Windy Grant, MD, and Jonathan Pletcher, MD
Case
J, an 18-year-old male, presented to the ED with 46 lb weight loss over 1 year, decreased appetite, worsening fatigue, and nausea. Initial laboratory studies showed mild hyponatremia, increased creatinine, transaminitis, hyperbilirubinemia, and mildly prolonged partial thromboplastin time (PTT). Malnutrition labs and EKG were obtained, and he was subsequently admitted to our service for ongoing evaluation and initiation of the Nutritional Rehabilitation Program (NRP).
Per behavioral health provider assessment, he met the criteria for anorexia nervosa restricting type. Despite advancing daily caloric intake per protocol, while his initial lab values improved, he did not demonstrate expected weight gain over the first week and remained mildly hyponatremic. On hospital day 7, he developed hyperkalemia with worsening hyponatremia, raising concern for adrenal insufficiency. Further, workup confirmed the diagnosis of Addison’s disease, warranting management with steroids while he stayed on the NRP.
He was discharged home 1 week later after achieving typical weight gain on a 5600-kcal meal plan, with instructions to follow up with Endocrinology and a referral for care with a family-based treatment therapist to treat his underlying eating disorder.
Take-Home Points for Primary Care Providers
Growth charts are important tools, providing a trajectory of how children and adolescents should continue to develop throughout the first 2 decades of life. Each patient follows their own unique growth curve, and deviations from expected growth patterns may indicate underlying health issues. Additional historical data on nutritional intake, activity level, factors indicating malabsorption, increased metabolic demand, and food insecurity can facilitate early identification and timely intervention. In addition to aiding diagnosis, growth charts provide a shared blueprint for restoring the patient’s growth trajectory based on BMI percentile, rather than setting a static “goal weight,” and have proven more effective when working with teens and families.
Providers should maintain a high index of suspicion for co-occurring medical conditions and alternative diagnoses when evaluating adolescent and young adult patients with malnutrition, even when they meet criteria for an eating disorder. It is crucial to recognize when patients deviate from the expected course of treatment. Anchoring on a specific diagnosis can be harmful and hinder our best clinical judgement. A range of metabolic, endocrine, gastrointestinal, oncologic, rheumatologic, and hematologic disorders can be masked by malnutrition and diagnoses of disordered eating. It is important to rely on cases such as these as they expand our clinical knowledge and expertise, while also reinforcing the importance of humility and leaning into questions to identify the underlying cause of malnutrition.
“Food is your medicine” is emphasized throughout the treatment process of patients with malnutrition. Food restores physical health, promotes healing, and contributes to psychological recovery. As patients receive adequate nutrition, they typically exhibit increased energy and mental clarity, enabling them to challenge disordered thoughts and behaviors associated with eating disorders, with the ongoing support of parents or caregivers.
Appropriate management of adolescent patients with malnutrition and underlying eating disorders requires a family-centered and multidisciplinary approach. Adolescent medicine providers, registered nurses, dieticians, behavioral health providers, social workers, and child life specialists should collaborate to provide comprehensive care and devise a cohesive treatment plan that is unique to each patient and promotes long-term recovery.
Treatment for eating disorders is stratified into various levels of care, including outpatient, intensive outpatient, partial hospitalization, residential, and inpatient following acute medical stabilization. Patients may face barriers to accessing care. Barriers include insurance coverage, financial limitations, geography, transportation, waitlists, and resistance to engaging in care due to stigma.
At Children’s Hospital of Philadelphia’s Adolescent Medicine Inpatient Service, there were 734 admissions in fiscal year 2024 for severe malnutrition, across both the Philadelphia and King of Prussia hospitals, with an average length of stay of 12 days. Our team acknowledges the incredible strength and resilience demonstrated by our patients through their recovery journey. We actively engage, educate, and empower parents/caregivers, as they are integral to the treatment team. By partnering and assisting them to acquire the tools and resources needed to aid their children, we have found that teens are most likely to thrive.
CHOP’s Inpatient Clinical Pathway for Evaluation/Treatment of Children with Malnutrition, Weight Loss, and Eating Disorders can be found at pathways.chop.edu/clinical-pathway/malnutrition-weight-loss-eating- disorders-clinical-pathway.
For more information on the CHOP Eating Disorder Assessment and Treatment Program (EDATP) or to make a referral, visit www.chop.edu/ eating disorders or call 215-590-7555.
References and Suggested Readings
Hornberger LL, Lane MA, Breuner CC, et al. Identification and management of eating disorders in children and adolescents. Pediatrics. 2021;147(1):e2020040279.
Society for Adolescent Health and Medicine. Medical management of restrictive eating disorders in adolescents and young adults. J Adolesc Health. 2022;71(5):648-654.
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Experts
Windy Grant, MD, and Jonathan Pletcher, MD
Case
J, an 18-year-old male, presented to the ED with 46 lb weight loss over 1 year, decreased appetite, worsening fatigue, and nausea. Initial laboratory studies showed mild hyponatremia, increased creatinine, transaminitis, hyperbilirubinemia, and mildly prolonged partial thromboplastin time (PTT). Malnutrition labs and EKG were obtained, and he was subsequently admitted to our service for ongoing evaluation and initiation of the Nutritional Rehabilitation Program (NRP).
Per behavioral health provider assessment, he met the criteria for anorexia nervosa restricting type. Despite advancing daily caloric intake per protocol, while his initial lab values improved, he did not demonstrate expected weight gain over the first week and remained mildly hyponatremic. On hospital day 7, he developed hyperkalemia with worsening hyponatremia, raising concern for adrenal insufficiency. Further, workup confirmed the diagnosis of Addison’s disease, warranting management with steroids while he stayed on the NRP.
He was discharged home 1 week later after achieving typical weight gain on a 5600-kcal meal plan, with instructions to follow up with Endocrinology and a referral for care with a family-based treatment therapist to treat his underlying eating disorder.
Take-Home Points for Primary Care Providers
Growth charts are important tools, providing a trajectory of how children and adolescents should continue to develop throughout the first 2 decades of life. Each patient follows their own unique growth curve, and deviations from expected growth patterns may indicate underlying health issues. Additional historical data on nutritional intake, activity level, factors indicating malabsorption, increased metabolic demand, and food insecurity can facilitate early identification and timely intervention. In addition to aiding diagnosis, growth charts provide a shared blueprint for restoring the patient’s growth trajectory based on BMI percentile, rather than setting a static “goal weight,” and have proven more effective when working with teens and families.
Providers should maintain a high index of suspicion for co-occurring medical conditions and alternative diagnoses when evaluating adolescent and young adult patients with malnutrition, even when they meet criteria for an eating disorder. It is crucial to recognize when patients deviate from the expected course of treatment. Anchoring on a specific diagnosis can be harmful and hinder our best clinical judgement. A range of metabolic, endocrine, gastrointestinal, oncologic, rheumatologic, and hematologic disorders can be masked by malnutrition and diagnoses of disordered eating. It is important to rely on cases such as these as they expand our clinical knowledge and expertise, while also reinforcing the importance of humility and leaning into questions to identify the underlying cause of malnutrition.
“Food is your medicine” is emphasized throughout the treatment process of patients with malnutrition. Food restores physical health, promotes healing, and contributes to psychological recovery. As patients receive adequate nutrition, they typically exhibit increased energy and mental clarity, enabling them to challenge disordered thoughts and behaviors associated with eating disorders, with the ongoing support of parents or caregivers.
Appropriate management of adolescent patients with malnutrition and underlying eating disorders requires a family-centered and multidisciplinary approach. Adolescent medicine providers, registered nurses, dieticians, behavioral health providers, social workers, and child life specialists should collaborate to provide comprehensive care and devise a cohesive treatment plan that is unique to each patient and promotes long-term recovery.
Treatment for eating disorders is stratified into various levels of care, including outpatient, intensive outpatient, partial hospitalization, residential, and inpatient following acute medical stabilization. Patients may face barriers to accessing care. Barriers include insurance coverage, financial limitations, geography, transportation, waitlists, and resistance to engaging in care due to stigma.
At Children’s Hospital of Philadelphia’s Adolescent Medicine Inpatient Service, there were 734 admissions in fiscal year 2024 for severe malnutrition, across both the Philadelphia and King of Prussia hospitals, with an average length of stay of 12 days. Our team acknowledges the incredible strength and resilience demonstrated by our patients through their recovery journey. We actively engage, educate, and empower parents/caregivers, as they are integral to the treatment team. By partnering and assisting them to acquire the tools and resources needed to aid their children, we have found that teens are most likely to thrive.
CHOP’s Inpatient Clinical Pathway for Evaluation/Treatment of Children with Malnutrition, Weight Loss, and Eating Disorders can be found at pathways.chop.edu/clinical-pathway/malnutrition-weight-loss-eating- disorders-clinical-pathway.
For more information on the CHOP Eating Disorder Assessment and Treatment Program (EDATP) or to make a referral, visit www.chop.edu/ eating disorders or call 215-590-7555.
References and Suggested Readings
Hornberger LL, Lane MA, Breuner CC, et al. Identification and management of eating disorders in children and adolescents. Pediatrics. 2021;147(1):e2020040279.
Society for Adolescent Health and Medicine. Medical management of restrictive eating disorders in adolescents and young adults. J Adolesc Health. 2022;71(5):648-654.