Medical Assessments in Adolescence Junior MaRSiPAN Dr Mark Anderson

Background 0.5% of adolescent females have anorexia nervosa 1-5% of adolescent females have bulimia nervosa 5-10% of eating disorders occur in males Early recognition and intervention are thought to improve outcome

Whose problem is it? Psychiatric disorder Significant physical issues Starvation Growth Re-feeding syndrome Long term sequelae Acute medical issues Safety in community Multi-disciplinary approach

What can paediatricians offer? Medical assessment Junior MaRSiPAN Determine “risk” Investigations Admission At risk Medical complications Risk of re-feeding syndrome Break the cycle, relieve pressure

Newcastle routes of referral CYPS (CAMHS) GP Emergency department Mostly via myself

Initial assessment Full history and medical assessment Blood tests and ECG Risk assessment according to Junior MaRSiPAN Management of Really Sick Patients with Anorexia Nervosa (Junior!)

Junior Marsipan Risk Assessment Semi-objective Aims to give an overall assessment of risk It is not: A scoring system Validated to predict need for admission, specific management or outcome Needs to be seen as part of the gestalt of assessment

Measurements Percentage median BMI Recent weight loss >85% 80-85% 70-80% <70% Recent weight loss No change Up to 500g/week for 2 weeks 500-999g/week for 2 weeks >1kg for 2 weeks

Cardiovascular 1 Heart rate (awake) Cool peripheries >60 bpm

Cardiovascular 2 Blood pressure Syncope Normal <2nd centile <0.4th centile Syncope No symptoms Presyncopal symptoms Occasional syncope with postural drop in BP Recurrent syncope with marked postural drop

Cardiovascular 3 Arrhythmia ECG changes Normal Irregular heart rhythm QTc <450ms QTc <450ms and taking QT prolonging medication QTc >450ms QTc >450ms and evidence of arrhythmia or electrolyte disturbance

Other physiological parameters Hydration Not dehydrated Mild dehydration Moderate dehydration or peripheral oedema Severe dehydration Temperature <36°C <35°C

Biochemical abnormalities Hypophosphataemia Hypokalaemia Hyponatraemia Hypocalcaemia Severe abnormalities of above

Calorie intake Moderate restriction or bingeing Severe restriction (<50% of requirement) Purging Acute food refusal or <600kcal/day

Activity & exercise No uncontrolled exercise Mild uncontrolled exercise (<1h/day) Moderate uncontrolled exercise (1-2h/day) Severe uncontrolled exercise (>2h/day)

Muscular weakness SUSS test No difficulty Unable to get up without noticeable difficulty Unable to get up without using arms Unable to get up at all

Engagement with management plan Some insight and motivation, not ambivalent Some insight and motivation, but ambivalent Poor insight and motivation; parents unable to implement meal plan Violent when parents try to implement plan; parental violence

Co-morbidities Deliberate self harm Suicidal ideation Other major psychiatric co-diagnosis

Outcomes of medical assessment Mostly blue-green, no red Outpatient follow-up More amber, or some red Admission for period of assessment No definite “admission criteria”

Admission Decision re: feeding method Dietitian input – daily Set nursing guidance – obs, bed rest, “rules” Make plan with YP (and family) Daily review – close medical monitoring Regular input from CYPS Plan discharge

What we have learnt… AN is very difficult The illness makes it hard Staff often feel manipulated Nursing time is a major issue 16-18 year olds fall through the gaps

Longer term issues General health Bone health

Bones Low bone mineral density Critical time Risk of later osteoporosis Back pain Chronic ill health

Bones Nutrition Hypogonadism Relative hypercortisolaemia Low IgF1 Weight and nutrition improve BMD Residual defect left

Bones Possible options OCP (high dose OE) Bisphosphonates Low dose OE Transdermal OE Calcium/Vitamin D

Toronto study 2011 Randomised placebo controlled study 40 girls normal weight - controls 110 girls AN – randomised OE + OE – OE transdermal 100mcg patch twice weekly OR escalating doses of oral OE 3.75mcg daily increasing over 18 months OE + given medroxyprogesterone 2.5 mg daily for 10 days every month OE – placebo patch and placebo medroxyprogesterone Controls followed for 18 months no intervention ALL had calcium carbonate and Vit D

Results BMD change

Results No change in weight No change in lean body mass No change in percentage fat mass No change in BMI No change in IgF1

Recommendations DEXA scan Commence OE replacement ?when Who should do this/monitor progress What happens >18 years of age What about the boys?

Conclusions Acute management Good liaison Easy for <16 year old Need to support 16-18 year olds Long term input Bones and future health

Questions?

Junior MARSIPAN: MAnagement of Really Sick Patients under 18 with Anorexia Nervosa College report CR 168, January 2012 RCPSYCH Norrington, Stanley, Tremlett, Birrell. Medical management of acute severe anorexia nervosa Arch Dis Child Educ Pract Ed 2012;97:48-54 Physiologic Estrogen Replacement Increases Bone Density in Adolescent Girls With Anorexia Nervosa. Misra M, Katzman D, Miller K , Mendes N, Snelgrove D, Russell M, Goldstein, Ebrahimi M, Clauss L, Weigel T, Mickley D, Schoenfeld D , Herzog D, Klibanski A. Journal of Bone and Mineral Research, Vol. 26, No. 10, October 2011, pp 2430–2438