[A Comprehensive Care System for Children with Anorexia Nervosa in Pediatric Practice]

Against the backdrop of rapid industrialization and westernization after the World War II, there has been an ever increasing number of children with anorexia nervosa (AN) in pediatric practice, making it one of the most common diseases in children. With a severe lack of AN specialists in Japan, pediatricians need to face the daunting task of treating AN on their own. Malnutrition overlooked during periods of growth and development yields a risk of death, growth disturbance and an intractable conditions with secondary disorders of brain atrophy, osteoporosis, infertility, maltreatment and childrearing failures, mental disorders and others, which can last for life. Prevention is the best and a must for AN, and an early detection and treatment need to be in place to mitigate its progress and aggravation. It is crucial that an effective care is provided in early, treatable stage to assist the patient back to a healthy developmental trajectory. In 1993, the Department of Pediatrics, School of Medicine, Keio University (hereafter PKU) appointed a child psychiatrist as its fulltime staff and has included inpatient treatment of AN as a compulsory item of its postgraduate training program. Over the past twenty years, PKU has developed a comprehensive treatment system of AN (Scientific Report of Ministry of Welfare and Labor 2006). In the primary care of AN, a screening tool using simple physical measurement of weight on growth chart combined with pulse proves effective. When a weight on growth chart reveals an unhealthy weight loss and is combined with bradycardia, it detects AN at sensitivity of 83% and specificity of 93%. In the secondary care of AN, 40 pediatric institutions affiliated with PKU implemented early treatment of AN with the support of the Mental Health Division of PKU. In the tertiary care for severely emaciated AN patients, an around-the-clock intensive treatment program, called Anorexia Nervosa Intensive Care Unit (ANICU) was instituted. The gist of ANICU is to enhance the patient's awareness of the danger of catabolism and her incentive to overcome AN through active commitment to the treatment. This treatment program harbors principles of integrity, structure and persistence; starting with a complete bed rest and regular small-step provision of nutrition and steady enhancement of daily activities, it steadily and systematically converts the body's metabolism from catabolism to anabolism. In this treatment program, more than one hundred patients' lives were saved without a single fatal case. Trainees in PKU were provided with firsthand experience of providing comprehensive care, including taking on a role of feeding the AN patients three times a day. Around three hundred trainees were trained at PKU over the past twenty years, many of whom now treat AN in their affiliated hospitals. This collaborative care, comprised of a pediatric team, family and school, supported by a specialist, will become the most reliable way of treating AN in the coming days. We hope to decrease the sufferings of children with AN through spreading this comprehensive care system for children with AN in Japan.