The management of unwell young people with eating disorders A review of (most) current guidelines Lee Hudson Clinical Fellow Gen Paeds and Adol Medicine, UCLH Dr Fermeda Mahomed SPR in Child and Adolescent Psychiatry, Great Ormond Street

NSW Eating disorder handbook MARSIPAN draft American Psychiatric Assocation Guideline for the treatment of patients with eating disorders American Academy of Paediatrics Guidelines Nottingham University NHS trust guideline for early recognition, assessment and initial management of eating disorders in children and young people. Finnish Guidelines for management of eating disorders in children and young people Aus NZ clinical practice guidelines for the treatment of anorexia nervosa NHS Scotland management and treatment of eating disorders NICE : Eating disorders (over 8 yrs) Guidelines for the nutritional management of anorexia nervosa Royal College of Psychiatrists London, October 2004

Who should be involved? Which weight indicator used to diagnose, monitor, treat based-upon, target with. Initial work-up and assessment Medical complications to look for Criteria for admission Inpatient management : where, who? Feeding regime – how much, how Refeeding syndrome : monitoring, preventing, treating. When to discharge General points about admissions

Which multidisciplinary team members or domains should be involved in the management of young people with eating disorders? Psychiatrist 9 Extended psychiatric team : eg psychologist / family therapy/art 7 Social worker 2 Pharmacist 1 Occupational therapist 2 Specialist nursing 2 Physiotherapist 2 Dietician 7 Physician /GP or paediatrician 8

Good communication between all involved vital (3) Involve those in school (2) Paediatrician can be leader (AAP) Paediatrician and physician should have a special interest preferably and skills (MARSIPAN and NICE)

Which weight indicator Weight for height / Centile charts (4) Ideal body weight (2) Weight (4) Growth / rate of loss (5) Body Mass Index (7) : caution in childrena and adol (1) Healthy weight range (1)

Risk factors weight by BMI in MARSIPAN High risk <13 Med risk Anorexia <17.5

Ultimate aim of weight restoration and target weights Menstruation (4) Pre-menarche 100 % IBW or normal BMI and Post-menarchal 90% IBW (significant chance of achieving menstruation) All ages 90% IBW (2) BMI (1) “Average weight for age” Previous charts (2) Mid-parental heights, bone age (1) Healthy growth (1) Normal hormonal profile (1)

Approach to exercise Look for it as a problem (6) Gradual increase / program (3) Only when reached a healthy weight (1)

Initial work-up for diagnosis and assessment Electrolytes (6) Blood gas (2) TSH (4) FBC (3) Coeliac screen (1) Oestrogen and gonadotrophin : yes (1) ; consider (1) ; if persists after weight restoration (1) MRI for differential diagnosis (1) ECG (5) Urinalysis (4) – including pregnancy LFT (1)

Things to generally monitor at clinic assessments Weight (6) – post void (1) Pulse (6) BP (4) – lying and standing (3) Rate of weight gain (5) Dietary intake (3) Pubertal staging (4) Dehydration assessment (3) Psychiatric ongoing issues (2)

Medical complications of AN HR, BP (7) – do ECG if so (3) Dehydration (6) –avoid IV unless shock (1) Cardiac function (4) Hypokalaemia (9)–IV < 2.5 (1) ;ECG (2)oral(4) Hypophosphataemia (3) – use oral (1) Hypoglycaemia (4) Hypomagnesaemia (2) – correct IV <0.6 Alkalosis (4) Hyponatraemia (4) - <125 (1) ; slow correct (1)

Thyroid (3) Weakness (2) Hair loss (6) Gastric motility / constipation (5) Vomiting complications (4) Liver dysfunction (3) Anaemia (6) – check Iron and folate (3) Vitamin B deficiency (2)

Hypothermia (5) ; risk of infection (2) Osteopaenia (6) – reduce activity (1) Dental (7) – refer (5) ; cleaning advice (3) Pubertal development (1) Psychiatric co-morbidities (6)

Management / investigating bone density DEXA if amenorhoea > 6 months (3) Baseline every 2 years (1) Monitor and consider referral (1) >12 months of BMI < 15, calcium < 600mg / day Consider pelvic USS and bone age (1) NICE : avoid oestrogen if possible

Criteria for admission

Criteria for admission : PULSE Check but not specified (1) <40 adults ; < 50 children <40 (1) 100 ; >206 standing <50 day ; <45 night (2) Not specified at all Increase in pulse > 110 on standing (1)

Criteria for admission : BP Systolic < 90 Systolic < 80 < 80 / 50 (2) <70/40 Systolic <70 Increase on standing > 20 Postural drop > 10 Postural drop > 15 Postural drop >= 20

Criteria for admission : WEIGHT LOSS Rapid (6) - > 1kg / week (1) BMI < 13 (2) BMI < 14 <5 % centile for weight Adults < 85% estimated weight <70% IBW (2) <70% weight for height Body fat < 10% Previous growth charts

Dehydration (2) – moderate or severe (1) Electrolytes (7) Psychiatric causes / risks (9) Uncontrolled anorexic symptoms (6) Failure of outpatient (5) Family or social reasons (3 Hypothermia (5) Weakness (1) ECG Abnormalities (2) Other medical complications – pancreatitis, seizures etc (1) Other medical complication (DM, preg) (1)

Management as an inpatient Avoid general paediatric wards (1) Last resort where possible (1) Day case where possible (2) Service dependent (3) – ie whether inpatient psych or medical inpatient MARSIPAN highlights advantages and disadvantages of both and highlights different skill sets and need for mutual support

Feeding regime kcal /day 1 st week Aim 0.5-1kg / week (3) kcal / day kcal / day kcal / day (more in males) 20 kcal/kg/day (MARSIPAN) BUT 5-10 kcal/kg/day in severe / high risk Dietician to decide (3) ; advise (2) Avoid TPN (1)

NG or oral? Dietician driven (2) Specifically no recommendation (3) NG if life threatening (1) Rarely required (1) Not mentioned (1) Continuous if unwell at first (2), slow at first (2).

Blood tests / re-feed syndrome Perform whilst feeding (5) Daily electrolyte (2) : ECG daily (1) or just ECG (1) Twice daily (MARSIPAN) if high risk NSW : nothing for 7-10 days orally high risk Very low weights, existing biochem probs (1) Phosphate supplements standard (5) ; if re-feeding syndrome occurs (3) Thiamine, multivitamin (2) Slow down feeds or stop (3) Under-feed syndrome (MARSIPAN) Oedema and differentiate cardiac failure (1)

Discharge As close to normal weight as possible (2) Rapid and aggressive treatment better (1) All discharge criteria should be considered collectively prior to discharge (MARSIPAN) Transfer to mental health unit as soon as is possible (MARSIPAN).

Day-to-day general care Weighing frequency twice / week (2) ; 3 x per week max (1) After voiding (2), before breakfast (1) Less restrictive better (1) Incorporate food preferences / ethnicity (3) Clear rules and documentation (3) Involve other units to share skills (MARSIPAN and NICE). MARSIPAN : Modified Newcastle – bedrest, supervised showering and toilets

Legal framework (3) Inform parents / good communication (4) Careful with psychotropic dosing in low weight (4) Discussion of meds that can be used (4)