Dr Polly Powell | Dr Simon Chapman
This latest bit of guidance is on eating disorders, and is a collaboration between Polly Powell and reviewed by Simon Chapman, Consultant at King’s College Hospital and all-round good egg. It’s genuinely essential reading for paediatricians.
When to think about eating disorders
Somehow we feel it should be obvious to us when someone has an eating disorder, but it’s not always so clear cut.
The various types are broken down in DSM-5 into anorexia nervosa (AN), bulimia nervosa (BN), binge eating and the catch-all, ‘eating disorder not otherwise specified’ (EDNOS). AN still has a significant mortality rate – the highest of all psychiatric conditions – and yet, how many of us feel totally confident in managing a young person with an eating disorder – or even starting the conversation?
You may come across young people with eating disorders in A+E, in clinic or on the ward, presenting with either physical or mental health problems. Common presentations may be due to their own or a parent’s concern over their weight, gastrointestinal symptoms including vomiting, developmental delay or disruption to the menstrual cycle. It’s worth exploring eating habits when you see a patient whose BMI is drifting below the 9th centile as this roughly equates to 85% of the median (equivalent to 18.5kg/m2 at final height).
The most important thing is being aware and not being afraid to explore eating habits and lifestyle with young people.
How to ask about eating disorders
If you’re concerned but unsure exactly what to ask, there is a useful tool that may be of help. The SCOFF questionnaire was developed by John Morgan and colleagues and is a useful screening questionnaire for anorexia nervosa and bulimia nervosa. It was shown to have 100% sensitivity and a specificity of 89% for patients with anorexia and bulimia.
Do you ever make yourself SICK because you feel uncomfortably full?
Do you worry you have lost CONTROL over how much you eat?
Have you recently lost more than ONE stone in a three month period?
Do you believe yourself to be FAT when others say you are too thin?
Would you say that FOOD dominates your life?
Of course, young people with anorexia nervosa may deny all the above, in which case it is very important to use your clinical judgement, monitor the situation and provide follow-up.
Where to start if you’re concerned
Management of eating disorders should be holistic and include a comprehensive assessment of the physical, psychological and social state of the child including assessing risk to self. Of course, physical causes for weight loss, such as infection, diabetes, thyroid disease or cancer, should be ruled out before heading down the (much longer) path of helping to manage an eating disorder. And, as this is paediatrics after all, child protection concerns should also be considered and managed appropriately.
A full physical examination, including weight, height, and BMI, noting development of secondary sexual characteristics, heart rate, blood pressure (postural drop is a useful clinical sign) and temperature. You should look for specific signs of malnutrition (rash, stomatitis, delayed healing), muscle wasting and lanugo hair. ECG (look for QTc prolongation and bradycardia) and muscle power (you can use the SUSS test, see picture) if suspecting AN should always be performed.
A BMI below 85% of the median (between the 2nd and 9th centiles) should prompt you to think about an eating disorder, but is less helpful in the younger patients that we are seeing more of. In AN, blood should also be sent for FBC, U+Es, bone chemistry, magnesium and phosphate, LFTs, CK and blood sugar (include coeliac, full blood count with film, TFTs and inflammatory markers for differential diagnosis. Consider prolactin with gonadotrophins and oestradiol when secondary amenorrhoea is present).
It is important to know what to look out for in those with a significantly low BMI and what key findings would persuade you the young person needed to be an inpatient. These include concerns over their cardiac status (bradycardia, hypotension) and electrolyte abnormalities. Significant risk factors include weight loss of more than 1 kg/week for 2 weeks or where BMI is <70% of the median (<13kg/m2 in an adult. The MARSIPAN guidance gives good, clear guidance on this and include a risk assessment tool for physical health examination.
Managing Eating Disorders
Clearly you cannot manage an eating disorder in one session, but a useful place to start might be to provide sources of support and information, a clear plan about who will lead on the young person’s management and a plan of how progress will be monitored. It is important not to ‘sit on’ eating disorders, but refer early to specialist services. Early intervention improves prognosis. Forming the management plan should be interactive, involving the young person and the family where possible and appropriate. The young person’s right to confidentiality must also be considered.
There are a number of self-help options and support websites available, which may in particular be of benefit to young people with binge-eating or possibly bulimia nervosa. One such website, aimed at teenage girls and young women is ebodyproject.org. MindEd also do a nice module aimed at health professionals. It is also worth exploring other local facilities for psychoeducation and support services.
If you are concerned, refer to CAMHS early. There are a number of different psychological therapies used in eating disorders, but the mainstay of evidence is currently favouring family-based therapy. There is also some evidence to support olanzapine as an addition to these interventions. For BN and binge-eating, specific CBT is often used.
The priority early on should be nutritional rehabilitation and medical stabilisation. If laxative-abuse is suspected (it does not significantly reduce calorie intake) – use of these should be supervised. Intentional weight loss through skipping insulin in type 1 diabetes – sometimes referred to as ‘diabulimia‘ – is a specific and difficult to manage problem and requires the specialist input of eating disorder and paediatric diabetes teams. In binge-eating, exercise may help with both physical and psychological well-being.
Antidepressants may have a role in binge-eating but not particularly in AN or BN. In AN particularly, medicine should be used with extreme caution.
Most patients can be managed as outpatients, but if in-patient care is needed this should be in an age-appropriate place, ideally under a team with expertise in eating disorder management. If this is not possible, the team should seek specialised advice.
The details of inpatient management are out of the scope of this short article but, in brief, should involve a structured feeding plan setting out clear weight gain expectations, nutritional supplementation with avoidance of TPN, with close monitoring for re-feeding syndrome and psychological support. Paediatric, psychiatric and dietetic teams should all be involved.
How to talk to young people with eating disorders
Don’t be afraid of doing this – we paediatricians are all used to speaking to young people and are likely to be able to discuss eating disorders well if we remember a few pointers…
Do not hide your own level of clinical concern at how unwell the young person is in front of them – the concern of the clinician is a powerful catalyst in bringing about change in the family.
Do not be reassured by normal blood tests – explain this to the young person.
Emphasise health and safety – avoid details about calories – nutrition is energy and restoration of health.
Do not let the young person’s anxiety stop you from reintroducing nutrition safely. Be supportive and understanding, but unswayed in your clinical priority. Draw on psychiatry expertise if this becomes uncomfortable.
Dr Polly Powell, Paediatric Registrar, with consultant input from Dr Simon Chapman, Consultant Paediatrician
References and resources:
The SCOFF questionnaire: a new screening tool for eating disorders. Morgan J et al, West J Med. 2000
The MindEd website: www.minded.org.uk
NICE guidance on Eating Disorders, available online at: https://www.nice.org.uk/guidance/cg9
-They also do guidance for young people and families which is quite clear and well set-out.
Essential for all front-line staff:
MARSIPAN guidance available on-line through the Royal College of Psychiatry website
RCPSYCH also do an information leaflet for parents of children with eating disorders
BEAT is the main UK charity for eating disorders. Their website is helpful and provides an online support group for young people recovering from eating disorders and also has a helpline available for sufferers.
YoungMinds Provides information and advice on child mental health issues and also have a Parents’ Helpline: 0800 802 5544
This post originally appeared on the Paediatric Mental Health Association (PMHA) website here. The PMHA are a group of professionals concerned with the mental health of paediatric patients, visit their website for more resources, for information on their activities, courses and events, or to join!