Eating disorder in-patient admissions: Children and Young people (OOH) (Paediatric Guidelines)

MEED guidelines should be followed for all patients presenting with an eating disorder. Patients can look very well but may be minimising illness or unaware of how unwell they are. The risk assessment framework should be completed for all eating disorder assessments.

Risk assessment framework for assessing impending risk to life (<18 years)

Printable MEED Risk Assessment

Examinations

Patients should be examined paying particular attention to:

• Cardiovascular instability and complications:
  • cool peripheries, acrocyanosis, bradycardia, postural hypotension, mitral valve prolapse, arrhythmias, hypotension (use age-adjusted charts)
• Signs of electrolyte instability
• Pubertal development: 
  • growth assessment and documentation of pubertal stage.
• Signs of vomiting: 
  • gingivitis and dental caries, loss of enamel on teeth, callouses on dorsum of the hand (Russell’s sign), swollen parotid glands.
• Signs to suggest alternative diagnosis.
• Baseline 12 lead-ECG on admission to assess for prolonged QTc interval.
  • Haemodynamically unstable patients should be monitored with continuous cardiac monitoring.

Median percentage BMI (also called weight-for-height)

To complete a full MEED risk assessment in a patient <18 years old you will need to know their median % BMI (weight-for-height). To calculate this, please see the table below and equation.

Blood tests

All patients with a suspected eating disorder should have the following blood tests on admission:

• U&E’s
• Full blood count
• LFT’s
• Glucose­­
• Phosphate, magnesium, calcium
• Venous blood gas
• Thyroid function tests
• Coeliac screen
• Vitamin B12, ferritin and folate

Differential diagnosis

Differential diagnosis should be considered and ruled out e.g:

• hyperthyroidism, Addisons, inflammatory bowel disease, coeliac disease, malignancy.

Patients with significant malnutrition can also have a degree of immunocompromise and infections should be identified and treated promptly.

Nutrition screen

To be discussed with Dietetic team if required:

• Full nutrition screen, including fat soluble vitamins (A, D and E).

Patients with diabetes

Diabetic patients with eating disorders are particularly high risk and the diabetic team should be involved as soon as possible.

• See MEED guidelines: Annex 3 Type 1 diabetes and eating disorders (T1DE)

Commencing a re-feeding plan

There is evidence that higher kcal re-feeding is tolerated in adolescents, provided they are closely monitored. 

• Further information: MEED guidelines, section 4.  

• Follow the re-feeding decision tree below for blood monitoring and commencing nutrition. Note that there is specific information for <18’s. Most patients will be safe to commence Meal Plan 1 (1,400 kcal).
• Do NOT start someone on a plan that is less than their pre-admission intake, useful to check with meal plans for reference. (it is unlikely that someone being admitted urgently will be managing more than 1,400 kcal, but important to assess pre-admission intake from patient and family/ carers).
• Thiamine and Forceval should be commenced as per re-feeding guidelines before nutritional treatment is commenced: Thiamine 50 mg four times daily and Forceval capsule or soluble once daily.
• Meal plans should be increased by at least 200 kcal every 1 to 2 days.
• Increases in feeding should not be withheld unless K <2.5mmol/L, Mg <0.4mmol/L or PO⁴ <0.4mmol/L, provided that electrolytes are supplemented: BAPEN Position Statement on Electrolyte and Vitamin Replacement in Adult Patients with Severe Malnutrition, including those with Eating Disorders and other Related Conditions.

Re-feeding Decision Tree Note: follow the guidance for <18’s

Oral meal plans

Commence a suitable meal plan based on the re-feeding decision tree. Most patients will be commenced on Meal Plan 1 (1,400 kcal), unless they are thought to be managing more than this.

Suitable Adaptions

• Genuine food allergies, intolerances and dislikes (pre-eating disorder) should be confirmed by a parent or carer, and must be documented. Any fear-based foods due to the eating disorder should still be included in the meal plan.
• If the patient is unable to take dairy products:
  • Swap Fortisip 200mL bottle for Fortisip Plant, which contains the same kcal and protein content.
  • Whole oat milk is the most equivalent plant-based milk to whole milk and should be requested from the kitchen.
  • Dairy-free meal and snack options, such as plant-based yoghurts and dessert options are available on request from the kitchen.
• Ideally the patient should be given a copy of the meal plan without the kcal and Fortisip content. Do NOT provide patients with staff copies of the plan.
• If the patient is unable to make a decision when ordering food, family or staff must order something from the plan on their behalf.

NHS Highland intranet access required for these documents: 

• Meal Plan 1 (1,400 kcal) 
• Meal Plan 2 (1,600 kcal)
• Meal Plan 3 (1.800 kcal)
• Meal Plan 4 (2,000 kcal)
• Meal Plan 5 (2,200 kcal)
• Meal Plan 6 (2,400 kcal)

Oral intake via meal plans and oral nutritional supplements should be the first line of treatment for children and young people with an eating disorder.

When NG feeding is required, this is ideally agreed as an MDT.

However, there may be emergency circumstances out of hours, where the patient is too medically unstable to wait for this. NG feeding may be indicated immediately in very high risk patients e.g. if they are not alert enough for oral intake or if they are requiring a significant amount of medical stabilisation.

Emergency NG Feeding Plan

• This should only be used in an emergency situation as agreed with the Medical Consultant.
• Discuss with on-call Psychiatrist if detention under the Mental Health Act is required.
• Start thiamine 50 mg four times daily via NGT (or IV Vitamins B+C, 1 pair once daily, if preferred option) prior to starting NG feed.
• Bloods should be monitored every 24 hours. Increase frequency to every 12 hours if any significant concerns.
• Blood sugars should be checked four times daily.

Re-feeding

The most up-to-date evidence suggests that for adolescents, starting at 1,400 to 2,000 kcal/day, and increasing by at least 200 kcal/day up to around 2,400 kcal/day, is safe for all except patients at highest risk, provided that medical parameters are closely monitored.

• Some patients require higher calorie intakes to gain weight.
• A key consideration is that no patient should be started on a lower calorie amount than they were eating prior to admission.

Adapted from MEED guidelines, Table 7 

Indicators of higher risk for refeeding syndrome

Predictors for the development of refeeding hypophosphataemia include low white blood cell count and higher haemoglobin level. Patients at the highest risk of refeeding syndrome are those with very low weight, minimal or no nutritional intake for more than 3 to 4 days, weight loss of over 15% in the past 3 months, and with abnormal electrolytes and medical comorbidities such as pneumonia or other serious infections, cardiac dysfunction or disease and liver damage (e.g. due to alcohol dependence) before refeeding (Table 8).

Any patient at high risk of refeeding syndrome should be managed in an acute medical environment with high-dependency facilities available if needed. In the majority, this will be an acute medical/paediatric unit but could be a SEDU if it is co-located on an acute hospital site with high dependency (HDU) facilities should they be required or unless there is an extenuating clinical circumstance which suggests another care environment is more appropriate as determined by the multidisciplinary team.

Table 8: Factors associated with the risk of refeeding syndrome

Adapted from MEED guidelines, Table 8 

NHS Highland re-feeding guidelines: Policy for Prevention and Management of Re-feeding Syndrome in Adults 

OOH NG feeding plan

If someone is medically unstable and continuous NG feeding via pump is required e.g. the patient is not alert enough for oral intake, consider the plan below until they can be reviewed by a dietitian (see also re-feeding decision tree below – figure 4)

Re-feeding Decision Tree Note: follow the guidance for <18’s

• BMI: Body mass index
• CAMHS: Children and Adolescent Mental Health Service
• HDU High dependency unit
• ICU: Intensive care unit
• m%BMI: Median percentage BMI
• MDT: Multidisciplinary team
• MEED: Medical emergencies in eating disorders
• NG: Nasogastric 
• NGT: Nasogastric tube
• OOH: Out of hours
• RFS: Refeeding syndrome
• SEDU: Specialist Easting Disorder Unit