Guidelines for the Admission of Children and Young People with an Eating Disorder

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1 Guidelines fr the Admissin f Children and Yung Peple with an Eating Disrder This dcument is designed t be used by clinicians lcated in hspitals f wards withut specialist eating disrder facilities, t guide in indicatrs fr admissin f children and yung peple with an eating disrder.

2 Intrductin This dcument is designed t be used by clinicians lcated in hspitals r wards withut specialist eating disrder facilities, t guide in the assessment f eating disrders, indicatrs fr admissin, and management strategies. This guideline was prduced by the NSW Statewide Cmmittee f Eating Disrder Medical Lead (SCEDML) Subcmmittee which reprts t the NSW Service Plan fr Peple with Eating Disrders Implementatin Steering Cmmittee. Purpse f the Guidelines T prvide lcal health staff with infrmatin abut when t admit a child r adlescent with an eating disrder wh presents t the hspital setting either thrugh Emergency Departments r ther pathways. It is recgnised that children and adlescents wh present with an eating disrder are at high risk f medical instability, cgnitive impairment, psychiatric cnditins, suicidal ideatin, and/r deliberate self-harm. These utcmes require timely and apprpriate interventin t prevent further deteriratin and enable recvery. Scpe f the Guidelines These guidelines cver children and adlescents wh present t the emergency department with a diagnsis r query diagnsis f an eating disrder. They are designed t be used in cnjunctin with lcal prtcls and clinical expertise. Fr cmprehensive inpatient management guidance, clinicians shuld refer t the Eating Disrders Tlkit: A Practice-Based Guide t the Inpatient Management f Children and Adlescents with Eating Disrders fund n the Centre fr Eating and Dieting Disrders Website ( Backgrund Children and adlescents with an eating disrder are at great risk f medical and psychiatric cmplicatins, in particular thse presenting with Anrexia Nervsa. It is therefre essential t have efficient and timely medical and psychiatric assessment and treatment cmmenced. The cause f medical cmplicatins can be due t bth the amunt f weight lss, the rapidity f the weight lss and the cmpensatry behaviurs (vmiting, laxative abuse, diuretic abuse, diet tablets and cmpulsive exercise) that may be being used. Children and adlescents with an eating disrder have high levels f psychiatric cmrbidity. Acute psychiatric presentatins include majr depressin, deliberate self-harm, suicidal ideatin, anxiety disrders and bsessive cmpulsive disrder.

3 Emergency Medical Assessment Triage All children and yung peple presenting t the Emergency Department will be triaged using the Australian Triage Scale (ATS). Triage categry will reflect urgency f care. Baseline medical bservatins (pulse, bld pressure and temperature) Mnitring Medical instability fr the purpse f this dcument is defined as: Heart Rate < 50 beats/min Temperature < 35.5 C Bld Pressure < 80/40 mm/hg r pstural drp >30 mm/hg All unstable patients shuld have cntinuus mnitring f their heart rate and regular mnitring f their bld pressure and temperature. This can be dne by placing the patient in a mnitred bed r the use f a prtable cardiac mnitr. If a patient is deemed medically unstable treatment is t cmmence as sn as pssible (refer t medical treatment). Patients wh are medically stable shuld have 4 hurly mnitring f heart rate, bld pressure and temperature. If a persn presents dehydrated (urine SG 1020) then this needs t be taken int cnsideratin with their bservatins i.e. a persn s heart rate will be higher when dehydrated.

4 Eating Disrder Assessment Histry Histry f presenting illness Minimum weight (Current weight) Maximum weight Duratin f weight lss Means f weight lss: dietary restrictin, purging, excessive exercise, vmiting, laxatives Fear f weight gain Bdy image distrtin Date f menarche Primary r secndary amenrrhea Family cmpsitin C-mrbid cnditins Medical Psychiatric (see mental health assessment belw) Physical Examinatin and Investigatins Height and weight (withut shes and in light clthing) Measurement f vital signs (pulse, pstural BP and temperature) Cardivascular examinatin including peripheral circulatin GIT examinatin Evidence f self-harm Urinalysis ECG Recmmended bld analysis: EUC, FBC, LFT, CMP TSH, T3, T4, LH, FSH, estradil, amylase, ferritin, CK, and BSL

5 Eating Disrder Inpatient Admissin Admissin If any f the signs listed belw are present the patient shuld be admitted t hspital. Medical instability: HR < 50 bpm, Temp < 35.5 C, BP < 80/40 mm/hg r pstural drp >30 mm/hg, electrlyte imbalance, cardiac arrhythmia Significant risk f self-harm r suicide Cnsider Admissin Psychiatric r medical admissin shuld be cnsidered if any f the fllwing criteria are met. Dehydratin and refusal t eat r drink BMI 14 Rapid weight lss (>6kg in 6 weeks) Increased aggressin resulting in either the patient and/r family being at risk f harm Prlnged utpatient care with minimal r n prgressin Cnsent In children under the age f 14 years treatment including nas-gastric refeeding can ccur with parental cnsent In children between the ages f 14 and 16 years treatment ideally requires adlescent and parental cnsent. In children aged 16 years and lder treatment requires the cnsent f the adlescent. In children aged ver 14 years wh are medically unstable and cnsent is refused, alternate cnsent shuld be sught with cnsideratin given t the use f the Mental Health Act r the Guardianship Act. Cnsent shuld be dcumented in patients ntes

6 Medical Treatment It is essential t cmmence treatment as sn as pssible nce it is determined that a patient is medically unstable. It is recmmended that a lng-term silastic nas-gastric tube (size 8) is inserted and feeding cmmenced as belw (t be dcumented in patients ntes): If phsphate < 1.0 mml/l, feeds t be 0.5 kcal/ml at 100ml/hur If dehydrated (urine SG 1020), feeds t be 0.5 kcal/ml at 100ml/hur If BMI < 14 the feeds t be 0.5 kcal/ml at 100ml/hur Otherwise cmmence feeds at 1 kcal/ml at 100mls/hur Apprpriate feeds include nutritinally cmplete liquid enteral frmula 1kcal/ml Aggressively replete all electrlyte deficiencies. Oral repletin is preferable but IV supplementatin may be necessary. It is nt necessary t crrect fluid and electrlyte imbalance befre initiating feeding. With careful mnitring, this can be safely achieved simultaneusly. Prir t the cmmencement f feeds 500mg Phsphate t be given either rally r via NGT Cntinue Phsphate at 500mg BD Give thiamine rally at a dse f 100mg a day and a multivitamin with phsphate Cntinuus cardiac mnitring Bed rest N regular meals during nasgastric feeding Cmmence verhead heating with Bair Hugger r heating lamps if HR <50 b/min Temperature 35.5 C Alter calling criteria nly in cnsultatin with a cnsultant Yellw zne = HR < 40 b/min Red zne = HR <35 b/min A minimum f nce daily mnitring f EUC, CMP and LFTs fr at least a week t address the risk f refeeding syndrme

7 Mental Health Assessment Pst-Acute Medical Treatment Mental health assessment shuld ccur in all medically stable patients prir t discharge. Psychiatric assessment shuld als ccur in medically unstable patients nce acute medical treatment, including nas-gastric refeeding, has cmmenced. Assessment shuld include: Histry f presenting illness including Onset and duratin f illness Maximum and minimum weights Duratin and speed f weight lss Methds f weight-lss (dietary restrictin, exercise, purging) Fear f weight gain Abnrmal bdy image Denial f illness severity Previus eating disrder admissins Presence f cmrbid psychiatric illnesses Md Disrders (Majr Depressive Disrder, Biplar Disrder) Anxiety Disrders (Generalised Anxiety Disrder, Scial Anxiety Disrder, PTSD, Panic Disrder, Separatin Anxiety Disrder) Obsessive Cmpulsive Disrder Psychtic Disrders Drug and Alchl use Safety assessment Suicidal ideatin Deliberate self-harm Past suicidal behaviur and deliberate self-harm Risk t thers Sexual histry Family and Scial Histry Family cmpsitin Family stressrs Family histry f eating disrders r psychiatric disrders Past Medical and Psychiatric Histry Current Medicatins

8 Psychiatric Treatment Treatment shuld be decided fllwing assessment in cnjunctin with the n call mental health team. In the case f significant patient distress cnsideratin shuld be given t the use f regular r PRN antipsychtic medicatin (Olanzapine mg, Quetiapine mg, Risperidne mg) Discharge t cmmunity If the yung persn des nt require an inpatient admissin it is essential t ensure adequate fllw up is rganised befre they leave the department. Key cnsideratins: Medical fllw up with Paediatrician GP Psychlgical supprt frm CAMHS Eating Disrder Service if available Private psychlgist Headspace Tertiary Supprt If yu require supprt r advice regarding a yung persn wh presents with an eating disrder yu can cntact: J Tittertn, Clinical Nurse Cnsultant, Eating Disrder Netwrk Crdinatr: Sydney Children s Hspital Netwrk (SCHN). janne.tittertn@health.nsw.gv.au r

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