20.3 Medical Complications of Eating Disorders, Substance Use Disorders & Acute Behavioral Stabilization
Key Takeaways
Bradycardia, important electrolyte or ECG abnormalities, and other signs of instability can justify hospitalization at any weight.
AAP and SAHM use different adolescent pulse-rise thresholds. Check the measured changes and the whole clinical picture before choosing disposition.
Correct fluid and electrolyte losses and individualize supervised refeeding. Monitor phosphorus, magnesium and potassium, especially in the first days.
Treat clinically significant stimulant intoxication and alcohol or sedative withdrawal with cause-specific care. Give thiamine when indicated without delaying emergency glucose.
Support ventilation during opioid overdose, give naloxone when indicated, and start CPR if pulseless. Monitor for recurrence and arrange ongoing treatment and take-home naloxone.
Medical Complications of Eating Disorders and Adolescent Substance Emergencies
Quick Answer: Admit for medical stabilization when restrictive eating or purging causes clinically important vital-sign, ECG or electrolyte abnormalities, even at a higher weight. Restore perfusion and electrolytes and start supervised, individualized refeeding with serial phosphorus, magnesium and potassium. In substance emergencies, stabilize breathing, circulation, glucose and temperature first. Use the exposure and examination to distinguish intoxication, withdrawal and other illness. Follow recovery with confidential screening, treatment and referral.
Assess medical instability in an eating disorder
Review the growth curve, amount and pace of weight loss, oral intake, exercise, vomiting, laxatives and diuretics. Ask about syncope, palpitations, food refusal and suicide risk. Obtain orthostatic vital signs when safe, ECG, glucose, electrolytes including phosphorus and magnesium, and renal function. Calculate percent median BMI as the patient's BMI divided by the median BMI for age and sex, multiplied by 100. Atypical anorexia nervosa may be medically severe after substantial weight loss despite a BMI in or above the expected range. Avoidant/restrictive food intake disorder (ARFID) can produce growth failure and nutrient deficits without weight- or shape-driven restriction. AAP clinical report · SAHM position paper
| Findings supporting hospitalization | Examples from the SAHM position paper |
|---|---|
| Severe malnutrition or physiologic instability | At or below 75% median BMI, daytime HR below 50 or nighttime HR below 45 beats/min, BP below 90/45 mmHg, or temperature below 35.6°C |
| Orthostatic change in an adolescent under 19 years | Sustained HR rise above 40 beats/min, systolic BP drop above 20 mmHg or diastolic drop above 10 mmHg. The 2021 AAP report lists a pulse rise above 20 beats/min. Use the named guidance and clinical context. |
| Cardiometabolic complications | Dehydration, clinically important hypokalemia, hyponatremia or hypophosphatemia, prolonged QTc or other concerning ECG finding, syncope, seizures or heart failure |
| Feeding, growth or psychiatric safety concerns | Acute food refusal, uncontrollable bingeing or purging, arrested growth, unsuccessful outpatient care, or a psychiatric or medical condition that makes outpatient care unsafe |
One factor can justify hospitalization. Choose the level of care from the combined medical findings, psychiatric risk and available supports. For example, in an adolescent with resting HR 48, potassium 2.8 mEq/L and an 18 mmHg systolic fall on standing, the bradycardia and hypokalemia justify stabilization even though the fall does not exceed the SAHM systolic cutoff.
Correct purging-related fluid and electrolyte losses
Vomiting causes gastric hydrogen and chloride loss. Volume contraction activates the renin–angiotensin–aldosterone system, maintaining alkalosis and increasing renal potassium loss. A typical result is hypokalemic, hypochloremic metabolic alkalosis. Laxative-induced diarrhea can instead cause bicarbonate loss and non-anion-gap acidosis. Check ECG and renal function, replace potassium chloride as indicated, and correct magnesium if low. Assess whether volume replacement is needed. With hypovolemia, use carefully reassessed isotonic fluid and monitor for overload. Chronic purging can leave persistent aldosterone activity and cause edema after purging stops. Shock still requires immediate resuscitation and escalation. AAP eating disorder report · Children's Healthcare of Atlanta ED pathway · APA eating disorder practice guideline
Refeed with monitoring and adjust to the response
- Use trial results in the studied population. In StRONG, hospitalized patients aged 12–24 with anorexia nervosa or atypical anorexia nervosa and at least 60% median BMI received either 2,000 kcal/day advancing by 200 daily or 1,400 kcal/day advancing by 200 every other day. With baseline abnormalities corrected and serial monitoring, the higher-calorie group stabilized earlier without an increase in observed electrolyte abnormalities. The trial excluded extreme malnutrition below 60% median BMI and did not study ARFID. Individualize the initial prescription for severe depletion, prolonged very low intake or significant electrolyte abnormalities with adolescent medicine and dietetics.
- Prevent and detect refeeding complications. Obtain baseline phosphorus, magnesium and potassium and trend them during early refeeding. ASPEN suggests every 12 hours for the first three days in high-risk pediatric patients, with more frequent checks as needed. Replace deficits and reassess caloric advancement if levels fall precipitously or are hard to correct. Use cardiorespiratory monitoring for instability or severe deficits. Give thiamine before planned nutrition or dextrose-containing fluids when refeeding risk is high. Treat emergency hypoglycemia promptly.
- Support intake and recovery. Use supervised meals, supplements and a standardized weight and intake record. Consider nasogastric nutrition if the oral plan fails or intake is unsafe. Set activity and observation according to medical stability and purging risk. Coordinate discharge with caregivers, nutrition and mental health teams. Family-based treatment is a first-line outpatient option for adolescents with anorexia nervosa.
StRONG randomized trial · SAHM position paper · ASPEN pediatric refeeding consensus · Johns Hopkins All Children's stabilization pathway
Identify and manage the substance emergency
After stabilization, ask privately about last use, frequency, route, amount, prescribed drugs, counterfeit products and co-ingestants. Screening, brief intervention and referral to treatment (SBIRT) can connect youth to care. S2BI uses past-year frequency by substance to stratify risk. CRAFFT 2.1 uses past-year frequency questions followed by consequence and risk questions. A score of at least two prompts further assessment. CRAFFT 2.1+N adds nicotine questions. Use the screen to guide a conversation and diagnostic assessment. AAP SBIRT report · S2BI validation · CRAFFT instruments
| Presentation | Acute care decision |
|---|---|
| Cannabinoid hyperemesis | Repeated severe vomiting after frequent cannabis use may improve temporarily with hot bathing, which is a clue rather than a diagnosis. Assess other causes, correct fluid and electrolyte losses and support sustained cessation. Topical capsaicin or haloperidol can be considered for selected persistent symptoms. Pediatric evidence is limited. Review QT risk, electrolytes and dystonia risk before a dopamine antagonist. |
| Vaping-associated lung injury (EVALI) | Recent vaping with respiratory symptoms, sometimes fever or GI symptoms, and bilateral opacities raises concern. Ground-glass opacities are nonspecific. Give oxygen as needed. CDC recommends admission for room-air SpO2 below 95% or respiratory distress, with context such as altitude and baseline pulmonary reserve. Investigate and treat infection when indicated. In hospitalized patients with severe suspected EVALI, consider corticosteroids with pulmonary or infectious disease input. Infection risk can change the timing. Counsel on vaping cessation. |
| Stimulant intoxication | Agitation, tachycardia, hypertension, sweating and hyperthermia may accompany arrhythmia, ischemia or rhabdomyolysis. Use benzodiazepines for significant hyperadrenergic toxicity and active cooling for dangerous hyperthermia. Assess persistent severe hypertension or chest pain urgently with toxicology and cardiology. Use cause-directed treatment for vasospasm or hypertensive emergency. For pediatric cocaine-induced coronary vasospasm or hypertensive emergency, AHA recommends against beta blockers. For persistent hyperadrenergic signs in other stimulant intoxication, ASAM/AAAP conditionally discusses agents with combined alpha-1 and beta blockade after initial treatment, with specialist input. |
| Alcohol or sedative withdrawal | Tremor, diaphoresis, agitation and autonomic activation can progress to seizures or delirium. Review timing, baseline exposure and co-ingestion. Use a pediatric pathway for monitored benzodiazepine therapy and an individualized taper when indicated. CIWA-Ar can support alcohol withdrawal monitoring in a patient able to participate. It relies on self-report and is unsuitable in delirium. Give thiamine when indicated, particularly with poor nutrition or severe alcohol withdrawal, without delaying urgent glucose. |
| Opioid overdose | Slow or absent breathing, depressed consciousness and often miosis suggest opioid toxicity. With a pulse, ventilate immediately and give naloxone for suspected opioid respiratory arrest. If pulseless, start CPR. Observe after reversal and offer treatment for opioid use disorder. |
Vitamin E acetate was strongly associated with the 2019 EVALI outbreak. Exposure history supports the differential without identifying the inhaled toxicant in an individual patient. When EVALI and pneumonia are both possible, begin respiratory support while evaluating both. CDC EVALI guidance · EVALI bronchoalveolar lavage study · Adolescent hyperemesis case series · AHA 2025 life-threatening poisoning guidance · ASAM/AAAP stimulant guideline · CHOP adolescent withdrawal pathway · ASAM alcohol withdrawal guideline
Opioid reversal, treatment and confidentiality
- Opioid reversal and observation. Start assisted ventilation for inadequate breathing with a pulse. Give naloxone without delaying ventilation. For a pulseless child, start CPR and follow the pediatric arrest algorithm. Observe after reversal until mental status and vital signs are normal and recurrent respiratory depression is unlikely. Co-ingestion, a long-acting formulation or repeat naloxone can change the observation plan. AHA 2025 opioid guidance
- Buprenorphine initiation. After stabilization, offer or arrange treatment for opioid use disorder. Buprenorphine is a partial µ-opioid receptor agonist. Assess sustained objective withdrawal and recent fentanyl or other opioid exposure before choosing an induction strategy. Withdrawal scores guide the assessment. Buprenorphine can precipitate withdrawal, so individualize induction and follow-up with the local pediatric pathway or addiction team. Provide take-home naloxone and teach how to respond to overdose. ASAM fentanyl considerations · Pediatric ED case reports
- Consent and information sharing. Stabilize an emergency promptly when a minor cannot consent and a guardian is unavailable. Discuss confidentiality and its limits. State law and the type of care determine minor consent and caregiver access. Federal 42 CFR Part 2 adds protections for records from covered substance use disorder programs and specifies circumstances for emergency disclosures. Discuss what must or may be shared with the team under applicable law and involve supportive adults when safe and permitted. AAP adolescent confidentiality policy · HHS Part 2 guidance · 42 CFR Part 2
A 15-year-old with restrictive eating and daily vomiting has dizziness and weakness. BMI is 82% of median for age and sex. Supine HR is 48 beats/min and BP is 88/52 mmHg. Standing HR is 74 and BP is 70/44. Temperature is 35.9°C, potassium 2.8 mEq/L, chloride 88 mEq/L and bicarbonate 34 mEq/L. Which initial plan is appropriate?
Admit for monitored medical stabilization, assess perfusion and replace potassium chloride. Check phosphorus and magnesium and start a supervised refeeding plan after initial correction.
Use outpatient management based on BMI above 75% of median and recheck potassium after a week.
Give an automatic 40 mL/kg saline bolus and propranolol for the rise in standing heart rate.
Give IV bicarbonate for the elevated bicarbonate concentration and defer nutrition until all orthostatic symptoms resolve.
A 17-year-old with daily THC vaping presents after three weeks of worsening dyspnea, cough, fever and nausea. Room-air SpO2 is 86%. Chest CT shows bilateral ground-glass opacities with areas of subpleural sparing. Infectious testing is pending. Which initial approach is appropriate?
Diagnose cannabinoid hyperemesis, treat vomiting and discharge after a successful oral fluid challenge.
Assume bacterial pneumonia is established by the CT and defer oxygen until the culture results return.
Suspect vaping-associated lung injury, give oxygen and admit. Evaluate for infection and consider corticosteroids with specialist input based on severity and infection risk.
Confirm vaping-associated lung injury from the CT pattern and give corticosteroids as the sole treatment.
A 17-year-old with opioid use disorder was found apneic with a pulse and pinpoint pupils. EMS provided bag-mask ventilation and intranasal naloxone. In the ED he is awake, diaphoretic and yawning, with a COWS score of 10. He requests help stopping fentanyl use. Which is the safest next step?
Discharge once he is awake because successful reversal rules out recurrent respiratory depression.
Give a prophylactic naloxone bolus despite adequate breathing and defer opioid use disorder treatment.
Use the initial COWS score alone to trigger standard buprenorphine induction and discharge immediately.
Observe for recurrent respiratory depression. Reassess objective withdrawal and fentanyl exposure, plan individualized buprenorphine initiation and follow-up, and provide take-home naloxone.
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