Tag Archives: nutrition

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

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 2018 newsletter

This month brings a handout entitled “Towards a healthy lifestyle…” which is a collaboration between dietitians, physiotherapists, psychiatrists and paediatricians at Homerton Hospital.  We have found many families are keen to do something about their child’s weight but don’t know where to start.  Hopefully this friendly article aiming for families to be “healthy enough” is a good place to start.

Also a bit on faltering growth, on-line safety, BRUE and the investigations that do not need to be done.  Tachycardia is (of course) mentioned again.  Do leave comments below.

September 2018 PDF content

September’s newsletter reminds us of the CPD requirements for child safeguarding for all of us, warns us of the dangers of missing Kawasaki Disease, talks about PHE’s #askaboutasthma campaign and describes the differences between fever and sepsis.  Do leave comments below:

March 2018 PDF in time for Easter

NICE on faltering growth this month, paediatric stroke, a reminder of the new epilepsy classification and a contribution from the safeguarding team on what constitutes a “legal high”?  Do leave comments below:

September 2107 PDF ready to go

A bit more on babies’ stooling habits this month, NICE’s update on the epilepsies and glycosuria.  Also the annual round up of useful blogs to get newcomers off to a good start in their paediatric practice.  Please do leave comments below:

February 2017

The burns triage tool this month plus a bit on urinalysis (pH) and the start of our decoding the FBC series.  Also a reminder about the MAP guideline for management of CMPA in primary care, a link to some good courses on this topic and to a document I have put together on milks to use in the UK for CMPA.

Welcome to January 2016

January 2016 newsletter continues on the theme of asthma and covers internet safety, IDA and early weight loss in breastfed babies.  Do leave comments below:

Potted background, assessment and management of vitamin D deficiency

Vitamin D deficiency in children with thanks to Dr Jini Haldar, paediatric registrar at Whipps Cross University Hospital.

Introduction

Vitamin D is an essential nutrient needed for healthy bones, and to control the amount of calcium in our blood. There is recent evidence that it may prevent many other diseases.  There are many different recommendations for the prevention, detection and treatment of Vitamin D deficiency in the UK.  The one outlined below is what we tend to do at Whipps Cross Hospital.

 Prevention

The Department of Health and the Chief Medical Officers recommend a dose of 7-8.5 micrograms (approx. 300 units) for all children from six months to five years of age. This is the dose that the NHS ‘Healthy Start’ vitamin drops provide. The British Paediatric and Adolescent Bone Group’s recommendation is that exclusively breastfed infants receive Vitamin D supplements from soon after birth. Adverse effects of Vitamin D overdose are rare but care should be taken with multivitamin preparations as Vitamin A toxicity is a concern. Multivitamin preparations often contain a surprisingly low dose of Vitamin D.

Indications for measurement of vitamin D

 1. Symptoms and signs of rickets/osteomalacia

  • Progressive bowing deformity of legs
  • Waddling gait
  • Abnormal knock knee deformity (intermalleolar distance > 5 cm)
  • Swelling of wrists and costochondral junctions (rachitic rosary)
  • Prolonged bone pain (>3 months duration)

2. Symptoms and signs of muscle weakness

  • Cardiomyopathy in an infant
  • Delayed walking
  • Difficulty climbing stairs

3. Abnormal bone profile or x-rays

  • Low plasma calcium or phosphate
  • Raised alkaline phosphatase
  • Osteopenia or changes of rickets on x-ray
  • Pathological fractures

4. Disorders impacting on vitamin D metabolism

  • Chronic renal failure
  • Chronic liver disease
  • Malabsorption syndromes, for example, cystic fibrosis, Crohn’s disease, coeliac disease
  • Older anticonvulsants, for example, phenobarbitone, phenytoin, carbamazepine

5. Children with bone disease in whom correcting vitamin D deficiency prior to specific treatment would be indicated:

 

Symptoms and signs in children of vitamin D deficiency

1. Infants: Seizures, tetany and cardiomyopathy

2. Children: Aches and pains: myopathy causing delayed walking; rickets with bowed legs, knock knees, poor growth and muscle weakness

3. Adolescents: Aches and pains, muscle weakness, bone changes of rickets or osteomalacia

 

Risk factors for reduced vitamin D levels include:

  • Dark/pigmented skin colour e.g. black, Asian populations
  • Routine use of sun protection factor 15 and above as this blocks 99% of vitamin D synthesis
  • Reduced skin exposure e.g. for cultural reasons (clothing)
  • Latitude (In the UK, there is no radiation of appropriate wavelength between October and March)
  • Chronic ill health with prolonged hospital admissions e.g. oncology patients
  • Children and adolescents with disabilities which limit the time they spend outside
  • Institutionalised individuals
  • Photosensitive skin conditions
  • Reduced vitamin D intake
  • Maternal vitamin D deficiency
  • Infants that are exclusively breast fed
  • Dietary habits – low intake of foods containing vitamin D
  • Abnormal vitamin D metabolism, abnormal gut function, malabsorption or short bowel syndrome
  • Chronic liver or renal disease

 

Management depends on the patient’s characteristics:

 A. No risk factors

No investigations, lifestyle advice* and consider prevention of risk factors

 

B. Risk Factors Only

1. Children under the age of 5 years: Lifestyle advice* and vitamin D supplementation.

Purchase OTC or via Healthy Start

Under 1 year: 200 units vitamin D once daily

1 – 4 years: 400 units vitamin D once daily

 

2. Children 5 years and over – offer lifestyle advice*

 

 

C. Risk Factors AND Symptoms, Signs

Lifestyle advice*

Investigations:

  • Renal function, Calcium, Phosphate, Magnesium (infants), alkaline phosphatase,
  • 25-OH Vitamin D levels, Urea and electrolytes, parathyroid hormone

 

Children can be managed in Primary Care as long as:

  • No significant renal impairment
  • Normal calcium (If <2.1 mmol/l in infants, refer as there is a risk of seizures)

If further assessment is required consider referral to specialist. **

Patient’s family is likely to have similar risk of Vitamin D deficiency – consider investigation ant treatment if necessary.

 

 

*Life style advice

 

1. Sunlight

Exposure of face, arms and legs for 5-10 mins (15-25 mins if dark pigmented skin) would provide good source of Vitamin D. In the UK April to September between 11am and 3pm will provide the best source of UVB. Application of sunscreen will reduce the Vitamin D synthesis by >95%. Advise to avoid sunscreen for the first 20-30 minutes of sunlight exposure. Persons wearing traditional black clothing can be advised to have sunlight exposure of face, arms and legs in the privacy of their garden.

2. Diet

Vitamin D can be obtained from dietary sources (salmon, mackerel, tuna, egg yolk), fortified foods (cow, soy or rice milk) and supplements. There are no plant sources that provide a significant amount of Vitamin D naturally.

 

  **Criteria for referral
  • Criteria for management in primary care not met
  • Deficiency established with absence of known risk factors
  • Atypical biochemistry (persistent hypophosphatemia, elevated creatinine)
  • Failure to reduce alkaline phosphatase levels within 3 months
  • Family history (parent, siblings) with severe rickets
  • Infants under one month with calcium <2.1mmmol/l at diagnosis as risk of seizure.  (Check vitamin D level of mothers in this group immediately and treat, particularly if breast feeding.)
  • If compliance issues are anticipated or encountered during treatment.
  • Satisfactory levels of vitamin D not achieved after initial treatment.

 

  Vitamin D levels, effects on health and management of deficiency

level effects

management

< 25 nmol/l (10micrograms/l) Deficient.  Associated with rickets, osteomalacia Treat with high dose vitamin D

Lifestyle advice AND vitamin D (ideally cholecalciferol)

• 0 – 6 months: 3,000 units daily

• 6 months – 12 yrs: 6,000 units daily

• 12 – 18 yrs: 10,000 units daily

vitamin D 25 – 50 nmol/l (10 – 20micrograms/l Insufficient and associated with disease risk Over the counter (OTC) Vitamin D supplementation (and maintenance therapy following treatment for deficiency) should be sufficient.

 

• Lifestyle advice and  vitamin D supplementation

< 6 months: 200 – 400 units daily (200 units may be inadequate for breastfed babies)

Over 6 months – 18 years: 400 – 800 units daily

50 – 75 nmol/l (20 – 30micrograms/l) Adequate Healthy Lifestyle advice
> 75 nmol/l (30 micrograms/l) Optimal Healthy None

 

Course length is 8 – 12 weeks followed by maintenance therapy.

 

 Checking of levels again

As Vitamin D has a relatively long half-life levels will take approximately 6 months to reach a steady state after a loading dose or on maintenance therapy. Check serum calcium levels at 3 months and 6 months, and 25 – OHD repeat at 6 months. Review the need for maintenance treatment.  NB:  the Barts Health management protocol uses lower treatment doses for a minimum of 3 months and then there is no need for repeat blood tests in the majority of cases of children satisfying the criteria for management in primary care.

 Serum 25 OHD after 3 months treatment Action

level action review
>80nmol/ml Recommend OTC prophylaxis and lifestyle advice as required
50 – 80 nmol/mL Continue with current treatment dose reassess in 3 months
< 50 nmol/mL Increase dose or, in case of non-adherence/concern refer to secondary care.  

It is essential to check the child has a sufficient dietary calcium intake and that a maintenance vitamin D dose follows the treatment dose and is continued long term.

Follow-up:

Some recommend a clinical review a month after treatment starts, asking to see all vitamin and drug bottles. A blood test can be repeated then, if it is not clear that sufficient vitamin has been taken.

Current advice for children who have had symptomatic Vitamin D deficiency is that they continue a maintenance prevention dose at least until they stop growing. Dosing regimens vary and clinical evidence is weak in this area. The RCPCH has called for research to be conducted.  The RCPCH advice on vitamin D is at http://www.rcpch.ac.uk/system/files/protected/page/vitdguidancedraftspreads%20FINAL%20for%20website.pdf

JINI HALDAR

 

March 2015 published

March 2015: the first post of the new ENT feature this month – glue ear, more help with viral exanthems, important safeguarding information on the UK government’s Prevent Strategy, breastfeeding for mums and research in the paediatric ED.