24. Screening and Managing Eating disorders in Primary care with Dr. Sarah Garwood

Dr. Elise Fallucco interviews Dr. Sarah Garwood, a professor of pediatrics who specializes in eating disorders, about screening and managing eating disorders in primary care. They discuss screening tools, medical workup, and practical steps that pediatric clinicians can take to support children with eating disorders.

• Practical tools to  identify kids who are struggling with eating disorders including:
  • growth chart changes
  • SCOFF - 5 question eating disorder screening tool
  • NIAS - 9 item avoidance screener
• what pediatricians can do  to help patients with eating disorders 
  • medical work-up
  • comprehensive labs
  • establish regular eating patterns
• when to hospitalize a child/teen with eating disorders

 Dr. Garwood is a Professor of Pediatrics at Washington University School of Medicine who specializes in eating disorders.  Dr. Garwood’s work through the Adolescent Center in the Department of Pediatrics focuses on the unique health care needs of adolescents.  In August 2017, Dr. Garwood co-founded the Washington University Transgender Center at St Louis Children’s Hospital in order to support comprehensive medical and mental health services for transgender children and young adults.  Advocacy related to this role has included a TEDx Talk in 2019 

Check out our website PsychEd4Peds.com for more resources.
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Transcript

Dr. Elise Fallucco: 0:21

Welcome back to psyched for paeds, the child mental health podcasts for pediatric clinicians, helping you help kids. I'm your host, Dr. Elise Fallucco child psychiatrist and mom. We're continuing our discussion on eating disorders. And today we're going to be talking about. What screening tools can we use to identify kids with early signs of disordered eating? What sort of medical workup should we be doing to rule out other potential comorbidities? And most importantly, what can a primary care pediatric clinician do? To help support these kids and their families as they wait to get to connected with various eating disorder specialists. Our guest today is Dr. Sarah Garwood, who is a professor of pediatrics at Washington university school of medicine in St. Louis. She's dedicated her career to addressing the unique healthcare needs of adolescents and particularly to the care and treatment of youth with eating disorders. You may know her from her TEDx talk and we are very excited to have her with us today. Welcome to Psyched for Peds, Dr. Sarah Garwood.

Dr. Sarah Garwood: 1:32

Hi. Thanks for having me.

Dr. Elise Fallucco: 1:34

Thanks for coming. So let's start off from the beginning. JAMA Peds recently published this big meta analysis saying that somewhere between one in five kids worldwide have symptoms of disordered eating. And I'm sure you've seen this in your practice, that there's been a major increase since the start of the pandemic in disordered eating. So is there anything, any practical tools or tips that pediatric clinicians can use to help identify kids who are struggling with eating disorders?

Dr. Sarah Garwood: 2:05

Yes, absolutely. the primary pediatricians are really on the front lines of this epidemic that we're seeing since COVID. So in terms of clinical screening tools, one of the biggest things that I think pediatricians have at their disposal is that growth chart. And one of the biggest resources that they can review at every single visit, checking the height, weight, looking at what the BMI is and putting that on those growth charts and so changes in that growth chart are a big part of it. But as we all know, there are some kids who might be of normal weight or may not have had major weight changes yet, who are also Dealing with disordered behaviors. In terms of other ways to screen kids, if you're talking about the general population that comes into the clinic, a short and an easy tool is the SCOFF, the SCOFF tool.

Dr. Elise Fallucco: 2:50

For any of our friends and colleagues who might not be as familiar with the scoff, it is a five question. Eating disorder, screening tool developed for primary care. And we'll make sure to include a link to the S C O F F scoff tool in the resource section of our web page site, the number four paeds.com.

3:09

So the scoff can be really good for identifying kids with signs of anorexia or bulemia. But when we think about kids with potential ARFID or avoidant restrictive food intake disorder. Is there any screening tool you'd recommend for use in younger kids?

Dr. Sarah Garwood: 3:26

There are a couple screeners, but the one that I like the best is the NIAS, the nine item avoidance screener, and that can also help you kind of focus in on whether this might be a patient with ARFID.

Dr. Elise Fallucco: 3:37

Is there an age group or an age range that you think would Yield the most value in doing universal screening at well visits for disordered eating?

Dr. Sarah Garwood: 3:46

Yeah. Definitely the adolescent, the solid adolescent age group. We would say is worthy of being screened for disordered eating. And of course, if we're talking about ARFID many of those kids will have symptoms emerging in really early childhood through middle school as well. there are kids with ARFID who may actually have okay growth but they may still have very disordered eating patterns that are causing enough impairment psychosocially that they can still meet those criteria. So just to be aware of that.

Dr. Elise Fallucco: 4:19

A lot of kids with eating disorders may be normal weight range or overweight. If they're an adolescent, would you recommend universal screening regardless of growth charts?

Dr. Sarah Garwood: 4:27

Yes. I would definitely recommend universal screening regardless of growth charts for adolescence.

Dr. Elise Fallucco: 4:32

I think that'll help pediatric clinicians in primary care better identify kids who are at risk and not miss them. In an ideal world a child with an eating disorder is plugged into a multi specialist eating disorder treatment center with nutritionists and therapists and pediatric clinicians who are specialized in eating disorders. But what if you happen to be in a rural area or Not have easy or immediate access to these services. Is There anything that pediatricians can do in their practice, realistically in the context of a 10 or 15 minute well visit to start to address some of the eating disorder while they wait to get in to see a specialist?

Dr. Sarah Garwood: 5:10

Absolutely. The first steps that pediatricians can take are first steps I would take as an adolescent medicine specialist as well, because, even though we can connect people to resources and we have those resources, maybe more readily available, there's often still a wait time even to get in, to therapists or dietitians for us as well. And so the first steps Would be making sure you've completed the medical workup, so you want to make sure that you've ruled out other organic causes of weight loss. So that may be through some basic screening labs in addition to that very thorough review of systems and past medical history as well eliciting any other parent concerns or observations so usually I would recommend a complete metabolic profile, urine analysis, complete blood count, magnesium, phosphorus. And then for screening purposes for those other causes, in addition to what I've said, thyroid studies. Screen for celiac disease and sometimes people also do an ESR. I'm plus minus on that one, but some people will get that as well. And then after you've completed that, making sure that, you haven't, there's not some other cause inflammatory bowel disease or malignancy or celiac disease, thyroid disorder.

Dr. Elise Fallucco: 6:22

So to recap, the bloodwork you'd recommend for an initial eval: cBC. CMP, mag phos, thyroid studies. Testing for celiac and a UA. we'll have a handout on our website that lists some of this information for those of our listeners who want to reference it later. But let's say we've done this workup and nothing is concerning for organic causes of weight loss. What would the next steps be for pediatric clinicians while they wait for the kids to be seen?

Dr. Sarah Garwood: 6:51

Usually we start with trying to recommend three meals, two to three snacks a day, just reestablishing the normal pattern because often people have been skipping meals, have extended fasting, compensating for binging by fasting later. So we start with just trying to resume a regular pattern of three meals and two to three snacks. In addition to that, I think the other thing pediatricians can really encourage parents to start doing is just increasing supervision at the meals at the snacks and then making sure that after a meal, they're not disappearing for 20 minutes to the bathroom and no one's keeping tabs on what's happening as well. Hopefully sooner than later, they'll have some mental health support to help them with additional coaching on behaviors and how to get through those things so that they're not just increasing conflict without having the tools of how to manage those things. But those are usually the first steps that I recommend.

Dr. Elise Fallucco: 7:43

To recap some of what you just said to make sure I understood. So first step, first thing first is rule out organic causes through blood work, extensive physical exam, review of systems, review of medical history. The second part is just establishing a regular pattern of meals with adult or parental supervision during the meal and up to 20 minutes following the meal. Encouraging children to get back to eating on a regular basis can be really challenging. I appreciate that the focus is on resuming a pattern of eating or getting your body into a normal, regular schedule and less of a focus on overloading with calories necessarily.

Dr. Sarah Garwood: 8:22

Yeah.

Dr. Elise Fallucco: 8:23

yeah, and tell me a little bit about the rationale for that.

Dr. Sarah Garwood: 8:26

Yeah. my thought is Rome wasn't built in a day. And if you are attempting to keep this patient in an outpatient setting for treatment, you can only ask so much of the patient and the parents. And sometimes you have to kind of start with the smaller first steps if you can, if the patient is medically stable, if you have the luxury of remaining as an outpatient. And so, starting with the first training steps of parent and child working together to have regular meals again and establish the pattern of some increased supervision and involvement by parents. If it's a patient who needs weight restoration, they will have to then eventually increase calorie content over time. But for some patients, the weight, as we talked about before, may actually be in a normal range, but the behaviors may be still very erratic and may lead to weight problems or other health problems.

Dr. Elise Fallucco: 9:20

How frequently would you recommend that a pediatric clinician see these kids and follow up?

Dr. Sarah Garwood: 9:25

So seeing these kids back every week, every 2 weeks and at every 1 of those visits weighing them in a systematic way So that they go to the bathroom, maybe give you a urine sample. We usually make sure the SPEC GRav isn't diluted, have them be weighed in a standard way with their back to the scale, and then have their vital signs checked and possibly physical exam as well. If they need that.

Dr. Elise Fallucco: 9:48

Each visit checking a UA, blinded weights so that they don't see the number on the scale and also checking vitals.

Dr. Sarah Garwood: 9:55

I do feel like pediatricians can also start the psychoeducation process for families about what an eating disorder is and the health effects and connecting parents to other resources for further reading. There are even virtual support groups out there and things like that for people who live in places where they don't have access to things in person.

Dr. Elise Fallucco: 10:14

I think psychoeducation is helpful, and I bet primarily for the parent and the family members to understand what's going on. but I anticipate that the patient or the teen themselves is going to be so resistant, so defended, and so guarded against the idea that I have an eating disorder. So, well, this is really helpful and these are incredibly practical tips for what pediatricians can do while their kids are waiting to get connected with specialists. I also appreciate that you, you're being really reasonable and practical in a 10 to 15 minute visit. First steps- is just returning to a normal schedule and routine of eating and snacks with parental supervision while we're waiting to get in. There's lots of guidelines for when do we need to hospitalize somebody? When does somebody meet criteria? do you have a simplified way that you use of determining when you think somebody really is medically unstable and needs to come in?

Dr. Sarah Garwood: 11:08

I really use the Society for Adolescent Medicine's guidelines Also failure of outpatient treatment is another reason. So, if week after week, we are not really getting anywhere. Sometimes people get admitted for failure of outpatient treatment, even if the rest is okay.

Dr. Elise Fallucco: 11:21

Right. If their heart rate's okay, and their blood pressure's okay, and, there aren't necessarily critical labs, but you've been trying with the resources you have access to, and the child's just not getting better, then, sometimes it's a call to action. And for reference for our friends and colleagues who are listening, we're going to put this information in the resource section of our website. So. In your work, taking care of these kids for decades and in multiple different settings but also taking care of really the sickest of the sick. What final advice could you offer to primary care pediatricians about how they can best help these children with eating disorders and their families?

Dr. Sarah Garwood: 12:02

I think I mentioned this earlier, but that growth chart really is gold. So, really carefully observing the patterns-changes in weight over time. Knowing that you really have gold there on the growth chart is great. And early intervention and follow up make a huge difference for prognosis. Often it's a year or two before they come to attention for an eating disorder So, the earlier you can raise a concern, have an intervention with the family, probably the better for the family, and for the patient. So early intervention is really key. And then just the acknowledgement that most people with a eating disorder are going to need help to get better. Very few people, if left on their own, are going to just recover on their own without some type of support or intervention through the family or through other professional help. And so, early intervention and identification and treatment are really important.

Dr. Elise Fallucco: 12:56

Well, thank you, Dr. Garwood for taking your time and talking with us today on psyched for peds. And thanks for also kind of reminding us, Rome wasn't built in a day. You start with baby steps and you reach out to the rest of the team, which is really good advice. We're going to share some of the information from the Society of Adolescent Medicine on our website, psychedthenumber4peds. com. And if you have any questions about this topic, feel free to message us on our Instagram account at psyched, the number four paeds or through the chat function on our websites. Like the number four paeds.com. We hope you'll tune in next week as we talk about how to talk with teens who are struggling with disordered eating and how to handle these really challenging conversations. Thanks again for joining us. See you next time