Eating disorders presenting to ED

The ICD-11 defines four different eating disorders: anorexia nervosa (AN), bulimia nervosa (BN), binge eating disorder (BED) and avoidant/restrictive food intake disorder (ARFID). For those who do not meet these definitions, there is an additional classification of other specified feeding/eating disorder (OSFED). All five eating disorders share some characteristics such as unusually low/high BMI, change in eating behaviour, disproportionate body weight/shape concern and menstrual problems. Table 1 illustrates some of the key features of each eating disorder to help differentiate them.8 9

It is important to consider and rule out any organic causes, particularly if this is the first presentation. The list of possible differentials is long and varies depending on the clinical features. As an example, haematological changes found in anorexia nervosa can also be seen in haematological malignancies and weight loss can be a feature of chronic infections such as tuberculosis, or other chronic conditions such as coeliac disease. As with any patient, a full history and examination should be done to start to narrow the differential down, and initial basic investigations performed.8

History

Diagnosis and the management of eating disorders can be challenging in CYP.10 Presentation to the emergency department may be the child’s initial contact with any healthcare professional about their eating disorder. It is important to remember that complications as a result of eating disorders can occur at any weight and, therefore, the absolute weight or BMI should not dictate the need for admission in isolation.8

As well as a general paediatric history, a focused eating history and psychosocial history should be taken. The HEEADSSS assessment (covering Home and environment, Education and employment, Eating and exercise, Activities, Drugs/substances, Sexuality, Suicide/depression and Safety) is useful to get an overall psychosocial history.11

A thorough medical history is important. The prevalence of autistic spectrum disorder (ASD) and emotionally unstable personality disorder (EUPD) is higher in those with eating disorders, so asking about other known diagnoses is important.8

A more detailed history on the patient’s weight and eating patterns should include the following (figure 1)8 12 13:

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Figure 1

Points to cover in history taking.8 10 20 21

Examination/investigations

A full set of vital signs observations with the patient’s height and weight should be taken (the latter ideally without shoes or heavy clothing), plotting them on age-adjusted growth charts or per cent median BMI for age calculated ((BMI/median BMI for age and gender)×100); <85% mBMI is defined as malnutrition and <70% as severe emaciation.8 Remember that being weighed is anxiety provoking for someone with an eating disorder; therefore, it needs to be performed sensitively and without judgement. Consider whether weight might be altered through drinking fluids or other means.

Any change in postural blood pressure and heart rate should be recorded.14

Eating disorders affect a wide range of body systems,15 and the examination should take a systems-based approach to identify the potential problems listed below.

• Neurology: Confusion and delirium are signs of severe disease and may represent refeeding syndrome, Wernicke’s encephalopathy or an alternative organic cause. Tetany and seizures are rare but may be secondary to hypocalcaemia.

• Cardiovascular: Bradycardia is common in eating disorders and in particular for those who are underweight. Hypotension secondary to dehydration or pronounced vagal tone along with syncopal episodes may point to cardiovascular instability. ECG changes include right axis deviation and prolonged QTC due to hypokalaemia. Structural changes such as mitral valve prolapse are also seen.8

• Gastro: Abdominal bloating, faecal loading and haemorrhoids secondary to constipation have been attributed to a range of eating disorders. Oedema is likely multifactorial, due to a mixture of nutritional status, refeeding syndrome or cardiac failure. Dermatological findings can be widespread,8 so skin and hair should be examined. Lugano hair, yellowish discolouration of the skin (carotenoderma) or hair loss may all be present. The knuckles may demonstrate Russell’s sign—scars on the knuckles may indicate self-inflicted vomiting. Pressure areas and bony prominences may highlight bruising or skin breakdown.

• Ear nose throat: Dental erosion is the most common oral manifestation of recurrent vomiting.16 Painless parotid enlargement, pharyngitis as well as trauma to the oral cavity may be found on examination of the mouth.

Relevant blood tests should be sent in the acute setting: full blood count, renal profile, glucose, electrolytes (including sodium, potassium, phosphate, calcium, chloride and magnesium), liver function tests and amylase. Further blood investigations should include vitamin D, thyroid and gonadotrophins.6 However, the findings of blood tests alone rarely change management and normal blood results do not rule out an eating disorder.

An ECG should be performed, in particular looking for arrythmias and a prolonged QTc.

The SUSS test (table 2) for muscle power (Sit Up Squat Stand) may be used. A low score is concerning, but bear in mind that adolescents will often ‘pass’ this test, particularly if they are quite athletic, so don’t be falsely reassured by a good score.8

It is important to note that young people with eating disorders may be more unwell than they look and may not have insight into their illness. Examination needs to be carried out sensitively, but with this in mind, ensuring that examination is thorough including looking beneath baggy clothes and an examination of the skin.

Management

NICE recommend that anyone who requires admission should have a designated general paediatrician as well as a consultant psychiatrist.15 They should be admitted to an age-appropriate ward with adequate supervision and care.

The overall consensus is that patients with the following complications or examination findings will need to be considered for inpatient management and discussed with the appropriate teams.8 14 17 18

1. Weight—BMI below the 0.4th centile (age and gender adjusted) or <70% mBMI, more than 1 kg of weight loss in each of the last 2 weeks

2. Eating—Acute food refusal or estimated calorie intake of <500kcal/day for 2+ days

3. Cardiovascular—Heart rate of less than 40 beats per minute while awake, with changes in the postural blood pressure or heart rate (postural drop in systolic BP of >20 mmHg or increase in heart rate of >30 bpm). Standing systolic BP of <0.4th centile for age

4. An abnormal ECG—Prolonged QTc (consulting normal ranges for age and sex) or changes secondary to electrolyte disturbance

5. Fluid status—Fluid refusal or evidence of severe dehydration such as reduced urine output, decreased skin turgor, tachycardia, tachypnoea or postural BP drop

6. Electrolyte disturbance

7. Hypothermia temperature—Less than 35.0°C axillary or 35.5°C tympanic

8. Hypoglycaemia—This is usually seen as ketotic hypoglycaemia. Ketotic hypoglycaemia should be treated with complex carbohydrates (eg, Food or Maxijul), rather than be managed with rapid acting carbohydrates like Glucogel. However, in an emergency setting where the cause of hypoglycaemia is not yet certain, it should be managed as per general hypoglycaemia guidance. A hypoglycaemia screen may be helpful and other causes of hypoglycaemia such as Addison’s disease should be considered.

9. Behaviour—Food refusal, failure to comply with healthcare professionals, treatment failure as an outpatient.

10. Concurrent mental health problems or significant safeguarding concerns.

11. A score of 0 or 1 on the SUSS test.

The new Medical Emergencies in Eating Disorders guidance has an “Eating disorder risk checklist for emergencies” (figure 2) which is helpful when assessing patients presenting with eating disorders to the ED.8

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Figure 2

Eating disorder risk checklist for emergencies.8

Deciding where to admit the patient often not only depends on the physical state of the child or young person but also what services are available. Services may range from an inpatient paediatric bed, specialised eating disorder bed or a generic CAMHS bed. In most cases, admission to a paediatric ward for medical stabilisation followed by community care by a specialist eating disorders team is the treatment of choice.8

Patients, who are shocked (this is relatively uncommon in the UK, but is seen) or those with ECG changes secondary to electrolyte disturbance, should be reviewed by the paediatric intensive care team or discussed with the regional PICU team if there is no on-site PICU.18 Fluid boluses should only be given after discussion with a senior paediatrician as they may precipitate heart failure. If the child is otherwise dehydrated, then they should be given oral or NG fluids.

Hypoglycaemia is not uncommon and, again, should ideally be managed with oral replacement. On the rare occasion that intravenous dextrose is needed, it should be preceded with intravenous thiamine.18

Should the CYP be admitted, the main aims of the paediatric inpatient team are to

1. Stabilise the patient, managing fluid and electrolyte disturbances.

2. Refeed the patient while avoiding refeeding syndrome or underfeeding.

3. Manage any compulsive behaviours.

4. Discharge/transfer to appropriate community or inpatient psychiatric care as agreed with the specialist community eating disorders team.

It is also an opportunity to provide respite for the young person and their family, and to provide support, treatment and education for the young person and their family in a safe environment.

Refeeding should ideally be done orally. Nasogastric feeding is occasionally used but is only a short-term option and normal meals or oral nutritional supplements should be continued to be offered. All patients being referred should have a meal plan designed by a paediatric dietitian. Complications of refeeding are prevented by close monitoring. An agreed protocol for refeeding is helpful for the patient, family and staff.8

Patients not requiring admission from ED must have a clear plan prior to discharge. CYP with a suspected or confirmed eating disorder should take an age-appropriate multivitamin.19 The follow-up plan will depend on the resources available in the local area, but there should be follow-up in place either with CAMHS or paediatric outpatient teams. Finally, they should be discharged with explicit safety netting advice and clear guidance as to when to re-attend ED (figure 3).8 19

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Figure 3

Advice on discharge.8 19

Patients and their parents/carers can be signposted to online resources such as charities “Beat eating disorders” and “Mind” which provide good quality information and resources for patients as well as parents/carers including helplines and online chat rooms for further support (figure 4).

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Figure 4

Helpful resources for patients and parents/carers.