Paediatric Clinical Guideline
Adolescent Medicine
12.2 Eating Disorders
Short Title:
Eating Disorders
Full Title:
Date of production/Last revision:
Guideline for the early recognition, assessment and initial management of
eating disorders in children and young people
January 2007
Explicit definition of patient group
to which it applies:
This guideline applies to all children and young people under the age of 19
years.
Name of contact author
Dr Damian Wood, Consultant Paediatrician
Ext: 64041
January 2009
Revision Date
This guideline has been registered with the Trust. However, clinical guidelines are 'guidelines' only. The interpretation
and application of clinical guidelines will remain the responsibility of the individual clinician. If in doubt contact a
senior colleague or expert. Caution is advised when using guidelines after the review date.
Eating Disorders in Children and Young People:
Early Recognition, Assessment and Initial Management
Child or young person with eating disorder presents to paediatric
services
Assessment & Investigations
Does this person meet criteria for medical admission?
Yes
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No/Uncertain
Admit under Dr Damian
Wood or Dr Louise Wells
Correct dehydration and
critical electrolyte
abnormalities
Refer to CAMHS
Refer to dietician
Monitor carefully when
refeeding
Damian Wood
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Page 1 of 10
Discuss with Consultant on
call
Establish weight
monitoring plan
Refer to CAMHS
Refer to dietician
Contact GP
Inform Dr Damian Wood
January 2007
Paediatric Clinical Guideline
Adolescent Medicine
12.2 Eating Disorders
Summary

Early and accurate recognition of eating disorders is important as early intervention is
associated with a better outcome

Diagnostic criteria used in adults with eating disorders are not wholly applicable to young
people who require calculation of BMI centile and percentage weight for height

Majority of patients can be managed as out-patients but some will require in-patient
admission

Young people with severe malnutrition are at risk of re-feeding syndrome and require
particular attention to their feeding regime and electrolyte balance

Management of eating disorders in young people requires a coordinated approach
involving dietician, therapists and paediatricians
Introduction
Eating disorders in children and young people are associated with significant morbidity and
mortality.
They are relatively common disorders with
 0.5% of adolescent females have anorexia nervosa
 1-5% of adolescent females have bulimia nervosa
 5-10% of all eating disorders occur in males
Early recognition and intervention are thought to result in improved outcome. A number of
patients with eating disorders will present in crisis to the emergency department. This
guideline outlines the recognition, assessment and initial management of the child or young
person with an eating disorder.
Recognition of eating disorders
The diagnosis of an eating disorder should be considered when a young person
 Engages in potentially unhealthy weight control practices (eg excessive dieting, laxative
misuse, bingeing and induced vomiting)
 Demonstrates obsessive thinking about weight, height, body composition or stage of
sexual maturation for gender and age;
 Presents with physical complications of an eating disorder which are not due to another
cause
Although there is usually a long history of weight loss and altered eating behaviours, children
and adolescents with an eating disorder may rarely present with an acute complication.
Assessment of children and young people with suspected eating
disorders
Assessment is directed at three main areas
1. Identification of abnormal thinking about weight, body image and diet
2. Recognition of physical complications
3. Ruling out other causes of poor appetite and weight loss
Damian Wood
Page 2 of 10
January 2007
Paediatric Clinical Guideline
Adolescent Medicine
12.2 Eating Disorders
History
Helpful questions to explore attitudes towards weight control:
Weight
How much would you like to
weigh?
How do you feel about your
current weight?
How frequently do you weigh
yourself?
What’s the most you can
remember weighing?
When did you start to lose
weight?
How have you tried to control
your weight?
Diet
Restriction
What’s your diet like at the moment?
Run me through what you had to eat
yesterday?
What sort of things do you avoid?
Exercise
How often do you exercise
each week? For how long?
What exercise do you do?
How do you feel about
exercising?
Bingeing
Many young people have times when they eat
large amounts quickly? We sometimes call
this a binge? Do you ever binge on food? If
so how often? What do you binge on? How
much of that would you eat?
Purging
Sometimes when young people are trying to
control their weight they use medicines or
other methods to get rid of food, either by
making themselves vomit or by going to the
toilet a lot? Have you ever tried this? If so
frequency, amount.
Have you ever tried any diet pills or water
tablets to help you lose weight?
Menstrual history
 age at menarche
 regularity of cycles
 last normal monthly period
Review of systems
 Dizziness, blackouts, weakness, fatigue
 Pallor, easy bruising/bleeding
 Cold intolerance
 Hair loss/dry skin
 Vomiting, diarrhoea, constipation
 Fullness, bloating, abdominal pain, epigastric burning
 Muscle cramps, joint pains, palpitations, chest pain
 Symptoms of hyperthyroidism, diabetes, malignancy, infection, inflammatory bowel
disease
 Symptoms of depression, anxiety, OCD
HEADSSS assessment
All young people admitted to the paediatric unit should also have a HEADSSS psychosocial
assessment. This assessment is particularly helpful to identify co-morbidities (such as drug
misuse and self-harm) in young people.
Damian Wood
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January 2007
Paediatric Clinical Guideline
Adolescent Medicine
12.2 Eating Disorders
Examination
On examination patients with anorexia nervosa are often emaciated with sunken cheeks &
eyes, sallow dry skin and a flat affect. They often have cool peripheries and lanugo hair (fine
downy hair over the trunk).
They should be examined paying particular attention to:

Cardiovascular instability and complications – cool peripheries, acrocyanosis,
bradycardia, postural hypotension, hypothermia, mitral valve prolapse, arrhythmias
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Signs of recurrent vomiting – gingivitis and dental caries, loss of enamel on lingulal and
occlusal surfaces of teeth, callouses on dorsum of the hand (Russell’s sign), swollen
parotid glands
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Signs of electrolyte instability – Trosseau sign, diminished deep tendon reflexes
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Pubertal development – assessment and documentation of pubertal stage
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Signs to suggest alternative diagnosis – lymphadenopathy, mouth ulceration,
abdominal tenderness or mass, hepatosplenomegaly
All young people with eating disorders need their growth measuring and plotting on standard
centile charts. In addition they should have:
 their BMI calculated and plotted on a BMI centile chart
 their percentage weight for height calculated
Calculating percentage weight for height
 Plot height on a standard growth chart and note the centile
 Read off expected weight from the same centile on the weight portion of the chart
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% weight for height =
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calculate BMI (weight(kg)/height2(m)) and plot onto BMI centile chart
Damian Wood
Measured weight
Expected weight
Page 4 of 10
x 100
January 2007
Paediatric Clinical Guideline
Adolescent Medicine
12.2 Eating Disorders
Differential Diagnosis
The key to the diagnosis of eating disorders is abnormal eating behaviour plus disordered
thinking and beliefs about weight and body shape. If such abnormal beliefs and behaviours
are not present one should give consideration to alternative diagnoses such as:
 Gastroenterological causes: Inflammatory bowel disease, malabsorption, coeliac
disease
 Malignancy
 Endocrine causes: diabetes, hyperthyroidism, hypopituitarism, Addison’s disease
 Chronic infection
 CNS disease
 Other psychiatric disorders: depression, OCD
Diagnosis
Anorexia Nervosa
Refusal to maintain body weight over a minimum
normal weight for age and height – weight is
maintained at least 15% below that expected for
height.
Bulimia Nervosa
Recurrent episodes of binge eating.
Disturbance in the way in which one's body
weight, size or shape is experienced, undue
influence of body shape and weight on selfevaluation, or denial of the seriousness of low body
weight.
An episode of binge eating is characterised by
both of the following:

Eating in a discrete period of time (e.g. any 2
hour period), an amount of food that is definitely
larger than most people would eat during a
similar period of time in similar circumstances
and

A sense of lack of control over eating during the
episode (e.g. a feeling that one cannot stop
eating or control what or how much one is
eating)
In females, absence of at least three
consecutive menstrual cycles when otherwise
expected to occur (primary or secondary
amenorrhoea).
Recurrent inappropriate compensatory behaviour
in order to prevent weight gain such as: self
induced vomiting, use of laxatives, diuretics or other
medications, fasting or excessive exercise.
In younger people, the diagnosis may be made in
those who fail to gain weight during the expected
growth spurt of puberty, as they can become
underweight without weight loss.
A minimum average of two binge eating and
inappropriate compensatory behaviours per week for
at least three months.
Intense fear of gaining weight or becoming fat
even though underweight.
Self evaluation is unduly influenced by body shape
and weight.
Investigations
To some extent on the investigation will depend on the need to exclude other diagnoses. For
those in whom the diagnosis is clear baseline investigations should include:
 Urinalysis - if amenorrhoeic consider urine pregnancy test after discussion with young
person
 ECG
 FBC
 U&E, Bone profile
 Thyroid function tests
 Blood gas
Damian Wood
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January 2007
Paediatric Clinical Guideline
Adolescent Medicine
12.2 Eating Disorders
Management
Resuscitation
Young people with anorexia nervosa often have cool peripheries, prolonged capillary refill and
bradycardia. The majority will not require intravenous fluid replacement.
Prolonged malnutrition results in reduced cardiac muscle mass, ventricular systolic
dysfunction, increased vagal tone and increased predisposition to ECG abnormalities and
arrythmias.
The presence of prolonged capillary refill time, with a normal resting heart rate suggests
hypovolaemia. In these patients consider cautious intravenous fluid replacement using
alliqouts of 10mls/kg of 0.9% saline.
Admission Criteria
The majority of young people with an eating disorder will be managed as an out-patient.
Some will require admission for stabilisation and institution of a feeding regime.
Out-patient management
If you suspect an eating disorder you should:
 Feed back findings from the physical examination including the weight
 Establish weight monitoring plan with young person and family
 Contact the GP by phone or fax within 24 hours
 Refer to CAMHS
 Refer to dietician
 Provide patient and family with written information regarding eating disorders
 Leave message for Dr Damian Wood by email (damian.wood@nuh.nhs.uk) or by
contacting his secretary on ex 64041
Inpatient management
Inpatient management of a young person with an identified eating disorder requires
multidisciplinary involvement to tackle medical, nutritional and psychological aspects of care.
Patients who meet admission criteria should be admitted under either Dr Damian Wood or Dr
Louise Wells.
Admission criteria
 %IBW <75%
 Dehydration
 Electrolyte disturbance
 Cardiac dysrhythmia
 Syncope
 Seizures
 Cardiac failure
 Pancreatitis
 Severe bradycardia HR <50bpm (day)
<45bpm (night)
Damian Wood
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Hypotension BP <80/50mmHg
Hypothermia Temp<36.0OC
Acute food refusal
Failure of OP treatment
Uncontrollable binging and purging
Suicidal ideation
Acute psychosis
Co-morbid diagnosis that interferes with
treatment eg OCD
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Paediatric Clinical Guideline
Adolescent Medicine
12.2 Eating Disorders
Management of dehydration
If the young person is severely dehydrated then see the section on resuscitation above.
If the young person is mild or moderately dehydrated then calculate daily maintenance fluid
requirement and percentage dehydration and replace over 48hrs in the usual way.
The young person with an eating disorder who is refusing oral intake
If the young person is refusing all food intake then Fortisp can be safely used as meal
replacement.
If a young person is refusing all flood and fluid intake and they are significantly dehydrated
they may require nasogastric tube feeding. This should only be instituted after discussion
with the young person, family and the CAMHs team. In such cases issues of consent and
competence are complex and require special consideration. If you consider a young person
needs urgent fluid replacement but is refusing all fluid intake contact either Dr Damian Wood
or Dr Louise Wells or if out of hours the Consultant Paediatrician on-call.
Correction of electrolyte imbalance
Electrolyte imbalance is common at presentation and can usually be corrected by oral
supplementation. In the event of a critical electrolyte imbalance urgent intravenous
replacement may be required as patients with anorexia nervosa are at increased risk of
cardiac arrhythmias (see guidance below).
Suitable oral supplements:
 Sando K (each tablet contains 12 mmols of potassium) 2-4 tablets per day
 Phosphate Sandoz (each tablet contains 16.1 mmols of phosphate) two tablets with
meals.
Nutritional Management
Children and young people with eating disorders should be referred to the paediatric
dieticians for an appropriate feeding plan. Their daily diet should be planned with and
overseen by a dietician.
Liaison Psychiatry
In the first instance a referral should be made to the liaison CAMHs team at QMC. Patients
may then be referred to either their local CAHMs out-patient team or to the Adolescent Unit at
Thorneywood.
Nursing
Patients with anorexia nervosa and severe malnutrition often have disordered cognition and
poor attention, concentration and memory. In such patients the drive to lose weight is
powerful and the feeding plan may generate a great deal of anxiety. Hence they require close
observation of their activity and eating and a clear written nursing plan which outlines:
 Intensity of nursing observation (eg nurse on open ward in bed next to nurse’s
station)
 Frequency of vital sign recording and parameters for contacting medical staff
 Supervision requirements at meal times
 Activity guidelines (eg strict bed rest with commode, wheelchair for trips outside the
ward)
 Privileges (eg visiting, time out of bed/off the ward, personal belongings)
 Communication guidelines (eg no changes to written plan unless agreed by
professionals and family at weekly meeting)
Dental Care
Young people with eating disorders who are vomiting should see their dentist and should be
given advice on dental hygiene including avoiding brushing after vomiting and rinsing with a
non-acidic mouthwash.
Damian Wood
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Paediatric Clinical Guideline
Adolescent Medicine
12.2 Eating Disorders
Management of Complications
Hypoglycaemia and critical electrolyte derangement
Hypoglycaemia
Plasma glucose <2.5mmol/L
Hypomagnesaemia
Serum Mg <0.6mmol/L
Hypophosphataemia
Serum Phosphate <0.32mmol/L
Hypokalaemia
Serum potassium <2.5mmol/L
Correct with 5mls/kg of 10% glucose iv
Institute ECG and blood pressure monitoring.
Correct with iv 0.2ml/kg 50% MgSO4 (max 10ml) in
250ml NaCl over 4 hours
Institute ECG and blood pressure monitoring
Use intravenous potassium dihydrogen phosphate
(0.08 - 0.16 mmol/kg diluted appropriately over 6 hours)
Institute ECG monitoring. Correct with the addition of
intravenous KCl to IV fluids. (DO NOT EXCEED
0.4mmol/kg/h)
Refeeding syndrome
When nutrition is re-introduced after a prolonged period of malnutrition there is a risk of
refeeding syndrome which may result in cardiac failure and death. Refeeding syndrome is
due to total body phosphate depletion and a shift of extracellular to intracellular phosphate
when there is a switch from catabolism to anabolism. The risk of cardiac decompensation
with arrythmias and cardiac failure is highest in the initial stages of refeeding when left
ventricular function is already compromised by chronic malnutrition.
Features of the syndrome include:
 delirium with visual and auditory hallucinations
 dyspnoea
 paraesthesia
 generalized weakness and fatigue
 peripheral oedema
 seizures
 coma
All young people admitted with an eating disorder should have routine
phosphate supplementation during refeeding.
Prevention of the refeeding syndrome
 Gradual introduction of nutrition (discuss with dietician)
 Correction of dehydration
 Monitoring of electrolytes including
 Routine phosphate supplementation Sandoz Phosphate one tablet twice daily for
first five days after re-introduction of nutrition
If a young person has clinical features of the re-feeding syndrome:
 Stop enteral and parenteral nutrition
 Ensure monitoring of
o blood pressure, ECG and cardiac status
o neurological observations
o weight, fluid balance and hydration status
 Urgent correction of electrolyte abnormalities with subsequent careful monitoring of
electrolytes, calcium, phosphate and magnesium
 Correct dehydration with intravenous fluids over 48hours (note too rapid correction of
dehydration may result in cardiac decompensation) with correction of hydration status
 Consider multivitamin, zinc and thiamine supplementation
Damian Wood
Page 8 of 10
January 2007
Paediatric Clinical Guideline
Adolescent Medicine
12.2 Eating Disorders
References
National Institute of Clinical Excellence Guideline No. 9. Eating Disorders Core Interventions
in the treatment and management of anorexia nervosa, bulimia nervosa and related eating
disorders. January 2004 (www.nice.org.uk)
Neinstein LS Adolescent Healthcare: A practical guide 4th Edition Lippincott Williams and
Wilkins, Philadelphia
Viner R ABC of Adolesence BMJ Publishing London
American Psychiatric Association. 2nd Edition Practice Guideline for the Treatment of Patients
with Eating Disorders. Arlington
Rome ES et al Children and Adolescents with Eating Disorders: The State of the Art
PediatricsPediatrics 2003;111: e95-e108
Lask B Eating Disorders in Children and Adolescence Current Paediatrics 2000;10:254-258
Rome ES Ammerman S Medical Complications of Eating Disorders: An Update. Journal of
Adolescent Health 2003;33:418-426
The authors also incoporated elements form similar guidelines produced by Starship
Children’s Hospital, Auckland New Zealand and the Royal Children’s Hospital, Melbourne,
Australia.
Information for Young People, Parents and their Families
The Eating Disorders Association
103 Prince of Wales Road
Norwich
NR1 1DW
Adult Helpline: 0845 634 1414 (open 8:30 to 20:30 weekdays)
Youthline: 0845 634 7650 (open 16:00 to 18:30 weekdays)
www.edauk.com
YoungMinds
An organization that provides information and advice on child mental health issues.
102-108 Clerkenwell Road,
London
EC1M 5SA.
Parents' Information Service 0800 018 2138;
www.youngminds.org.uk
Royal College of Psychiatry
The Mental Health and Growing Up series contains 36 leaflets on a range of common mental
health problems.
To order the pack, contact
Book Sales
Royal College of Psychiatrists
17 Belgrave Square
London SW1X 8PG
Tel. 020 7235 2351, ext. 146
Fax 020 7245 1231; e-mail: booksales@rcpsych.ac.uk
Damian Wood
Page 9 of 10
January 2007
Paediatric Clinical Guideline
Adolescent Medicine
12.2 Eating Disorders
Title
Eating Disorders: Recognition and Initial Management
Guideline Number
12.2
Version
Final
Distribution
All wards QMC and CHN
Author
Dr Mark Anderson
Paediatric Specialist Registrar
Dr Damian Wood
Consultant Paediatrician
First Issued
January 2007
Document Derivation
NICE Eating Disorders
Guideline
Latest Version Date
January 2007
Review Date
January 2010
Ratified By
Paediatric Clinical Guidelines Meeting
Date
January 2007
Audit
Amendments
Damian Wood
Induction Programme
Page 10 of 10
January 2007