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Eating Disorders - suspected

Scope

Young people under age of 18 years with suspected eating disorder: anorexia nervosa, bulimia nervosa, avoidant restrictive food intake disorder (ARFID).

Background

The number of young people being diagnosed with eating disorders in the UK is rapidly increasing and the age of presentation is getting younger. Average age is 14 years.

Eating disorders in children and adolescents can be complex and often do not fit the diagnostic criteria used for adults. Weight loss, very low body weight or failure to increase weight as expected with age should raise concern in any young person. Other medical causes should always be excluded.

Young people with restrictive eating disorders are at risk of immediate physical health complications due to rapid weight loss and starvation, and longer term physical health complications such as growth failure, delayed/disrupted puberty and reduced bone density (see below). Mental health comorbidities and social/educational disruption are also risks.

The below describes features of the three main types of eating disorder in children and young people to aid with suspecting the diagnosis. Features often overlap. Cognitions are sometimes difficult to elicit at first assessment and in younger children. Some young people will present with physical symptoms to explain their lack of eating e.g. abdominal pain, nausea

Anorexia nervosa
  • Low body weight (less than 85% expected)
  • Restricted food/calorie intake
  • Weight losing behaviours (exercise, laxatives, vomiting)
  • Altered body image, fear of 'fatness'
  • Intent to lose weight, fear of weight gain
  • Amenorrhoea/delayed puberty
Bulimia nervosa
  • Weight more than 85% expected
  • Binge eating, lack of control
  • Compensatory behaviours (vomiting, exercise, laxatives)
  • Preoccupation with eating and body shape
  • Low self-esteem
ARFID (Avoidant restrictive food intake disorder)
  • Restrictive eating that does not fit criteria for Anorexia Nervosa
  • Significant consequence such as weight loss, inadequate growth, nutritional deficiency, dependence on nutritional supplements
  • Includes other psychosocial issues associated with eating

Out of scope

There is significant overlap between feeding and eating disorders over the paediatric age range please refer to the feeding disorders guideline in parallel to decide which management and referral routes are most appropriate.

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Signs and Symptoms

Physical complications of starvation

The majority are reversible with refeeding and weight gain.

  • Cardiovascular system (CVS) – bradycardia, hypotension (postural), dysrhythmias, ECG abnormalities (low voltage, prolonged QT), heart failure, pericardial effusions
  • Dietary deficiencies e.g. calcium, folate, vitamin D, B12
  • Gastrointestinal (GI) – constipation, bloating, fullness, delayed gastric emptying, fatty infiltration of liver with abnormal liver function tests (LFT's), hypercholesterolaemia, superior mesenteric artery syndrome, pancreatitis.
  • If vomiting risks of dental erosions, oesophagitis, Mallory-weiss tears, gastric rupture.
  • Renal – renal stones, polyuria, peripheral oedema, electrolyte disturbance
  • Haematological – leukopenia, anaemia, iron deficiency, thrombocytopenia, clotting disturbance, increased risk of sepsis
  • Endocrine – reduced growth, sick euthyroid syndrome, amenorrhoea, delayed puberty, osteopenia
  • Neurological – slowed cognition, irritability, lack of concentration, poor sleeping, depression, cortical atrophy, seizure

History and Examination

  • Presenting problem, who is concerned?
  • History of presenting problem
  • Pattern of weights/clothes size over preceding weeks/months
  • Current dietary and fluid intake (including supplements, 'diet pills')
  • Weight losing behaviours e.g. vomiting, exercising, laxative use, fluid overload
  • Full systems enquiry regarding any secondary symptoms or symptoms indicative of differential diagnoses e.g. chest pain, palpitations, abdo pains, bowel habit, headaches, F/F/Ft
  • Body image, self esteem, weight preoccupation
  • Menstruation
  • Sleep pattern
  • Past medical history, in particular previous feeding/eating problems, comorbid conditions likely to increase physical risk
  • Family history, in particular re dieting, body image, eating disorders, onset of puberty
  • Educational history e.g. school attendance and achievement
Features on examination
  • General appearance
  • Clothing worn
  • Eye contact and engagement
  • Peripheral signs of systemic illness indicating other differential diagnoses e.g. hyperthyroid, inflammatory bowel disease, diabetes, malignancy etc.
  • Knuckle callus
  • Self-harming scars
  • Lanugo hair
  • Cool peripheries
  • Peripheral skin change (examine hands and feet)
  • Anaemia
  • Hair loss
  • Hydration
  • Mouth and teeth (dental erosion, trauma from induced vomiting)
  • CVS including pulse and BP lying and standing
  • Abdominal examination particularly noting if bladder full (may be withholding to give falsely high weight), faecal loading
  • Inspection of perineum for pubertal staging and as necessary to exclude other differential diagnoses e.g. anal findings in Crohns
  • General neurological examination including muscle wasting
  • Assessment of muscle strength e.g. squat test
Accurate measure of weight and height
  • Ideally minimally clothed and after passing urine
  • Always plot on RCPCH growth chart
  • Plot previous weights if known
  • Calculate BMI (weight (kg)/height (m)2)
  • Calculate % median BMI (actual BMI/50th centile BMI for age)

Differential Diagnoses

  • Organic causes for anorexia
  • Feeding difficulties for other reasons

Assessing Risk
  • 80-85% Median BMI, concerned
  • 70-80% Median BMI, very concerned
  • Less than 70% Median BMI, extremely concerned

Relate history and examination findings to the risk table below (Junior MARSIPAN, 2012)

Consider both physical and psychological risk factors

Physical risk factors (link to tabular information)
High Risk Alert to high concerns Moderate Risk Low Risk
BMI and weight Percentage median BMI less than 70% (approx below 0.4th BMI centile)
Recent loss of weight of 1kg or more/week for 2 consecutive weeks
BMI 70-80% (2nd -0.4th centile)
Recent loss of wgt of 500 – 999g/week x 2 weeks 		BMI 80-85% (9th-2nd centile)
Recent loss of up to 500g/week x 2 consecutive weeks 		BMI greater than 85%No wgt loss over past 2 weeks
Cardiovascular Health
 Heart rate (awake) less than 40bpm

Hx of recurrent syncope; marked orthostatic changes (fall in systolic BP of 20mmHg or more, or below 0.4-2nd centile for age, or increase in heart rate of less than 30bpm)

Irregular heart rhythm (does not include sinus arrhythmia) 		Heart rate (awake) 40-50 bpm

Sitting BP: systolic, 0.4th centile (84-98mmHg dep on age and gender); diastolic, 0.4th centile (35-40mmHg dep on age and gender)

Occasional syncope; moderate orthostatic changes (fall in systolic BP of 15mm Hg more, or diastolic BP fall of 10mmHg or more within 3 min standing, or increase in heart rate of up to 30bpm)
Heart rate (awake) 50-60bpm.

Sitting BP: systolic less than 2nd centile (98-105mmHg dep on age and gender); diastolic less than 2nd centile (40-45mmHG dep on age and gender)

Pre-syncopal symptoms but normal orthostatic cardiovascular changes.
Heart rate (awake) less than 60 bpm

Normal sitting BP for age and gender with reference to centile charts.

Normal orthostatic cardiovascular changes.

Normal heart rhythm
ECG abnormalities QTc greater than 460ms (girls) or 400ms (boys) with evidence of bradyarrhythmia or tachyarrhythmia (excludes sinus bradycardia and sinus arrhythmia); ECG evidence of biochemical abnormality QTc greater than 460mg (girls) or 400ms (boys) QTc greater than 460ms (girls) or 400ms (boys) and taking medication known to prolong QTc interval, family history of prolonged QTc or sensorineural deafness
QTc less than 460ms (girls) or 400ms (boys)
Hydration status Fluid refusal. Severe dehydration (10%); reduced urine output, dry mouth, decreased skin turgor, sunken eyes, tachypnoea, tachycardia
Severe fluid restriction. Moderate dehydration (5-10%): reduced urine output, dry mouth, normal skin turgor, some tachypnoea, some tachycardia, peripheral oedema
Fluid restriction. Mild dehydration (less than 5%): may have dry mouth or not clinically dehydrated but with concerns about risk of dehydration with negative fluid balance
Not clinically dehydrated.
Temperature less than 35.5°C tympanic or 35.0°C axillary less than 36°C
Biochemical abnormalities Hypophosphataemia,
hypokalaemia,
hypoalbuminaemia,
hypoglycaemia,
hyponatraemia,
hypocalcaemia
Hypophosphateamia,
Hypokalaemia,
Hyponatraemia,
hypocalcaemia

Muscular weakness – SUSS test

Sit up from lying flat Unable to sit up at all from lying flat (score 0) Unable to sit up without using upper limbs (score 1) Unable to sit up without noticeable difficulty (score 2) Sits up from lying flat without any difficulty (score 3)
Stand up from squat Unable to get up at all from squatting (score 0) Unable to get up without using upper limbs (score 1) Unable to get up without noticeable difficulty (score 2) Stands up from squat without any difficulty (score 3)
Other Confusion and delirium, acute pancreatitis, gastric or oesophageal rupture Mallory-Weiss tear, gastro-oesophageal reflux or gastritis, pressure sores
Poor attention and concentration.
Psychological Risk Factors (link to tabular information)
High Risk Alert to high concern Moderate Risk Low Risk
BMI and weight
 Percentage median BMI less than 70% (approx below 0.4th BMI centile)
Recent loss of weight of 1kg or more/week for 2 consecutive weeks
BMI 70-80% (2nd -0.4th centile)
Recent loss of wgt of 500 – 999g/week x 2 weeks
BMI 80-85% (9th-2nd centile)
Recent loss of up to 500g/week x 2 consecutive weeks 		BMI greater than 85%No wgt loss over past 2 weeks
Disordered eating behaviours
 Acute food refusal or estimated calorie intake 400-600kcal/day Severe restriction (less than 50% of required intake), vomiting, purging with laxatives
Moderate restriction, bingeing
Engagement with management plan Violent when parents try to limit behaviour or encourage food/fluid intake, parental violence in relation to feeding (hitting, force feeding) Poor insight into eating problems, lacks motivation to tackle eating problems, resistance to changes required to gain weight, parents unable to implement meal plan advice given by health-care providers
Some insight into eating problems, some motivation to tackle eating problems, ambivalent towards changes required to gain weight but not actively resisting Some insight into eating problems, motivated to tackle eating problems, ambivalence towards changes required to gain weight not apparent in behaviour.
Activity and Exercise High levels of uncontrolled exercise in the context of malnutrition (less than 2h/day) Moderate levels (greater than 1h/day) Mild levels (less than 1h/day) No uncontrolled exercise
Self Harm and Suicide Self-poisoning, suicidal ideas with moderate – high risk of completed suicide Cutting or similar behaviours, suicidal ideas with low risk of completed suicide
Other MH diagnosis
Other major psychiatric co-diagnosis, e.g. OCD, psychosis, depression
Other Confusion and delirium, acute pancreatitis, gastic or oesophageal rupture Mallory-Weiss tear, gastro-oesophageal reflux or gastritis, pressure sores Poor attention and concentration

The following bloods are to exclude other diagnoses and assess secondary effects/risk but are not essential to referral and should not delay referral

  • Full Blood Count (FBC)
  • Ferritin
  • Clotting
  • Urea and electrolytes (U+E's)
  • Bone profile
  • Phosphate test (PO4)
  • Liver Function Tests (LFTs)
  • Amylase
  • Magnesium test (Mg)
  • Glucose
  • Thyroid Function Tests (TFT's)
  • Quantitative immunoglobulins (Igs)
  • Coeliac screen
  • C-reactive protein (CRP)
  • Plasma viscosity
  • Follicle-stimulating hormone (FSH) / Luteinizing Hormone (LH) / Prolactin / Oestradiol or Testosterone
  • B12, folate, vitimin D
  • Creatine Kinase

ECG if vomiting, cardiac symptoms/signs or low body weight (less than 85% expected)

Urinalysis for ketones, blood, protein

Any other specific investigations according to history and examination to exclude differential diagnoses

Initial management in primary care

If a young person is restricting their eating, cutting out food groups, skipping meals, or exercising excessively it is important to give them a clear message that this is not healthy and they should make immediate changes to avoid becoming seriously unwell. Often parents need to hear and reinforce this message with the young person as they are likely to need to support the young person to make changes.

Always review young people again soon after your initial assessment to have an objective measure of rate of weight loss and to reassess physical risk factors.

Continue to review regularly any young person with increasing risk until seen by paediatric medical eating disorder team (usually within 0-4 weeks according to risk reported in referral information).

After initial assessment in the paediatric eating disorder clinic a joint plan will be made with CAMHS and primary care regarding appropriate ongoing monitoring of weight and/or physical health.

For young people aged 16-18 years with typical eating disorder presentations and low physical risk, assessment and monitoring can be done in primary care in conjunction with their CAMHS input.

Weight loss advice to young people in primary care

If young people are losing weight on medical advice they should still maintain regular eating patterns and include all food groups. It is better in younger children/adolescents who are overweight to aim for less weight gain than their peer group (see RCPCH charts) rather than weight loss.

Referral Criteria

We recommend close monitoring and early referral of any young person with restrictive eating patterns. Evidence suggests that early intervention will give better long term outcomes. Do not wait for a low BMI before referring.

CAMHS eating disorder team referral

Therapy for eating disorders is through mental health services. Always refer any young person who you are concerned has or is developing an eating disorder to the CAMHS eating disorder team through the Integrated Children's Services single access point.

Otherwise refer to the criteria below to decide if they need a parallel referral to the paediatric eating disorders team
  • All young people under 16 years with suspected eating disorder
  • Young people 16-18 years with suspected eating disorder if less than 85% expected body weight and/or amenorrhoeic and/or with moderate/high risk factors
  • Young people where there is diagnostic uncertainty or significant physical complications of possible eating disorder
  • Young people with eating disorders who would benefit from dietician input

Please refer urgently any young person at high risk for rapid assessment in next available eating disorders clinic or through acute on call paediatric team.

Referral Instructions

Referral to CAMHS

See referral section in CAMHS guidance

Referral to paediatric eating disorders team

e-Referral Service Selection

  • Priority: Urgent/Routine
  • Specialty: Child and Adolescent
  • Clinic Type: Other medical
  • Service: DRSS-Eastern-Paediatrics- Devon ICB-15N

Referral Form

DRSS Referral Form

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