[The role of a pediatric endocrinologist in diagnostics and therapeutic management of anorexia nervosa--own experiences and review of literature].
BACKGROUND
Anorexia nervosa and bulimia nervosa are counted among psychosomatic diseases, whose incidence has been rapidly increasing in the last decades. To date, the etiology, diagnostic and therapeutic management of eating disorders have not been uniformly determined. The objective of the study is determination of the role of a pediatric endocrinologist in diagnostics and management of eating disorders.


METHODS
In the years 1992-2007 in Department of Pediatric and Adolescent Endocrinology Chair of Pediatrics, Polish-American Institute of Pediatrics, Collegium Medicum, Jagiellonian University in Krakow, Poland were hospitalized 164 patients with suspected anorexia nervosa, aged 9-20 years, 150 girls, and 14 boys. All girls were included in psychological and dietetic treatment. Additionally, in group of 36 girls, the 3-years observation of bone mineralization changes was performed.


METHODS
The indications for hospitalization included the assessment of nutritional status, particularly electrolyte imbalance, cardiovascular complications and nutritional treatment. II. Procedure included on department: 1) Correction of general children's state. 2) Monitoring of cardiovascular system disorders. 3) Nutritional treatment. 4) Differential diagnosis. III. Prevention and treatment of late complications was performed in group of 36 girls. In this group, every 6 months were evaluated: body mass index, duration of secondary amenorrhea, serum sex hormone, IGF-I and cortisol levels and 24-hour urine cortisol. Spine densitometry in the AP projection was performed every 12 months, using a Lunar unit (DEXA). The pharmacological treatment of osteoporosis was introduced in girls with duration of secondary amenorrhea lasted for more than 6 months, with decreased bone mineralization BMD < (-) 1SD and body mass deficit < 20%. 16 girls which did not presented disorders of bone mineralization, or refused treatment have not got the pharmacological treatment, while in 20 girls the pharmacological therapy (calcium and vitamin D3 supplementation and hormonal treatment - Estraderm TTS and Provera 5 mg) was provided.


RESULTS
Anorexia nervosa was diagnosed in 150 cases, bulimia in 6 cases, in 2 children was diagnosed celiac disease, in 2 patients adrenal insufficiency, in 1 girl myasthenia, in 1 girl diabetes mellitus type 1, in 1 boy hypothalamo-pituitary tumor and in 1 boy psychosis was diagnosed. The nutritional improvement was evaluated in group of 36 girls, which continued treatment in time 3 years. At the beginning of the observation period the mean value of the body mass index (BMI) was 15.95 kg/m2, and after 36 months of the treatment the mean BMI value was 20 kg/m2. Before the treatment one patient was still menstruated despite her body mass loss, 8 girls were pre-menarche, and the remaining 27 patients had secondary amenorrhea of the mean duration of 11.14 months. In the initial period of the follow-up, all the anorectic patients demonstrated a decreased bone mineral density. Before treatment the median Z score in the entire experimental group was (-)1,2 SD whereas after 3 years of treatment value of Z score decreased by 0,5 SD in group of 16 girls without the pharmacological treatment and increased by 0,5 SD in 20 girls on pharmacological treatment. The significant, negative correlation between secondary amenorrhea and Z score value was observed.


CONCLUSIONS
The role of a pediatrician in therapeutic management of eating disorders is intervention in life-threatening conditions, treatment of acute complications, differential diagnosis, nutritional treatment, prevention and management of late complications. Because of etiology and special way of treatment the management of anorexia nervosa should have been taken by psychiatrist. The duty of endocrinologists and gynecologists is the late complications treatment, such as an amenorrhea and osteoporosis.
Roztoczyńska
Dorota
D
Klinika Endokrynologii Dzieci i Młodziezy, Katedry Pediatrii, Polsko-Amerykański Instytut Pediatrii, Uniwersytet Jagielloński Collegium Medium w Krakowie.
Starzyk
Jerzy
J
D000293:Adolescent; D000328:Adult; D017677:Age Distribution; D000568:Amenorrhea / Q000175:diagnosis / Q000209:etiology / Q000517:prevention & control; D000856:Anorexia Nervosa / Q000150:complications / Q000175:diagnosis* / Q000453:epidemiology / Q000628:therapy*; D015519:Bone Density; D052018:Bulimia Nervosa / Q000150:complications / Q000175:diagnosis / Q000628:therapy; D002446:Celiac Disease / Q000175:diagnosis; D002648:Child; D003937:Diagnosis, Differential; D004704:Endocrinology; D005260:Female; D006801:Humans; D015994:Incidence; D008297:Male; D009752:Nutritional Status; D010024:Osteoporosis / Q000175:diagnosis / Q000209:etiology / Q000517:prevention & control; D010372:Pediatrics; D011044:Poland / Q000453:epidemiology; D010818:Practice Patterns, Physicians'; D055815:Young Adult