Settings and approaches to treatment
The acute medical management of children with eating disorders can take place in several very different settings, depending on the severity of the illness and the patient’s country of origin. Treatment settings fall, roughly, into three categories: hospital based care; partial or day treatment; and outpatient or home-based care. In the United States, the American Academy of Pediatrics (AAP) has an agreed-upon set of medical criteria, which mandate that re-feeding takes place in a hospital setting, ideally in a pediatric medical ward.
Even in a pediatric hospital setting, nursing staff are likely to have limited experience treating pediatric anorexia nervosa. They are likely to have, furthermore, out-dated beliefs about the volitional nature of this illness. Outpatient therapists may share these outmoded beliefs, which were commonly taught before the revolution brought about by neurobiology.
Framing anorexia as a brain disorder helps everyone understand that a child does not choose to be anorexic and should not, therefore, be expected to just stop being anorexic. For such a child, being required to eat (or to take the nasogastric tube) is a medical necessity, not a punishment for cognitions and behaviors over which they have almost no control.
Complete weight restoration is the conditio sine qua non of childhood eating disorder treatment. If you do not get weight restoration, you will get nothing.
Re-feeding itself should probably be done more aggressively in children than was common in the past. No physician should be afraid of using the naso-gastric tube in cases where a child is unable to eat enough to gain weight at home or as part of an outpatient program.
During the refeeding process, a child should gain weight, ideally, at an average rate of 0.2 kg/day. To allow a child’s weight gain to stall is to prolong hospitalization and/or growth recovery. It is important to know, and to emphasize to providers and parents, that food is the most important medication at our disposal. Re-feeding alone can have a substantial healing effect on psychological states and cognition.
Hopefully, a child’s pediatrician will have tracked their weight and height from birth. This information will be enormously helpful in setting weight gain goals and in monitoring linear growth. Stalls in height gains lag behind stalls in weight gain and it is important to understand that failure to gain weight in childhood results in as poor an outcome as does weight loss. If these growth charts are not available, the family or treatment providers should immediately begin to record height and weight as treatment progresses.
Refeeding for mental healing
In general, physical recovery is easier to achieve than psychological recovery and, although weight restoration is the cornerstone of both, it does not make up the entirety of recovery in most pediatric cases. This is probably due to the fact that the effects of starvation on the brain are less obvious than those on the subcutaneous tissues: the degree of wasting that we see makes more of an impression on us than does the cognitive stunting documented by researchers.
Often, cognitive impairments caused by anorexia are masked by co-existing temperament styles which induce the patient to focus intently on their school work and complete all tasks perfectly, even when this is taking them longer and longer to do.
Social withdrawal and distress can frequently be so extreme that it becomes impossible to have a child with anorexia nervosa continue to attend school. With the availability of adjuncts to home schooling, such as the Internet, a child may soon cease to have any social contact, further stunting their development. Like all primates, human beings are social animals who, as children, need other same-age tribe members to play with, learn from and imitate. Without these interactions, their social and personal growth will suffer.
It can be tempting to put a halt to weight gain when the child “looks fine,” though they are still not fully restored, cognitively. It’s imperative to see the refeeding process through completely for the sake of the child’s full cognitive recovery in addition to their full physical recovery.