannot be delayed. Within the care team, the pediatrician plays a key role as coordinator, facilitating the interactions between patients, families and the care team, and helping destigmatize mental health disorders. The pediatrician also has the responsibility of monitoring the patient throughout the followup.

Nutritional support and psychotherapy are the cornerstones of treatment. In patients with undernutrition, weight restoration is the primary goal, as it is considered an absolutely necessary to promote changes in cognition, emotion and behavior. Weight goals in the nutritional rehabilitation process must be individualized, taking into account premorbid growth trajectories (weight, height and BMI), the age at pubertal onset and the current pubertal stage.19,20 In female patients, the spontaneous resumption of menses is a key indicator of physical and nutritional recovery.

In children and adolescents with AN or BN, interventions at the family level, including family-based therapy (FBT), have proven most effective. The FBT approach emphasizes active parental involvement as a key element for the success of treatment and focuses on eliminating the factors that perpetuate the disorder. Its goals are to increase knowledge and competence in parents and caregivers and to offer them support, as they are considered the most important resource in the nutritional rehabilitation and recovery process.21–23 In addition, while the data on the subject are still scarce, there is evidence suggesting that FBT can be modified for management of children with ARFID and adolescents with AAN, expanding its utility to different disordered eating patterns.14,15

In children and adolescents, pharmacotherapy is generally not used as first-line treatment, but it may be useful in patients with significant psychiatric comorbidities, chiefly depression or anxiety, or in whom nutritional and psychological interventions prove insufficient.24,25

Pediatricians can play an active role, both in the initial stages (while the patient awaits access to specialized treatment) and throughout the therapeutic process. The following are the interventions that pediatricians can implement in coordination with the rest of the care team6,12–15:

There is substantial variation between studies in the reported long-term outcomes for adolescents with EDs in relation to the methodology, definition of recovery and duration of follow-up. In general, success rates are higher in adolescents compared to adults, with the overall recovery rate ranging between 60% and 70%.6

Compared to the general population, the risk of mortality is six times greater in individuals with AN and nearly double in individuals with BN or UFED.33 Anorexia nervosa has the highest fatality rate among the EDs, resulting from severe medical complications (eg, undernutrition, cardiovascular disturbances, sudden death) and a high risk of suicide. One in five deaths in patients with AN is the result of suicide.33–35

The current evidence indicates that early response to therapy is a reliable predictor of long-term recovery, which supports the need for early intervention and comprehensive treatment, especially in patients with AN.

Pediatricians play a key role in the prevention, detection and comprehensive management of EDs. Their role includes the promotion of a healthy relationship with food and the body, early identification of red flags, clinical diagnosis, monitoring of medical complications and coordination of multidisciplinary care. In addition, they provide health education that is essential for patients and families to understand the disease and adjust dietary patterns to meet the needs of the patient.

This research did not receive any external funding.