Category Archives: For General Practitioners

Eating disorders in young people

With thanks to Dr Ed Dallas, paediatric registrar, for putting together a succinct guide to eating disorders and the management of re-feeding syndrome.

Re-introduction of nutrition to severely malnourished individuals can precipitate refeeding syndrome which may result in cardiac failure and death.

The key biochemical abnormality is hypophosphataemia, due to total body phosphate depletion and a shift of extracellular to intracellular phosphate when the body changes from a catabolic state to anabolic.

The risk is greatest in the initial stages of refeeding (first week). The incidence increases with decreasing BMI and if weight loss is rapid.

Anorexia is a serious, potentially fatal disease—while refeeding syndrome can be fatal, the risk from malnutrition and ‘underfeeding’ is much greater.

In A&E:

– Assess using SCOFF questionnaire and Sit-up/Squat test.

– Consider differentials for weight loss in children (e.g. Malignancy, hormonal, illness)

Risk Assessment according to Junior MARSIPAN guidelines: Clinical parameters, location of care, compulsory admission/treatment, legislation (e.g. Gillick competence, Mental Health Act)

See Summary below of what to look for and when to be concerned!

Once admitted:

  • Baseline bloods: Red flags: Na+ < 130mmol/L, K+ < 3mmol/L, Phosph < 0.5mmol/L often symptomatic if phosphate <1mmol/L (range 1.3-2.1mmol/L), Glucose
  • ECG (look specifically for prolonged QTc)
  • For children, use the percentage of 50th centile BMI, not just the BMI.*
  • All vital signs, however, are to be checked against standard charts for their age. Patients can be hypotensive, bradycardic, hypothermic.

*Plot BMI on growth chart.  To calculate percentage median BMI:

Percentage BMI =             actual BMI (weight/height2) x 100

median BMI (50th percentile) for age & gender

 

Treatment & Re-feeding:

Patient should be fed in as normal a fashion as possible. If this fails, NG feeds should be considered early in the admission.  Make the decision within 24 hours. Specialist paediatric dietician must be involved early.

 

 

Risk from Re-feeding Syndrome can be reduced by careful monitoring and paediatric dietician input into choice of feed composition.  A diet too high in carbohydrates increases the risk of re-feeding syndrome.

 

Consider phosphate (and other) supplementation early. Replace and titrate according to bloods which should be taken just before the supplement is given. Stores are usually replenished after 1 week but continue for at least 2 weeks. Consider long term lower dose supplementation.

Re-feeding Bloods (U&Es, LFTs, Phosphate, Calcium, Magnesium) to be taken before re-feeding, 6 hours after starting and then daily for 2-5 days, then at 7-10 days, at least until 2 weeks. Ideally, bloods to be taken just before any supplementation are given (so levels are not falsely high).

Patients should not be ‘underfed’ for fear of refeeding syndrome: consider starting at 20 kcal/kg/day, 5-10kcal/kg/day if high risk

CAMHS

 

SCOFF questionnaire for screening Anorexia and Bulimia

Shown to have 100% sensitivity and a specificity of 89% for patients with anorexia and bulimia.

*One point for every “yes”

A score of ≥2 indicates a likely case of anorexia nervosa or bulimia

Young people with an eating disorder may deny all the above, in which case it is very important to use your clinical judgement, monitor the situation and provide follow-up.

 

SUSS Test – see diagram below

Those who are High risk for re-feeding syndrome

  •  Very low percentage median body mass index
  •  Minimal or no nutritional intake for the past 3–4 days
  •  Weight loss >15% in the past 3 months
  •  Abnormal electrolytes prior to starting re-feeding

→ May need a more cautious approach (5–10 kcal/ kg/day starting regimen) with twice daily bloods

Refeeding Plan:

  • Paediatric dietician for specialist advice.
  • Correct dehydration – usually over 48 hours as too rapid correction can result in cardiac decompensation
  • Prescribe multivitamin and mineral supplements; consider thiamine in older children. Start any multivitamins and mineral supplementations before feeding begins (NICE CG9)
  • Refeeding should ideally mimic normal eating
  • If the patient cannot comply with a meal plan then NG considered by 24 hours. Use a daytime bolus regimen to mimic physiological eating
  • Consider starting at 20 kcal/kg/day. Aim for 0.5–1 kg/week weight gain.
  • To prevent underfeeding—aim to increase by 200 kcal/day until full nutritional requirements for weight gain are achieved (this should be within 5–7 days).
  • If hypophosphataemia develops, maintain rather than reduce calorie intake; consider supplementation.
  • Daily Re-feeding bloods (U&Es, LFTs, phosphate, magnesium) during the ‘at-risk’ period of days 2–5 initially, and at 7– 10 days (to identify late refeeding syndrome) up to at least 2 weeks
  • Restrict carbohydrate intake and increase dietary phosphate (eg, using milk). If NG feeding, avoid high calorie concentration feeds (high carbohydrate content increases the risk of re-feeding syndrome).

 

WHAT SHOULD I START DOING?

  1. Assess nutritional status based on percentage median BMI, and not BMI alone.
  2. Baseline clinical assessment of risk includes baseline ECG and SUSS test for weakness.
  3. Have a low threshold for starting NG feeding and avoid an overcautious approach to re-feeding (consider starting at 20 kcal/kg/day and increasing by 200 kcal/day until nutrition is sufficient for weight gain).
  4. Always consider re-feeding syndrome—monitor patient’s electrolytes (especially phosphate) before and during re-feeding, and assess the risk of re-feeding syndrome prior to starting feeding.
  5. Prescribe a general vitamin and mineral supplement in younger children, and consider thiamine supplements in older children (main evidence in adults).

WHAT SHOULD I STOP DOING?

  1. Taking an overcautious approach to re-feeding (may result in underfeeding syndrome)—patients should be receiving sufficient nutrition for weight gain within 5–7 days of re-feeding.
  2. For patients receiving supplemental or NG feeds, avoid calorie dense feeds, which may be too high in carbohydrates and increase the risk of re-feeding syndrome.

 

Useful Summary of Marsipan guidelines from BMJ:

https://ep.bmj.com/content/edpract/early/2015/09/25/archdischild-2015-308679.full.pdf?keytype=ref&ijkey=zgb4e3x2vGIWEmL

Link to FULL Junior Marsipan Guidance from RCPSYCH (75 page PDF):

https://www.rcpsych.ac.uk/docs/default-source/improving-care/better-mh-policy/college-reports/college-report-cr168.pdf?sfvrsn=e38d0c3b_2

Medical Management of Anorexia Nervosa:

https://www.researchgate.net/profile/Michael_Tremlett/publication/51498098_Medical_management_of_acute_severe_anorexia_nervosa/links/57581da908ae5c6549074ca6/Medical-management-of-acute-severe-anorexia-nervosa.pdf?origin=publication_detail

Managing Anorexia;  BMJ Review:

https://adc.bmj.com/content/96/10/977

Hypophospataemia in Anorexia Nervosa; BMJ review:

https://pmj.bmj.com/content/77/907/305.full

 

Sit-up and Squat-stand (SUSS) test

March 2020 – first all safeguarding edition!

March has been guest edited by Dr Jackie Driscoll, Academic GP and erstwhile paediatric registrar.  Jackie was keen to produce a newsletter which centres on the child but sees them in the context of their family, their school and neighbourhood.

Do leave comments below:

 

February 29th 2020

Burns this month – with much discussion amongst the editorial group prior to publication.  There are lots of different children’s burns protocols it transpires.  RCEM’s is not aligned with the London and South East Burns Network’s.  The message is “use your own burns referral unit’s guideline”.  The other important message about burns is watch out for NAI but, even if the burn is accidental, refer all children to their health visitor as HVs in the UK are responsible for talking to families about safety in the home.

Also, complications of Kawasaki Disease, ADHD and the updated MAP guideline (managing cows milk allergy in primary care) which emphasises that 98% of crying babies do not have CMPA.  Do leave comments below.

Happy Christmas and best wishes for the new decade from the Paediatric Pearls team, December 2019

A bit of a viral soup this month with articles on ‘flu vaccines, how long should children have off school when unwell, NAFLD, and dermatomyositis.  Do leave comments below.

November 2019 PDF digest

Bloody diarrhoea this month.  Inflammatory bowel disease patients are getting younger.  Also croup and acanthosis nigricans, 2 things that probably don’t go together very often.  Do leave comments below.

October 2019 PDF

Causes of chest pain in children this month (hint: it’s not the heart), causes of tachycardia, nosebleeds, Down Syndrome annual reviews, causes of erythema nodosum and a link to a fantastic document on the top 20 paediatric outpatient referrals.  Read this document from Birmingham Women and Children’s Hospital and cut your referrals by at least 50%!

September 2019 PDF digest

I’m uploading this month’s newsletter while teaching in Vietnam at the invitation of a very impressive charity, https://www.newbornsvietnam.org/.  I’m glad of the extra 6 hours of September – thanks to the time difference – to publish this on time!

Palivizumab this month; are all your eligible patients having it?  A glance at the updated BTS/SIGN guideline on asthma, a very rare case of a cardiac cause of chest pain, how to estimate a child’s weight in an emergency and a bit on haemolysis secondary to G6PD deficiency.  Do leave comments below…

July 2019 PDF

July 2019:  Honing in on coca cola coloured urine this month and a closer look at armpits.  Links to suitable child safeguarding CPD on harmful sexual behaviour and a look at the ANA test.  Do leave comments below.

June 2019 newsletter

Possible causes of macrocephaly this month.  Also the start of a new series on causes of coca-cola coloured urine and updates on safeguarding CPD requirements and the terminology of children “in care”.  Do leave comments below:

April and May became combined this year…

April came and went a bit too fast for my Paediatric Pearls head.  So I’ve produced a joint April/May newsletter for 2019.  There’s a bit of safeguarding again this month with a link to a paper on what young people in care think of the language we use, a guide to enteral rehydration of children with D&V, acrodermatitis enteropathica and a reminder of what is normal on a paediatric ECG.  Do leave comments below: