What is the appropriate evaluation and management for an 11-year-old girl with a recent 11lb weight loss, easy bruising, and no change in appetite or energy level?

Evaluation and Management of 11-Year-Old Girl with 11lb Weight Loss and Easy Bruising

This child requires urgent comprehensive evaluation for both an eating disorder and a bleeding disorder, as the combination of significant weight loss (approximately 5kg in a pre-adolescent) with easy bruising and preserved appetite/energy is highly concerning and demands immediate laboratory workup and specialist referral. 1

Immediate Assessment Priorities

Growth Chart Analysis

• Plot current weight, height, and BMI on CDC growth charts immediately to assess for rapid decline across percentiles, which is a critical indicator even if absolute values remain above the 5th percentile 1, 2
• An 11lb weight loss in an 11-year-old represents a clinically significant drop that warrants urgent evaluation regardless of current percentile position 1
• Compare current measurements with all available previous data points to identify the trajectory and velocity of weight loss 1, 2

Critical History Elements

For Eating Disorder Assessment:

• Specifically ask about severe dietary restriction (<500 kcal/day), meal skipping, self-induced vomiting, use of diet pills/laxatives/diuretics, and compulsive exercise 3
• Assess for body image distortion, fear of weight gain, social isolation, and irritability—these psychological symptoms are high-risk indicators 3
• The preserved appetite and energy level are atypical for most eating disorders but do not exclude them, particularly early presentations or atypical variants 3

For Bleeding Disorder Assessment:

• Obtain detailed bleeding history including significant bleeding after surgery, dental procedures, circumcision, or minor trauma 3, 4
• Document all medications including NSAIDs, anticoagulants, antiplatelets, and corticosteroids that can affect bleeding 3, 4
• Assess family history for specific bleeding disorders and ethnicity associated with higher rates of certain conditions 3, 4

Physical Examination Findings to Document

Vital Signs (Critical for Eating Disorder):

• Bradycardia (heart rate <50 beats/minute during day), hypotension (<90/45 mmHg), hypothermia (body temperature <96°F), and orthostasis (pulse increase >20 with position change) 3
• These findings indicate vital sign instability requiring immediate specialized eating disorder center referral 1

Bruising Pattern Assessment:

• Document location, size, and pattern of all bruises—bruising on buttocks, ears, trunk, or neck is more concerning than extremity bruising 3
• Examine for other skin findings and signs of bleeding disorders 3, 4
• Assess for blue sclerae (osteogenesis imperfecta), sparse kinky hair (Menkes disease), or other syndromic features 3

Mandatory Laboratory Workup

Initial Screening Panel

For both eating disorder and bleeding disorder evaluation, obtain:

• Complete blood count with platelet count and peripheral blood smear 3, 4, 1
• Comprehensive metabolic panel (electrolytes, renal function, liver function) 1
• Prothrombin time (PT) and activated partial thromboplastin time (aPTT) 3, 4
• If easy bruising or bleeding problems are present, add: platelet function study and von Willebrand screen 3, 4
• Thyroid function tests 1

Critical caveat: PT and aPTT do not reliably detect von Willebrand disease, factor XIII deficiency, or platelet function disorders—if clinical suspicion remains high despite normal results, specialized testing is necessary 4

Additional Testing Based on Initial Results

• If PT or aPTT abnormal: fibrinogen level 4
• Consider serum calcium, phosphorus, alkaline phosphatase, parathyroid hormone, and 25-hydroxyvitamin D if metabolic bone disease suspected 3
• Fasting glucose, glycated hemoglobin, and lipid profile for metabolic assessment 1
• Consider celiac disease screening (tissue transglutaminase antibodies) given weight loss 1

Specialist Referral Algorithm

Immediate Referral to Eating Disorder Center (Same Day/Next Day)

Required if ANY of the following:

• Vital sign instability present 1
• BMI below 5th percentile with any eating disorder behaviors 1
• Rapid weight loss with psychological symptoms 1
• Severe dietary restriction or other high-risk eating behaviors identified 3

Urgent Pediatric Hematology Referral (Within 1 Week)

Required if:

• Abnormal CBC, platelet count, PT, or aPTT 3, 4
• Positive von Willebrand screen or abnormal platelet function studies 4
• High clinical suspicion despite normal initial workup 4
• History of significant bleeding episodes 4

Registered Dietitian Referral

• All children with significant weight loss require personalized feeding plan development 1
• Family-centered motivational interviewing is more effective than simple dietary advice 3, 1

Management Strategy

If Eating Disorder Suspected

• Do not delay referral for complete workup—early diagnosis and intervention are associated with improved outcomes 3
• Eating disorders are best managed by multidisciplinary teams with pediatrician as important member 3
• Serial weight measurements every 1-2 weeks initially to track trajectory 1

If Bleeding Disorder Identified

• Before any surgery (including dental procedures), ensure complete coagulation screening if not already done 3
• Refer to hematologist for abnormal results and management guidance 3, 4

If Initial Workup Normal

• Do not assume this excludes pathology—preserved appetite and energy with significant weight loss may indicate occult malignancy, inflammatory bowel disease, or atypical eating disorder presentation 1
• Schedule close follow-up with serial measurements every 2-4 weeks 1
• Consider additional screening for inflammatory bowel disease, malabsorption, or endocrine disorders 1

Common Pitfalls to Avoid

• Do not assume normal platelet count excludes all platelet disorders—qualitative platelet defects require specialized testing 4
• Do not perform extensive bleeding disorder testing without clinical indication if bruising pattern is typical for active child with no bleeding symptoms 3
• Do not delay eating disorder evaluation because appetite and energy are preserved—atypical presentations occur 3, 1
• Do not overlook medication effects on bleeding tendency or weight 3, 4
• Do not assume reassuring family history excludes bleeding disorders—many are de novo mutations 3