Introduction:
Anorexia nervosa is considered a psychiatric pathology; However, its somatic complications are multiple, and among these some may be fatal.
For decades, the classical form has been that of a young girl or young woman, a Caucasian woman, born in an affluent milieu, living in a city, in a country of Western culture.
However, recent epidemiological studies point to an increase in the prevalence of eating disorders, their spread across social classes, in different cultures and ethnicities, in the male sex and at different ages, especially in children Before puberty.
History:
After Morton, who in 1689 already distinguished consump- tion-type wasting, and those due to medical causes, Marcé (1860), Lasègue (1873) in France and Gull (1874) in England described precisely the anorexia mental of the girl.
And only 20 years later, Collins (1894) describes the first case of prepubescent anorexia: a 7-and-a-half-year-old girl loses weight by refusing to eat.
The following year, Marshal reported a fatal case of weight loss in an 11-year-old girl with no explanatory lesion.
Other cases are then published, but the difficulties of specifying the prepubertal character, and the fuzziness of definition between anorexia and other eating disorders of the child, raise questions.
Different studies have marked the study of prepubertal anorexia in the 1980s.
First, the Irwin review (1984), involving 23 series corresponding to 893 cases of anorexia nervosa, counts 49% of cases in patients under 13 years; Among these, 29 subjects are between 8 and 11 years old and therefore probably appear prepubertal.
Irwin emphasizes the rarity of the disorder, but also its authentic existence, and its presentation at the same time close and different from the anorexias mentales postpubères.
Jacob and Isaacs (1986) compare 20 prepubescent anorexics to 20 post-pubic anorexics and 20 neurotic prepubertal patients; Prepubescent anorexics have more personal and family history of early childhood eating disorders than the other two groups; Prepubescent anorexics lost more than 25% of their weight; On the other hand, there is no difference between pre- and post-pubescent anorexia with regard to clinical signs, sexual anxiety, family functioning. These authors then raise the question of the etiological and pathogenic factors of this disease which was affirmed in connection with the pubertal process …
In France, Jeammet differentiates immediately pre-pubertal forms from clinical forms of adolescence but with primary amenorrhoea, and strictly prepubertal forms (8-10 years) whose onset seems independent of puberty and which are accompanied by a Stopping growth.
At the same time, the analysis of cases in the literature seems to be increasingly difficult, as the publications report early-onset cases, cases of childhood, unspecified on exact pubertal status, with at best a definition according to l The existence or absence of rules (premenarchal / postmarchal), and at worst a definition by age (less than 13 years and more than 13 years for example).
The need also to define what is and what is not anorexia nervosa in these young subjects becomes indispensable.
Definitions and classifications:
Difficulties:
Currently, no classification system appears to be satisfactory, and the diagnostic criteria in the International Classification of Diseases (ICD) of the World Health Organization, International Diagnostic Manual of Mental Disorders (DSM) From adult and adolescent populations. In the most recent versions, there is an extension of the categories to prepubescent children but without more specification.
ICD10:
There are eight diagnostic categories of “eating disorders” within the ICD10 classification.
If we consider a population of children for whom a diagnosis of a behavioral disorder was carried by a child psychiatrist, 35.9% to 44.3% of them were diagnosed as “other eating disorders, eating disorders Unspecified “which are exclusion diagnoses or could not be classified.
DSMIV-TR:
In the DSMIV-TR classification, there are three broad categories: “anorexia nervosa”, “bulimia” and “unspecified eating disorders”; The latter category accounts for between 44.4% and 58% of the children for whom a behavioral disorder was identified by a specialist and 7.4% to 14.8% of these patients were related To any of the above categories.
Diagnostic criteria:
The diagnostic criteria for anorexia nervosa according to DSM IV-TR are:
• refusal to maintain body weight at or above a minimum weight for age and height (weight loss leading to weight maintenance at less than 85% of expected weight or inability to gain weight During the growth period leading to a weight less than 85% of the expected weight);
• an intense fear of gaining weight or becoming fat, while the weight is less than normal;
• an alteration in the perception of body weight or shape, excessive influence of body weight or form on self-esteem, or denial of the severity of current wasting;
• in postpubertal women, amenorrhea.
Sub-types:
There are two subtypes:
• type with binge eating / vomiting or taking purgatives: during the current episode of anorexia nervosa, the subject has regularly presented with binge eating and / or resorted to induced vomiting or purgative intake ( Laxatives, diuretics, enemas);
• restrictive type: if not.
Inaccuracies:
In children, amenorrhea is an inappropriate criterion, cognitive aspects are not obvious, there is an effect on growth, and the diagnosis can be that of anorexia even if the weight does not go down to 85%.
Two teams proposed other classifications.
GOS (Great Ormond Street):
The classification established by the Laskonian team led by Lask is called GOS (Great Ormond Street). It gives better information since the percentage of patients who do not belong to any clinical category increases from 7-15% to 3-5% with GOS. In this classification, the categories are: anorexia nervosa, bulimia nervosa, food restriction linked to emotional disorder, selective feeding syndrome, food restriction syndrome, functional dysphagia, total refusal syndrome, loss Appetite linked to depression, oppositional food refusal.
The definition of anorexia nervosa is:
• significant weight loss (by food avoidance, vomiting, excessive exercise, laxative abuse);
• excessive concerns about weight or shape;
• and one or more of the following: fear of swallowing and / or vomiting; Abdominal pain during or outside the meal; Restrictions on water intakes; Interest in calories.
Chatoor Classification:
The other classification is that of Chatoor in three groups according to the age:
• disorders that appear in early childhood and can persist during childhood (anorexia infant, food neophobia, small eaters);
• disorders beginning during childhood itself (anorexia nervosa and bulimia);
• post-traumatic eating disorders that can occur at any age.
Finally, in the definition of eating disorders, we emphasize the inadequacy of the “gross” body mass index in order to assess undernutrition in the light of changes in age, sex, and impact Of the eating disorder itself on statural growth.
Symptomatology:
In the girl:
Pre-pubescent mental anorexia is a disorder of eating behavior: weight loss is not related to decreased or loss of appetite; The patient is actively fighting against hunger. The child actively reduces his / her nutrition quantitatively and qualitatively, gradually eliminating the most caloric foods: fats and sugars.
Intake is increasingly limited, and sorting pipes are very invasive: it removes the slightest hint of fat from half a slice of ham, wipes the green beans one by one in the fear that After a few weeks or months of evolution, the accepted foods are limited in number: “nature” crudites, apples (especially green), a little steamed fish, possibly yoghurt and cheese White at 0%. These very selected foods are ingested in small quantities, cut into small pieces. All the rest was eliminated (bread, meat, eggs, cheeses, starches, pastries, ice cream …), and the patient knows by heart the calorie tables and checks on the packaging the energy value of the least lean yogurt, from the minipain to the milk. She avoids the collective meals, manages to make her “meals” herself and uses many pretexts so that she is not seen at meals: she says having had breakfast before the parents raised; She pretends to have eaten starchy at noon in the canteen to have green beans in the evening; It suppresses the taste; She said she had already eaten in the evening when the parents return late …
It gives a good exchange because it shows a certain interest for food and recipes, and it is not uncommon that it makes cakes or delicious food for the brothers and sisters and parents, but it takes good care Not to taste it.
Weight loss easily reaches several pounds in a few weeks, usually unbeknownst to the entourage. Despite this weight loss, the patient continually feels the fear of being too fat or obese if forced to eat. Cachectic, she sees herself obese.
In contrast to adolescents who can ingest large quantities of fluids to fool their hunger and fill their stomachs with water and tea, the prepubescent anorexic child reduces their fluid intake, and during or out of the meals they ingest Very small amounts of water; Any other drink is excluded.
If one tries to force her to eat, she complains of abdominal pain, nausea, “blockage” preventing her from swallowing or on the contrary feeling overflow and regurgitation.
In some cases, the child secretly vomits; It is rare, however, at this age to resort to laxatives and diuretics.
In parallel, she increases her physical activity by multiplying the hours of sport, dancing, running in the corridors of the metro, imposing hours of bicycle or swimming.
She sits as little as possible (does her homework standing) and reduces her sleep time. She also increases her intellectual and academic activity by spending more and more time on homework, with behaviors of excessive perfectionism.
Relational life shrinks: she refuses invitations, withdraws into herself, moves away from her friendly relationships and becomes more and more dependent on her family.
This addiction is nevertheless accompanied by a growing aggressiveness towards her family circle which she accuses of being too intrusive and persecutory at the table.
She refuses all pleasure, is proud of the mastery she imposes on her body; She feels all-powerful, and seeks to extend her power to the whole of her entourage, which she tyrannizes and controls.
This is how the diagnosis can be carried late because it keeps its tone; Parents and physicians find it difficult to imagine that such a young child knows the caloric value of food and is concerned about its weight.
When weight loss becomes clear, parents and doctors are primarily focused on somatic causes of weight loss (which, of course, must be ruled out) that do not have the same symptomatology: the “sick” child eats little but does not He does not have a distorted body image while the anorexic child finds that he has big cheeks, big thighs or a big stomach (whereas he is slender or skeletal) and his behavior is characterized by A fanatical pursuit of slimness.
In the boy:
Whereas in post-pubescent anorexia the sex ratio is nine girls per boy, in pre-pubescent anorexia it is estimated that 19-30% of cases involve boys. The symptoms are the same as in the diet with fat rejection. On the other hand, the concerns are different, with idealization of the bodies of athletes and bodybuilders, and physical hyperactivity by admiration of their musculation. Contrary to what could have been written in the past, the prognosis is not more serious in the boy than in the girl. The existence of obesity or overweight that led to peer mockery due to its lack of agility and its cumbersome side is a factor more commonly reported in boys when starting the dietary restriction .
Differential Diagnosis and Border Forms:
Eating Disorders in Early Childhood:
Between 1 and 2% of babies and young children have dietary difficulties during the first year of life; 70% of them retain food problems later.
Anorexia infantile:
Reaching girls as boys, it begins in the first months of life, essentially between 9 and 18 months: the child does not open his mouth, eats very small quantities, prefers to play instead of eating, never showing his hunger. This restrictive behavior can last for many years with repercussions on the growth of the stature; Smaller and thinner than other children their age, they appear 10 years old to have seven. Boys suffer from peer exclusion, while girls seem to suffer less from their small size and yet express themselves little by little Bodily concerns, fearing obesity and controlling their diet. The precise relationships between this type of anorexia and anorexia nervosa are not yet clear.
Small eaters and food neophobia:
The food restriction table begins at a young age: when food diversification occurs, a rejection reaction is manifested and can be generalized to other foods in the same category. Food refusals are based on the taste, texture, color, odor and appearance of the food. The child eats better if presented his favorite foods … The phenomenon can therefore be analyzed as a neophobic food: the child fears new foods and refuses them.
Parents, who wish the child to eat, offer him little by little exclusively the foods loved, and the repertoire of food remains very restricted.
These food selections can lead to specific nutritional deficiencies depending on the foods eliminated (sometimes, on the contrary, overweight if the child only accepts starchy foods and no fruit or vegetables).
While some authors suggest a genetic predisposition, the role of the family environment is paramount; The mothers of neophobic children often suffer from dietary difficulties: food neophobia, lack of pleasure, tendency to nibble, lack of variety, and fathers have difficulty controlling their weight. These children, frightened by novelty and the unknown, are anxious children, who feel a sense of insecurity, and whose anxiety is accentuated by maternal anxiety. Monitoring of small eaters from the first months of life shows that this behavior is a further risk factor for eating disorder, especially for girls.
Disorders related to another psychopathological disorder:
Obsessive Compulsive Disorder:
Food is selected for fear of contamination, and swallowing is impaired by rituals and compulsions.
The child or adolescent refuses to eat because he is afraid that the food has been contaminated by a sick person or that the utensils have been badly washed and he needs to attend the preparation, checking the packaging, etc. .
Depressive states:
In depression, in the same way that the child no longer wants to play, he is no longer interested in anything, he has no appetite for food or for life in general, and There is a disconnect between the previous behavior and the current behavior. There is food restriction by real loss of appetite and there is no bodily concern.
Disorders after a traumatic event:
According to the authors psychogenic dysphagia, functional dysphagia, phagophobia, phobia of swallowing, they are characterized by a food exclusion bearing total or incomplete on solid foods; The child has an exclusive liquid or semi-liquid diet: he no longer feeds on liquid, mixed foods, dairy products and fruit juices. The symptomatic course is rather unambiguous.
The child makes a false journey (“he chokes”) with a sweet or a piece of solid food; Possibly, he is not a victim himself but attends this event with a loved one.
The child feels intense fear; He has the impression of stifling, sometimes of dying. When the next meal begins, the child feels a growing fear, anticipatory anxiety, sometimes tremors, tachycardia; He cries, says he risks strangling again and dying stifled. It selects foods, chews long, filters through teeth and takes long minutes for each bite. Weight retention is never significant; Most often the weight is in relation to the size or very slightly lower.
The sequence of “trauma / anticipatory anxiety / avoidance” refers to the phenomenon of post-traumatic stress syndrome, where children under severe stress develop anxious manifestations, with sleep disorders, avoidance of traumatic situations, anticipatory anxiety, They are confronted with the same type of stress. We can analyze this disorder as a post-traumatic feeding disorder in assimilation to post-traumatic stress syndrome while recognizing that stress is not unusual but minor. The phobia of swallowing and the fear of strangling represent an equivalent of separation anxiety.
Complex disorders:
The aforementioned disorders may be intertwined.
Anorexia and depression are common comorbidities in children, and it is sometimes difficult to determine which is the main disorder and which has preceded the other.
The anorexic child is perfectionist; His diet follows certain rituals; In some cases there is a genuine obsessive compulsive symptomatology involving other areas than diet.
Some children have a history of small eaters and evolve towards true anorexia nervosa. A swallowing phobia may associate with an anorexic table, etc.
It is therefore important in the evaluation to determine the chronologies of the disorders and their particularities: solids / liquids, fats, etc.
Etiological and pathogenic hypotheses:
Anorexia nervosa is not a new disease and its cause is unknown, and even if the disorder begins on the occasion of a family event or when a peer mocks, the hypothesis of a single cause has Been abandoned for a long time.
Multifactorial pathology:
Anorexia nervosa is multifactorial and multidimensional.
According to the often cited bio-psycho-social model, it can be said that there are:
• risk factors: biological and genetic factors, individual and family psychological factors, sociocultural factors;
• precipitating factors: family events, environmental interventions (family, friendship, social …) and sometimes the first signs of puberty …;
• maintenance factors: for example, undernutrition itself leads to psychological changes, the environment is reorganized around the disease, and so on.
Family risk factors:
Among family risk factors, it is important to emphasize the role of parental eating disorders, especially as a continuity has been described between childhood, adolescent and Of the adult. Dietary difficulties during childhood and adolescence are predictive of a behavioral disorder in adults.
Rejuvenation theme:
One can also wonder about the increase in the prevalence of eating disorders at the end of the 20th century and on the theme of rejuvenation.
From an early age, children are concerned about their appearance. From the age of 3 or 4, children express a preference for thin bodies; From 5 years old, they express their fear of becoming fat and do not like to play with the obese children they describe as “lazy, dirty, stupid, ugly, cheating, liars”. The 5-year-old girls are concerned about their weight, are afraid to grow up and most of all their self-esteem is directly related to their weight: the more they are round the less they love each other and the less intelligent they are.
Girls, from the age of 10, tend to find their bellies too large.
The idealized body of reference is for the child a young, beautiful, thin, muscular body; “Calories, slimming, fitness” are part of their vocabulary. In these areas, they are influenced by their entourage (parents especially, friends afterwards) and by the media. Already in 1989, a study on a sample of 356 children aged 7-13 described a desire to be thinner for 45%, attempts to slim down for 37%, vomiting provoked for 1.3%.
Finally, although studies are limited, it appears that the treatment of overweight in children can lead to secondary eating disorder.
Finally, certain groups of children, who are under considerable pressure from their environment around their thinness and fitness, are at increased risk of eating disorders: classical dancers, gymnasts, skaters and other young athletes.
Socio-cultural aspects:
They have also evolved in recent years.
Until the 1970s, it was said that there was no case in the black race.
Then came publications describing cases within ethnic minorities of countries of Western culture and especially in countries of non-Western cultures: Africa, Middle East, India and Asian countries, etc. Suggesting a role for the penetration of Western values (worship of thinness, fashion, etc.) in these countries, either through Westernization or through confrontation with the shock between traditional values and new values. Publications on Asian countries draw attention to symptomatic nuances, the role of urbanization, and the search for thinness, including in school-age populations. Moreover, in a country like China where the policy of the one child reigns, there is a change in family relations; The child-king boy, exposed to obesity, may also exhibit anorexia and anorexia can be analyzed not only as a way to master the body but also to punish the family.
Evolution:
Somatic complications:
They are multiple, reaching all organs and the developing body; Their severity is variable, but if most are reversible under treatment, some are irreversible, and some are fatal.
In the short term, mundane are hypersensitivity, hypothermia, acrocyanosis, lanugo, hair loss become dull and brittle.
Also bradycardia and hypotension, and even pericardial effusions, but it is most often through cardiac complications that deaths occur in anorexia nervosa, and that is why we must be attentive to the onset Rhythm disorders and conduction, with particular attention to possible prolongation of QTc given the risk of sudden death. On the digestive level, beyond the very common constipation, occlusion, digestive hemorrhages can occur.
Many electrolyte and metabolic changes are possible, and some potentially dangerous: hypokalaemia, hypophosphatemia, hypoglycemia, hypercholesterolemia … Neurological complications are also frequent: convulsions, peripheral neuropathies.
In imaging, important malnutrition is accompanied by cerebral atrophy, incompletely reversible during renutrition.
In functional imaging, the Lask team reported unilateral hypoperfusion in the temporal region in 75% of a sample of anorexia patients aged 8 to 15 years, with decreased visuospatial abilities, visual memory and Of the speed of information processing.
Currently, it is not possible to determine whether this is a primary phenomenon or whether this hypoperfusion is a consequence of undernutrition and, if so, whether it is slowly reversible or irreversible.
Medium and long term complications:
Osteopenia and therefore early osteoporosis are a major complication; The best way to increase bone density is to restore weight because calcium, vitamin and hormonal supplements have not been shown to be effective.
Slowing or stopping growth: during the pre-pubertal period, anorexia leads to a slowing down of the rate of growth of the stomach, which can be significant in intensity and duration, with a slowing down of the pubertal evolution.
Undernutrition leads to resistance to hormone growth and neuroendocrine control abnormalities with increased hormone releasing hormone and somatostatin decrease, and a collapse of insulin growth factor 1 and BP3, and growth hormone binding protein .
Lower levels of leptin, and elevated levels of ghrelin and adiponectin were also observed. According to Swenn and Thurfjell’s study of restrictive dietary disorders diagnosed in the pre-gene stage, growth retardation even precedes weight loss, sometimes by several years.
Statural growth improves with renutrition, but catch-up is often incomplete.
Prognosis :
The prognosis of prepubertal anorexia is poorly understood because few studies specifically address the prepubertal category.
Overall, it can be said that it obeys the “three – thirds rule”: one – third of the patients heals completely, one third improves significantly at the cost of some sequelae, and one third evolves in a chronic mode, Adolescence and adulthood, with many re-admissions.
It is within the latter group that the cases of death are observed. Mortality is estimated at 20% over 20 years, linked to undernutrition, suicide and sudden cardiac death.
Treatment:
Treatment ideally combines four types of intervention: medical follow-up, nutritional follow-up, psychiatric follow-up and family care.
Referring an undernutrited child to a single mental health specialist is a poor medical practice; We can not deal with the psychological aspect without taking care of the pediatric aspect.
Medical treatment:
It is provided by a pediatrician or general practitioner and is intended to perform medical monitoring of weight, growth, general physical condition, detect complications, prescribe the necessary examinations for undernutrition and prescribe The possible corrective treatments.
Nutritional treatment:
It is provided by a dietician or a nutritionist.
The patient benefits from consultations, during which an alliance must be established: the two participants agree on a progressive replenishment program. The dietitian explains the necessities of the diet, the child says what foods he accepts and what foods he absolutely refuses. Consultations are negotiations on the variety of foods, quantities, number of food intake.
The goal is eventually that the child can attain a diversified diet, “normal” for his age and size, and that allows him to ensure a regular weight gain with a parallel resumption of growth in the statur.
The dietitian will involve the family in these consultations so that purchases and culinary preparations are made in accordance with the contract with the child.
Therapeutic meals, known as accompanied meals, may be offered where the dietitian lunch with the child to teach him how to use in quantities and in diversity.
These accompanied meals can also integrate a parent (or both) for an educational but also psychological purpose to help them manage their mutual anxiety.
Family support:
Historically, the treatment of anorexia nervosa in France was based on the separation of the child and his family; However, the validity of this treatment has never been demonstrated and, while it may be justifiable in some adolescents to work in psychotherapy on the separation / individuation process, it is not supported in children .
This is why, in the recent care, according to an integrative model, the parents are associated in a true alliance and become cothérapeutes of their child.
According to various studies, family psychotherapy is the treatment of choice for young anorexia and, according to the Inserm collective expert analysis, the effectiveness of family psychotherapies is demonstrated up to 5 years of follow-up, provided that patients are Young and that the disease has less than 3 years of evolution. The latest study by Le Grange et al. Confirms the positive results of family therapies in ambulatory follow-up in the treatment of 45 children and adolescents aged 9 to 18 years.
In its current formulas, family care has abandoned the vision of a pathogenic family that should be repaired in order to reach the vision of a family that can contribute to the improvement of the disorder by mobilizing its resources and skills.
Psychiatric follow-up:
Its purpose is to assess the psychic state of the child, to investigate possible other psychopathological disorders, and to establish the indication and modality of psychotherapeutic treatment.
The practical modalities and the theoretical references of psychotherapies are so varied and so little evaluated in the child that it is impossible to compare the results.
The anorexic child is more likely to be denial; It is therefore often inaccessible to psychotherapies of psychoanalytic inspiration and the most widespread psychotherapies are supportive psychotherapies.
Children can also be accessible to behavioral therapies that set goals in reality, in the short term, with progression in these goals and results quickly visible.
Psychotropic drug treatments do not have recognized indications in anorexia of the child.
Organization of care:
Ideally, ambulatory care is recommended, either in the form of consultations, or by consolidating therapeutic interventions into a day hospital system.
There are cases where full-time hospitalization is necessary or “vital”
• if ambulatory or day hospital treatment has failed, and the child continues to lose weight or does not take it;
• if the undernutrition of the child is too severe and puts his life at risk;
• if there are serious medical complications;
• if there are “at risk” psychiatric complications: serious depression, for example, ideas of death;
• if the family is failing or too far away.
Full-time hospitalization offers different integrated approaches, with institutional, school, etc. support. These procedures maintain a better social adaptation, greater involvement of parents, and expose to less chronicity and iatrogeny. Nutritional assistance, by enteral nutrition, is either proposed in severe or resistant cases, or is systematically ensured to achieve faster weight gain. It can be spread over 24 hours or during the night with snacks during the day at meal times.
The hospitalization is then of variable duration (often several weeks or months), then the pluridisciplinary follow-up continues in ambulatory.
Conclusion:
Anorexia nervosa exists in the child even before puberty. Although its prevalence is increasing, studies are still fragmented, both to define the concept and its limitations with other disorders of childhood feeding behavior, its commonalities and divergences from adolescent anorexia, and to know Better the trajectories evolutionary psychopathologically and somatic.
