It would be too arbitrary to define an early onset by age limits such as an onset from 8 to 16 years. A more meaningful frame of reference is the onset in relation to the stage of puberty which has been reached by the child.(98) Because puberty is a complex developmental process spanning 2 to 3 years, it is best to name as 'premenarchal' the illness which commences some time after the first signs of puberty and before its completion, as shown by the first menstrual period. In true prepubertal anorexia nervosa the illness begins even earlier, before the very first signs of puberty. Postpubertal anorexia nervosa is when the illness commences after menstruation has been established.
There is much similarity between the clinical features of an illness of early onset and one which is postpubertal. However, there are two important differences. The first is the potential for the illness to interfere with the child's pubertal development. The second is the impact of an early onset with particularly heart-rending consequences for the child's family. It follows that the management of the family is of supreme importance, and the clinician should be prepared for parental reactions which may sometimes detract from a rational plan of treatment.
The clinical presentation is variable. Often there are precipitating events such as a family bereavement or a physical illness leading to weight loss. The onset is likely to be insidious(22>, with the parents noticing nothing amiss except for non-specific features, which are nevertheless important. Symptoms of depression and irritability are common.*16,99 Some children cannot describe feelings of depression, but tearfulness may be obvious. They withdraw from friends and may refuse to go to school. Others express ideas of being undeserving of love or food. Increasingly these youngsters have been found to injure themselves, especially by scratching with their nails or cutting the skin of the wrists and forearms with sharp objects, and occasionally by knocking and bruising the head. In a severe depression the child may say she hears voices calling her 'bad', but further questioning indicates that these are not true hallucinations but vivid expressions of her own thoughts. Another common presentation is with complaints of bodily symptoms, especially headaches, abdominal discomfort, and a wide range of gastrointestinal symptoms, which inevitably elicit physical investigations.
At some stage, however, the parents observe that their child is avoiding food and is reluctant to eat at normal meal times. She resorts to deviousness and secrecy. The omission of school meals often goes undetected. Eventually it is noticed that she has become thinner and may have lost a great deal of weight. Resistance is met when attempts are made to reverse the loss of weight. Even a young child may become preoccupied with the caloric values of foods. Methods of inducing weight loss additional to food avoidance may become evident. The child is likely to exercise excessively—jogging, walking, or cycling long distances. An attempt to reduce the excess activity may lead to solitary exercising in the bedroom, including press-ups or running on the spot. Other patients may induce vomiting or take laxatives even after small meals, but overeating typical of bulimia nervosa is rare in young children. (100)
Because of the early onset while the child should still be growing in stature, there is a failure to gain the weight which normally accompanies the growth spurt. Later there occurs an actual loss of weight and, because the child has not yet reached her optimum weight, a very low weight indeed may result—25 kg or even less. Symptoms of malnutrition ensue including tiredness, constipation, and sensitivity to cold with cold extremities.
Even younger children are likely to disclose that they are fearful of becoming fat, a disturbance similar to the overvalued idea held by older patients. A minority of patients will disclose their reluctance to develop personal, sexual, or social maturity, in a manner which fits into Crisp's model. A few may express reluctance to have menstrual periods. A girl may say she is indifferent whether she menstruates or not, but would like to develop breasts so as not to lag behind other girls in her class. The reluctance to 'grow up' may be expressed in social terms, with the patient saying that she could not imagine herself ever leaving home or her mother. On the other hand most girls are keen to reach a normal stature.
Severe depression was found in 69 per cent of youngsters in the Göteborg study.(16) In the same series one-third of the patients had an obsessive-compulsive personality disorder, and 8 per cent developed hand-washing and other compulsions.
Physical examination will reveal a varying degree of wasting, affecting the limbs, the abdomen, the buttocks, and the facial appearance. The extremities are blue and cold, and ischaemic changes may lead to gangrene affecting the toes. Other physical changes are similar to those in the adult, except for the addition of a delay in puberty.
The illness may adversely affect pubertal development depending on its time of onset. If the onset is truly prepubertal the child will not yet have shown the first signs of puberty, such as the appearance of pubic hair and breast buds. When the illness begins during the course of puberty these early signs may have appeared, but the breasts will show early growth only (Tanner stages 1 or 2), and the child will not yet have menstruated. The effects on pubertal development can be divided into those affecting growth and stature, breast development, and menstrual function.(98)
1. Growth in stature may have become arrested. In a series of 20 patients with a premenarchal onset, only two of them had reached the 50th centile in height. With successful treatment and weight gain, catch-up growth of 2 to 5 cm may be achieved, but only in patients aged 17 or less. (98)
2. Breast development: in the same series only six patients had normal breasts and as many as 10 had infantile breasts. After prolonged weight gain, eight of the 14 patients showed a considerable response in breast growth.(98)
3. Menstrual function: a prepubertal or premenarchal onset of the illness will cause a delay in the onset of menstruation, defined as primary amenorrhoea. In the series already referred to only four of the 20 patients had menstruated by the age of 16 years. A further three began their periods between 16 and 18 years of age, and four at ages ranging from 18 to 25. The remaining patients had prolonged amenorrhoea.
The above series consisted of selected patients in whom pubertal delay was severe, whereas marked pubertal delay has seldom been reported in other series in which only delayed menstruation has been remarked upon.
A young boy who develops anorexia nervosa is also likely to become preoccupied with fatness and accordingly avoids food in order to lose weight. The endocrine disorder in the male similarly consists of a disturbance of the hypothalamic-pituitary-gonadal axis. With a prepubertal onset, the penis and scrotum remain infantile, there is only a scanty growth of pubic and facial hair, and the voice may not break.
Pelvic ultrasound monitoring of the ovaries and uterus is a useful method of ascertaining regression and recovery in children with anorexia nervosa. (!01) On first testing, and in the presence of low weight and amenorrhoea, ovarian volume and uterine volume were found to be reduced in comparison with normal pubertal girls. In the latter the normal range of ovarian volume is 3.95 ± 1.7 cm(3) and uterine volume is 14.8 ± 7.6 cm.(3) On retesting the patients 18 months after the first scan those who were menstruating showed significantly larger ovarian and uterine volumes than those with amenorrhoea. The authors concluded that for ovarian and uterine maturity to occur it is necessary to achieve a mean weight of 48 kg and a mean weight-to-height ratio of 96.5 per cent, higher targets than are usually set. They also found that pelvic ultrasound scanning helped to motivate the children to accept a higher body weight.
Differential diagnosis of early-onset anorexia nervosa
Frequent bodily complaints, loss of weight, and abnormalities of growth lead these children to be referred to paediatricians for special investigations. It has been proposed that young anorexic boys should be investigated by means of neuroimaging, so as not to miss occult intracranial tumours masquerading as early anorexia nervosa/61 The diagnosis of anorexia nervosa should be distinguished from atypical eating disorders in childhood. (99)
1. Pervasive refusal syndrome is characterized by a child, usually aged between 11 and 15, refusing to eat, drink, walk, talk, or take care of herself. Anxiety, phobic responses, and depression are also present.
2. Selective eating is the term applied to a child who restricts food intake to two or three different foods, such as biscuits, crisps, or potatoes, but usually remains in good health.
3. Food avoidance emotional disorder: this condition is one in which food avoidance is attributable to an emotional disturbance in the absence of a dread of fatness, a necessary criterion for the diagnosis of anorexia nervosa.
4. Food fads and food refusal: the refusal to eat is usually intermittent and physical health is not compromised.
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