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PREPUBERTAL ANOREXIA NERVOSA
“Anne-Cécile, age 10, thinks she is too fat: in the mirrors at her ballet class, she scrutinizes her chubby cheeks, her “plump” silhouette, she feels heavy, enormous…and she decides to lose weight. She does not tell anyone about it, but she starts to do without sweets, chocolate, fruit juice, etc…then she “forgets” to eat her snack one day, stops putting butter on her morning bread, makes various excuses for skipping desserts; then she stops liking potatoes (especially French fries), and pasta, and pizza.
Anne-Cécile grows thin, and becomes irritable if her mother tries to make her eat family meals. On a visit to her family doctor for an everyday sore throat, the doctor notices that since her last consultation six months earlier, Anne-Cécile has lost over 8 kg.”
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Although rarer than during adolescence, where there is a clear female predominance (nine girls to every one boy), anorexia nervosa exists before puberty. At this age, 20 % to 30 % of cases are males. Child anorexia has the same diagnostic criteria as adolescent and adult anorexia nervosa: Refusal to maintain body weight at or above a minimum normal weight for age and height; intense fear of gaining weight or becoming fat, even though underweight; distorted body image, disturbance in the way in which one's body weight or shape is experienced, undue influence of body weight or shape on self-esteem, or denial of the seriousness of the current low body weight.
Active, quantitative, and qualitative dietary restriction is accompanied by food sorting: eliminating the foods highest in calories (fats, starches, candy) eventually leading to severe diets consisting of some unseasoned raw vegetables and some zero-fat dairy products. Dietary sorting is accompanied by rituals, cutting food into tiny pieces, eliminating the slightest trace of fat, often with a significant prolongation of “meals” and hiding uneaten food. Often parents do not notice the loss of weight, gradual but inexorable, until it is already very pronounced. Although thin, and even emaciated, these children perceive themselves to be fat and continue to lose weight; they set an ideal weight for themselves (always extremely low) for irrational reasons and keep track of their weight on the scale or check the hollowness of their stomach, or the circumference of their thighs, etc. The physical hyperactivity, which is common, is reflected by long hours of dance lessons and gymnastics for girls, weightlifting, running, and abdominal workouts, etc. for boys. Self-induced vomiting may occur, but the use of laxatives and diuretics remains uncommon. Merycism (pondering), observed in young children, is only found in children over the age of 6 in cases of severe mental retardation. Two specific signs characterize the population of anorexic children in comparison to adolescents: fluid restriction which can lead to dehydration, and a slowing or even a stopping of growth, with a slope break in the growth curve and a risk to final height prognosis. Comorbid disorders may also exist: depressive or obsessive-compulsive symptoms (perfectionism or genuine OCD).
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SELECTION AND FOOD NEOPHOBIAS
“Adrien received a dairy diet until the age of 2, when he began to accept, albeit with some difficulties, jams, cereal, some cookies, and bread. At age 9, Adrien’s diet is the same, with the addition of milk, some ice creams, pancakes, and fresh orange juice. Adrien is a healthy child, not malnourished, but he cannot eat in the school cafeteria, or go to summer camp, or go to parties with other children."
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Some children have a less selective diet than Adrien but suffer from food phobias: any new food frightens them; they refuse to taste it and only agree to eat very ordinary foods. This behavior is unremarkable between the ages of 3 and 6, with varying degrees of importance depending on the individual and their family environment, but it becomes pathological if it persists and grows broader.
When these children, who are frightened by the new and unknown, only eat starches and sugary foods, they run the risk of becoming overweight. Anxious, they feel insecure, and often present with other symptoms which reflect their avoidance of all new situations (not going to summer camp, not going over to friends’ houses, etc). Their anxiety is often accentuated by that of their parents (fear of mad cow disease, chicken containing hormones, etc) who offer their children a diet with little variety.
CHOKING PHOBIA
”Eve, age 7 and a half, becomes more and more difficult during meals: she refuses to eat pieces of meat and potatoes, but still drinks hot chocolate (even when made with whole milk), can eat creams, soups, purees made with butter, etc. Eve is not preoccupied by her weight or her shape, her anxiety lies elsewhere: she is afraid of choking. This fear was triggered by a traumatic incident: Eve once choked on a piece of candy.”
Sometimes called post-traumatic eating disorder, this phobia develops after a traumatic incident is experienced or witnessed (choking on an olive or a piece of meat) or after a medical examination or surgical procedure involving the mouth or throat. The child sorts his or her food between solids and liquids, makes sure there are no pieces, keeps them for a long time in his or her mouth by filtering them out with their teeth. In these cases, there is little or no weight loss because the child, girl or boy, “compensates” with liquid or mixed foods.
”Eve, age 7 and a half, becomes more and more difficult during meals: she refuses to eat pieces of meat and potatoes, but still drinks hot chocolate (even when made with whole milk), can eat creams, soups, purees made with butter, etc. Eve is not preoccupied by her weight or her shape, her anxiety lies elsewhere: she is afraid of choking. This fear was triggered by a traumatic incident: Eve once choked on a piece of candy.”
Sometimes called post-traumatic eating disorder, this phobia develops after a traumatic incident is experienced or witnessed (choking on an olive or a piece of meat) or after a medical examination or surgical procedure involving the mouth or throat. The child sorts his or her food between solids and liquids, makes sure there are no pieces, keeps them for a long time in his or her mouth by filtering them out with their teeth. In these cases, there is little or no weight loss because the child, girl or boy, “compensates” with liquid or mixed foods.
OBSESSIVE COMPULSIVE EATING DISORDER
“Martin no longer wants to eat in the school cafeteria; at home he watches his mother as she prepares meals; he fears that the food may be contaminated, in particular by the AIDS virus. He makes sure that the food is safety-sealed, that his mother washes her hands, and washes the dishes properly. He washes himself repeatedly, spits out saliva, and cannot go to restaurants or to eat at friends’ houses anymore; he eats less and less and loses weight because all food seems dangerous to him.”
In this context, the disorder goes well beyond the dietary domain: the child is invaded by obsessive ideas (of contamination, dirtiness, etc) which he fights through his compulsions (repeated washings, verifications, etc). Treatment relies upon cognitive and behavioral psychotherapy techniques, sometimes combined with a selective serotonin-reuptake inhibitor (e.g. Zoloft/sertraline).
“Martin no longer wants to eat in the school cafeteria; at home he watches his mother as she prepares meals; he fears that the food may be contaminated, in particular by the AIDS virus. He makes sure that the food is safety-sealed, that his mother washes her hands, and washes the dishes properly. He washes himself repeatedly, spits out saliva, and cannot go to restaurants or to eat at friends’ houses anymore; he eats less and less and loses weight because all food seems dangerous to him.”
In this context, the disorder goes well beyond the dietary domain: the child is invaded by obsessive ideas (of contamination, dirtiness, etc) which he fights through his compulsions (repeated washings, verifications, etc). Treatment relies upon cognitive and behavioral psychotherapy techniques, sometimes combined with a selective serotonin-reuptake inhibitor (e.g. Zoloft/sertraline).
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NON-SPECIFIED DISORDERS AND “PICKY EATERS”
Julia always was a light eater, falling asleep with her bottle, never asking to eat, and she did not like candy. Slender yet dynamic, even tyrannical, Julia always ate “next to nothing.” But the family doctor reassured her parents saying “children don’t let themselves starve to death.” When Julia began to reduce her food intake even more, and her growth curve began to drop, it took a while for her parents and the doctor to react.”
The most widespread disorder in the child population, the light-eater behavior was until recently considered harmless, even positive (finally a child that is not obese!). Recent studies following light eaters from the first months of life show that the behavior is a risk factor for developing an eating disorder later in life.
Similarly, in our society, children from an early age reveal themselves to be concerned with their appearance and idealize the young, handsome, thin, muscular body starting at age 3 or 4; starting at age 5 some develop the fear of becoming fat, and do not like to play with their obese friends, who they describe as “lazy, dirty, stupid, ugly, cheating, lying,” etc). Starting at the age of 10, some girls tend to feel their stomach is too fat.
Children have the same preoccupation with body weight, shape, and appearance as adults: the same words are in their vocabularies “diet, calories, thinness, physical shape.” They are influenced in this by the people around them and the media. Lastly, some groups of children, under heavy pressure, are at a higher risk for eating disorders: ballet dancers, gymnasts, figure skaters, and other young athletes.
BINGE EATING
“Violette, 11 gorges herself on cookies or melted camembert before her parents come home. She does not get fat, because following a binge she controls herself, skips a meal or two, or even makes herself vomit.”
“Edouard goes to a fast-food restaurant after school where he wolfs down a huge double sandwich with a large order of French fries and a very large soft drink. He grows fat because he has no elimination habits.”
Edouard’s weight gain will lead him to visit his physician, while Violette’s admission to her mother regarding her plight, alternating between binges and purges, will help her to get care.
Bulimia is very uncommon under the age of 13. It is characterized by recurrent fits of excessive food intake and compensatory behavior: self-induced vomiting, the use of diuretics and laxatives, fasting, and intense physical exercise.
Dietary compulsions in children follow various patterns. The dividing line between normal and abnormal is not well defined. Many children, left alone (parents who come home late, do not cook or do not cook often, the refrigerator is self-serve, pocket money is available, etc.) will eat chocolaty cookies, ice cream, French fries, kebabs, etc. at any time of day. Sometimes these meals are not large and do not affect the child’s weight. In other cases, they lead to dietary anarchy, a veritable nutritional chaos resulting in either weight gain then obesity, or elimination habits (vomiting, fasting, meals skipped, etc).
“Violette, 11 gorges herself on cookies or melted camembert before her parents come home. She does not get fat, because following a binge she controls herself, skips a meal or two, or even makes herself vomit.”
“Edouard goes to a fast-food restaurant after school where he wolfs down a huge double sandwich with a large order of French fries and a very large soft drink. He grows fat because he has no elimination habits.”
Edouard’s weight gain will lead him to visit his physician, while Violette’s admission to her mother regarding her plight, alternating between binges and purges, will help her to get care.
Bulimia is very uncommon under the age of 13. It is characterized by recurrent fits of excessive food intake and compensatory behavior: self-induced vomiting, the use of diuretics and laxatives, fasting, and intense physical exercise.
Dietary compulsions in children follow various patterns. The dividing line between normal and abnormal is not well defined. Many children, left alone (parents who come home late, do not cook or do not cook often, the refrigerator is self-serve, pocket money is available, etc.) will eat chocolaty cookies, ice cream, French fries, kebabs, etc. at any time of day. Sometimes these meals are not large and do not affect the child’s weight. In other cases, they lead to dietary anarchy, a veritable nutritional chaos resulting in either weight gain then obesity, or elimination habits (vomiting, fasting, meals skipped, etc).
CONCLUSION
As we have seen, children aged 6 to 12 years are not exempt from eating disorders. Physicians play an essential preventive role. They must be watchful not to prescribe excessive diets, to explain to parents and children alike the risks of dietary restriction during growth, not to put too high a value on being thin and to temper some demands to lose weight. And in all cases, to encourage families to sit down to pleasant and friendly meals.
Dr. Marie-France Le Heuzey
Hôpital Robert Debré, AP-HP (Parisian Public Hospitals Network), Paris
Hôpital Robert Debré, AP-HP (Parisian Public Hospitals Network), Paris
Bibliography
–Davidson KK, Birch LL : Weight status, parent reaction and self concept in five-year-old girls Pediatrics, 2001, 107 ; 46-53
–Le Heuzey MF : L’enfant anorexique [The anorexic child] – Edit. Odile Jacob Paris 2003
–Le Heuzey MF, Mouren Simeoni MC : Does bulimia exist in children? AnnMed Psychol 1999 ; 157, 717-720
–Davidson KK, Birch LL : Weight status, parent reaction and self concept in five-year-old girls Pediatrics, 2001, 107 ; 46-53
–Le Heuzey MF : L’enfant anorexique [The anorexic child] – Edit. Odile Jacob Paris 2003
–Le Heuzey MF, Mouren Simeoni MC : Does bulimia exist in children? AnnMed Psychol 1999 ; 157, 717-720
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