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The Role of the Paediatric Team in the Management of Young People with Severe AN

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Critical Care for Anorexia Nervosa

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Abstract

Successful treatment of children and young people with anorexia nervosa requires the establishment of a successful partnership between mental health and paediatric staff. Whilst children and adolescents with AN are difficult to manage in a traditional paediatric setting, which is generally geared to patients under 5 years, the number of hospital admissions for AN aged 14 and under has doubled in the past 10 years. Evaluation of failure to thrive is a basic paediatric skill, although specific knowledge about eating disorders is often poor. Risk factors to consider include bradycardia, hypotension, prolonged QTc, dehydration and hypothermia and electrolytes can be deranged. The refeeding syndrome can be seen during treatment, especially with high rates of feeding, enteral feeding, high carbohydrate loads and if the patient has lost weight rapidly, is more severely underweight and has a low baseline white cell count. We provide detailed guidance on refeeding and how to treat refeeding syndrome should it occur.

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References

  • Bell A, Mcleod K (2007) Not so funny turns. Archiv Dis Childhood-Educ Pract Edn 92:7–13

    Google Scholar 

  • Bergman AS, Fritz GK (1985) Pediatricians and mental health professionals: patterns of collaboration and utilization. Arch Pediatr Adolesc Med 139:155

    CAS  Google Scholar 

  • Beumont P, Beumont R, Hay P, Beumont D, Birmingham L, Derham H, Jordan A, Kohn M, Mcdermott B, Marks P (2004a) Australian and New Zealand clinical practice guidelines for the treatment of anorexia nervosa. FOCUS

    Google Scholar 

  • Beumont P, Hay P, Beumont D, Birmingham L, Derham H, Jordan A, Kohn M, Mcdermott B, Marks P, Mitchell J, Paxton S, Surgenor L, Thornton C, Wakefield A, Weigall S (2004b) Australian and New Zealand clinical practice guidelines for the treatment of anorexia nervosa. Aust N Z J Psychiatry 38:659–70

    Article  PubMed  Google Scholar 

  • Boateng AA, Sriram K, Meguid MM, Crook M (2010) Refeeding syndrome: treatment considerations based on collective analysis of literature case reports. Nutrition 26:156–67

    Article  PubMed  Google Scholar 

  • Bouquegneau A, Dubois BE, Krzesinski J-M, Delanaye P (2012) Anorexia nervosa and the kidney. Am J Kidney Dis 60:299–307

    Article  PubMed  Google Scholar 

  • Casiero D, Frishman WH (2006) Cardiovascular complications of eating disorders. Cardiol Rev 14:227–231

    Article  PubMed  Google Scholar 

  • Cole TJ, Flegal KM, Nicholls D, Jackson AA (2007) Body mass index cut offs to define thinness in children and adolescents: international survey. BMJ 335:194

    Article  PubMed Central  PubMed  Google Scholar 

  • Cole TJ, Freeman JV, Preece MA (1995) Body mass index reference curves for the UK, 1990. Arch Dis Child 73:25–29

    Article  CAS  PubMed Central  PubMed  Google Scholar 

  • Collins S (2007) Treating severe acute malnutrition seriously. Arch Dis Child 92:453–461

    Article  PubMed Central  PubMed  Google Scholar 

  • Crook MA, Hally V, Panteli JV (2001) The importance of the refeeding syndrome. Nutrition 17:632–7

    Article  CAS  PubMed  Google Scholar 

  • Cuerda C, Ruiz A, Velasco C, Breton I, Camblor M, Garcia-Peris P (2007) How accurate are predictive formulas calculating energy expenditure in adolescent patients with anorexia nervosa? Clin Nutr 26:100–6

    Article  CAS  PubMed  Google Scholar 

  • De Simone G, Scalfi L, Galderisi M, Celentano A, Di Biase G, Tammaro P, Garofalo M, Mureddu GF, De Divitiis O, Contaldo F (1994) Cardiac abnormalities in young women with anorexia nervosa. Br Heart J 71:287–292

    Article  PubMed Central  PubMed  Google Scholar 

  • Diamanti A, Basso MS, Castro M, Bianco G, Ciacco E, Calce A, Caramadre AM, Noto C, Gambarara M (2008) Clinical efficacy and safety of parenteral nutrition in adolescent girls with anorexia nervosa. J Adolesc Health 42:111–8

    Article  CAS  PubMed  Google Scholar 

  • Docx MK, Gewillig M, Simons A, Vandenberghe P, Weyler J, Ramet J, Mertens L (2010) Pericardial effusions in adolescent girls with anorexia nervosa: clinical course and risk factors. Eat Disord 18:218–225

    Article  PubMed  Google Scholar 

  • Dulcan MK, Costello EJ, Costello AYJ, Edelbrock C, Brent D, Janiszewski S (1990) The pediatrician as gatekeeper to mental health care for children: do parents’ concerns open the gate? J Am Acad Child Adolesc Psychiatry 29:453–458

    Article  CAS  PubMed  Google Scholar 

  • Faje AT, Fazeli PK, Miller KK, Katzman DK, Ebrahimi S, Lee H, Mendes N, Snelgrove D, Meenaghan E, Misra M (2014) Fracture risk and areal bone mineral density in adolescent females with anorexia nervosa. Int J Eat Disord 47:458–66

    Article  PubMed  Google Scholar 

  • Fleming S, Thompson M, Stevens R, Heneghan C, PlĂĽddemann A, Maconochie I, Tarassenko L, Mant D (2011) Normal ranges of heart rate and respiratory rate in children from birth to 18 years of age: a systematic review of observational studies. The Lancet 377:1011–1018

    Article  Google Scholar 

  • Garber AK, Michihata N, Hetnal K, Shafer MA, Moscicki AB (2012) A prospective examination of weight gain in hospitalized adolescents with anorexia nervosa on a recommended refeeding protocol. J Adolesc Health 50:24–9

    Article  PubMed  Google Scholar 

  • Gentile MG (2012) Enteral nutrition for feeding severely underfed patients with anorexia nervosa. Nutrients 4:1293–303

    Article  CAS  PubMed Central  PubMed  Google Scholar 

  • Golden NH, Katzman DK, Kreipe RE, Stevens SL, Sawyer SM, Rees J, Nicholls D, Rome ES (2003) Eating disorders in adolescents: position paper of the Society for Adolescent Medicine. J Adolesc Health 33:496–503

    PubMed  Google Scholar 

  • Goldenberg I, Moss AJ, Zareba W (2006) QT interval: how to measure it and what is “normal’. J Cardiovasc Electrophysiol 17:333–336

    Article  PubMed  Google Scholar 

  • Grinspoon S, Thomas L, Miller K, Pitts S, Herzog D, Klibanski A (2001) Changes in regional fat redistribution and the effects of estrogen during spontaneous weight gain in women with anorexia nervosa. Am J Clin Nutr 73:865–9

    CAS  PubMed  Google Scholar 

  • Haggerty RJ (1995) Child health 2000: new pediatrics in the changing environment of children’s needs in the 21st century. Pediatrics 96:804

    CAS  PubMed  Google Scholar 

  • Haglin L (2001) Hypophosphataemia in anorexia nervosa. Postgrad Med J 77:305–11

    Article  CAS  PubMed Central  PubMed  Google Scholar 

  • Health and Social Care Information Centre (2014) Hospital episode statistics. http://www.hscic.gov.uk/hes accessed 25/6/14

  • Herzog W, Deter H-C, Fiehn W, Petzold E (1997) Medical findings and predictors of long-term physical outcome in anorexia nervosa: a prospective, 12-year follow-up study. Psychol Med 27:269–279

    Article  CAS  PubMed  Google Scholar 

  • Hudson L, Nicholls D, Katzman D, Kennedy A (2012a) Eating disorder in children and adolescents-risky business? The Psychiatrist 36:437–437

    Article  Google Scholar 

  • Hudson LD (2012) What paediatricians should know about eating disorders in children and young people. J Paediatr Child Health 48:869–75

    Article  PubMed  Google Scholar 

  • Hudson LD, Cumby C, Klaber RE, Nicholls DE, Winyard PJ, Viner RM (2013) Low levels of knowledge on the assessment of underweight in children and adolescents among middle-grade doctors in England and Wales. Arch Dis Child 98:309–311

    Article  PubMed  Google Scholar 

  • Hudson LD, Nicholls DE, Lynn RM, Viner RM (2012b) Medical instability and growth of children and adolescents with early onset eating disorders. Arch Dis Child 97:779–84

    Article  PubMed  Google Scholar 

  • HĂĽtter G, Ganepola S, Hofmann WK (2009) The hematology of anorexia nervosa. Int J Eat Disord 42:293–300

    Article  PubMed  Google Scholar 

  • Jackson LV, Thalange NK, Cole TJ (2007) Blood pressure centiles for Great Britain. Arch Dis Child 92:298–303

    Article  PubMed Central  PubMed  Google Scholar 

  • Jayasinghe Y, Grover SR, Zacharin M (2008) Current concepts in bone and reproductive health in adolescents with anorexia nervosa. BJOG 115:304–315

    Article  CAS  PubMed  Google Scholar 

  • Jones JM, Lawson ML, Daneman D, Olmsted MP, Rodin G (2000) Eating disorders in adolescent females with and without type 1 diabetes: cross sectional study. BMJ 320:1563

    Article  CAS  PubMed Central  PubMed  Google Scholar 

  • Kastner S, Salbach-Andrae H, Renneberg B, Pfeiffer E, Lehmkuhl U, Schmitz L (2012) Echocardiographic findings in adolescents with anorexia nervosa at beginning of treatment and after weight recovery. Eur Child Adolesc Psychiatry 21:15–21

    Article  PubMed  Google Scholar 

  • Katzman DK (2012) Refeeding hospitalized adolescents with anorexia nervosa: is “start low, advance slow” urban legend or evidence based? J Adolesc Health 50:1–2

    Article  PubMed  Google Scholar 

  • Kligfield P, Hancock EW, Helfenbein ED, Dawson EJ, Cook MA, Lindauer JM, Zhou SH, Xue J (2006) Relation of QT interval measurements to evolving automated algorithms from different manufacturers of electrocardiographs. Am J Cardiol 98:88–92

    Article  PubMed  Google Scholar 

  • Kohn MR, Golden NH, Shenker IR (1998) Cardiac arrest and delirium: presentations of the refeeding syndrome in severely malnourished adolescents with anorexia nervosa. J Adolesc Health 22:239–43

    Article  CAS  PubMed  Google Scholar 

  • Kohn MR, Madden S, Clarke SD (2011) Refeeding in anorexia nervosa: increased safety and efficiency through understanding the pathophysiology of protein calorie malnutrition. Curr Opin Pediatr 23:390–4

    Article  CAS  PubMed  Google Scholar 

  • Lancet (2013) The global crisis of severe acute malnutrition in children. Lancet 382:1858

    Google Scholar 

  • Lask B, Bryant Waugh R, Wright F, Campbell M, Willoughby K, Waller G (2005) Family physician consultation patterns indicate high risk for early onset anorexia nervosa. Int J Eat Disord 38:269–272

    Article  PubMed  Google Scholar 

  • Leclerc A, Turrini T, Sherwood K, Katzman DK (2013) Evaluation of a nutrition rehabilitation protocol in hospitalized adolescents with restrictive eating disorders. J Adolesc Health 53:585–9

    Article  PubMed  Google Scholar 

  • Loftus EV (2004) Clinical epidemiology of inflammatory bowel disease: incidence, prevalence, and environmental influences. Gastroenterology 126:1504–1517

    Article  PubMed  Google Scholar 

  • Lundahl A, Kidwell KM, Nelson TD (2014) Parental misperceptions of children’s underweight status: a meta-analysis. Ann Behav Med, 1–10

    Google Scholar 

  • Maayan L, Correll CU (2011) Weight gain and metabolic risks associated with antipsychotic medications in children and adolescents. J Child Adolesc Psychopharmacol 21:517–535

    Article  CAS  PubMed  Google Scholar 

  • Mackenzie A, Barnes G, Shann F (1989) Clinical signs of dehydration in children. The Lancet 334:605–607

    Article  Google Scholar 

  • Madden S, Morris A, Zurynski YA, Kohn M, Elliot EJ (2009) Burden of eating disorders in 5–13-year-old children in Australia. Med J Aust 190:410–414

    PubMed  Google Scholar 

  • Marinella MA (2005) Refeeding syndrome and hypophosphatemia. J Intensive Care Med 20:155–9

    Article  PubMed  Google Scholar 

  • MARSIPAN (2014) Management of really sick patients with anorexia nervosa, College Report CR189. Royal College of Psychiatrists, London

    Google Scholar 

  • National Institute for Health and Care Excellence (2004) Eating disorders. Core interventions in the treatment and management of anorexia nervosa, bulimia nervosa and related eating disorders CG09. NICE, London

    Google Scholar 

  • National Institute for Health and Care Excellence (2006) Nutritonal support in adults: oral, enteral and parenteral nutrition CG32. NICE, London

    Google Scholar 

  • Neumark-Sztainer D, Story M, Falkner NH, Beuhring T, Resnick MD (1998) Disordered eating among adolescents with chronic illness and disability: the role of family and other social factors. Arch Pediatr Adolesc Med 152:871–8

    CAS  PubMed  Google Scholar 

  • Nicholls D, Hudson L, Mahomed F (2011a) Managing anorexia nervosa. Arch Dis Child 96:977–982

    Article  PubMed  Google Scholar 

  • Nicholls DE, Lynn R, Viner RM (2011b) Childhood eating disorders: British national surveillance study. Br J Psychiatry 198:295–301

    Article  PubMed  Google Scholar 

  • O’Connor G, Goldin J (2011) The refeeding syndrome and glucose load. Int J Eat Disord 44:182–5

    PubMed  Google Scholar 

  • O’Connor G, Nicholls D (2013) Refeeding hypophosphatemia in adolescents with Anorexia Nervosa: a systematic review. Nutr Clin Pract 28:358–64

    Article  PubMed Central  PubMed  Google Scholar 

  • Obarzanek E, Lesem MD, Jimerson DC (1994) Resting metabolic rate of anorexia nervosa patients during weight gain. Am J Clin Nutr 60:666–75

    CAS  PubMed  Google Scholar 

  • Olivares JL, Vazquez M, Fleta J, Moreno LA, Perez-Gonzalez JM, Bueno M (2005) Cardiac findings in adolescents with anorexia nervosa at diagnosis and after weight restoration. Eur J Pediatr 164:383–6

    Article  PubMed  Google Scholar 

  • Ornstein RM, Golden NH, Jacobson MS, Shenker IR (2003) Hypophosphatemia during nutritional rehabilitation in anorexia nervosa: implications for refeeding and monitoring. J Adolesc Health 32:83–8

    Article  PubMed  Google Scholar 

  • Orphanidou CI, Mccargar LJ, Birmingham CL, Belzberg AS (1997) Changes in body composition and fat distribution after short-term weight gain in patients with anorexia nervosa. Am J Clin Nutr 65:1034–41

    CAS  PubMed  Google Scholar 

  • Ozier AD, Henry BW (2011) Position of the American Dietetic Association: nutrition intervention in the treatment of eating disorders. J Am Diet Assoc 111:1236–41

    Article  PubMed  Google Scholar 

  • Patterson CC, Dahlquist GG, Green A (2009) Incidence trends for childhood type 1 diabetes in Europe during 1989–2003 and predicted new cases 2005–20: a multicentre prospective registration study. The Lancet 373:2027–2033

    Article  Google Scholar 

  • Peebles R, Wilson JL, Lock JD (2006) How do children with eating disorders differ from adolescents with eating disorders at initial evaluation? J Adolesc Health 39:800–805

    Article  PubMed  Google Scholar 

  • Pichard C, Kyle UG, Slosman DO, Penalosa B (1996) Energy expenditure in anorexia nervosa: can fat-free mass as measured by bioelectrical impedance predict energy expenditure in hospitalized patients? Clin Nutr 15:109–14

    Article  CAS  PubMed  Google Scholar 

  • Raj KS, Keane-Miller C, Golden NH (2012) Hypomagnesemia in adolescents with eating disorders hospitalized for medical instability. Nutr Clin Pract 27:689–94

    Article  PubMed  Google Scholar 

  • Reiter CS, Graves L (2010) Nutrition therapy for eating disorders. Nutr Clin Pract 25:122–36

    Article  PubMed  Google Scholar 

  • Roden DM (1993) Torsade de pointes. Clin Cardiol 16:683–686

    Article  CAS  PubMed  Google Scholar 

  • Rome ES, Ammerman S, Rosen DS, Keller RJ, Lock J, Mammel KA, OĂ­toole J, Rees JM, Sanders MJ, Sawyer SM (2003) Children and adolescents with eating disorders: the state of the art. Pediatrics 111:e98

    Article  PubMed  Google Scholar 

  • Ross WJ, Chan E, Harris SK, Goldman SJ, Rappaport LA (2011) Pediatrician-psychiatrist collaboration to care for children with attention deficit hyperactivity disorder, depression, and anxiety. Clin Pediatr 50:37–43

    Article  Google Scholar 

  • Royal College Of Psychiatrists (2005) Guidelines for the nutritional management of Anorexia Nervosa. CR130. London

    Google Scholar 

  • Royal College of Psychiatrists (2011) Management of really sick patients with anorexia nervosa—under 18 yrs: Junior MARSIPAN. CR168. London

    Google Scholar 

  • SACN (2011) https://www.gov.uk/government/publications/sacndietary-reference-values-for-energy

  • Satoh Y, Shimizu T, Lee T, Nishizawa K, Iijima M, Yamashiro Y (2003) Resting energy expenditure and plasma leptin levels in adolescent girls with anorexia nervosa. Int J Eat Disord 34:156–161

    Article  PubMed  Google Scholar 

  • Schebendach J (2003) The use of indirect calorimetry in the clinical management of adolescents with nutritional disorders. Adolesc Med 14:77–85

    PubMed  Google Scholar 

  • Schwartz BI, Mansbach JM, Marion JG, Katzman DK, Forman SF (2008) Variations in admission practices for adolescents with anorexia nervosa: a North American sample. J Adolesc Health 43:425–31

    Article  PubMed  Google Scholar 

  • Seres DS (2005) Surrogate nutrition markers, malnutrition, and adequacy of nutrition support. Nutr Clin Pract 20:308–313

    Article  PubMed  Google Scholar 

  • Skipper A (2012) Refeeding syndrome or refeeding hypophosphatemia: a systematic review of cases. Nutr Clin Pract 27:34–40

    Article  PubMed  Google Scholar 

  • Solomons L, Treloar A, Noronha R (2008) Competence of psychiatric clinicians in interpreting electrocardiograms and QT intervals: can they do this? Does it matter? Psychiatr Bull 32:291–294

    Article  Google Scholar 

  • Stanga Z, Brunner A, Leuenberger M, Grimble RF, Shenkin A, Allison SP, Lobo DN (2008) Nutrition in clinical practice-the refeeding syndrome: illustrative cases and guidelines for prevention and treatment. Eur J Clin Nutr 62:687–94

    Article  CAS  PubMed  Google Scholar 

  • Stein RE, Horwitz SM, Storfer-Isser A, Heneghan A, Olson L, Hoagwood KE (2008) Do pediatricians think they are responsible for identification and management of child mental health problems? Results of the AAP periodic survey. Ambul Pediatr 8:11–17

    Article  PubMed  Google Scholar 

  • Sullivan PF (1995) Mortality in Anorexia Nervosa. Am J Psychiatr 152:1073–1074

    Article  CAS  PubMed  Google Scholar 

  • Sum M (2011) Bone mineral density accrual determines energy expenditure with refeeding in Anorexia Nervosa and supersedes return of menses. J Osteoporosis 2011

    Google Scholar 

  • Swenne I (2000) Heart risk associated with weight loss in anorexia nervosa and eating disorders: electrocardiographic changes during the early phase of refeeding. Acta Paediatr 89:447–52

    Article  CAS  PubMed  Google Scholar 

  • Sylvester CJ, Forman SF (2008) Clinical practice guidelines for treating restrictive eating disorder patients during medical hospitalization. Curr Opin Pediatr 20:390

    Article  PubMed  Google Scholar 

  • Uher R, Treasure J (2005) Brain lesions and eating disorders. J Neurol Neurosurg Psychiatry 76:852

    Article  CAS  PubMed Central  PubMed  Google Scholar 

  • Ulger Z, Gurses D, Ozyurek AR, Arikan C, Levent E, Aydogdu S (2006) Follow-up of cardiac abnormalities in female adolescents with anorexia nervosa after refeeding. Acta Cardiol 61:43–9

    Article  PubMed  Google Scholar 

  • Van Dorn CS, Johnson JN, Taggart NW, Thorkelson L, Ackerman MJ (2011) QTc values among children and adolescents presenting to the emergency department. Pediatrics 128:e1395–e1401

    Article  PubMed  Google Scholar 

  • Van Son GE, Van HD, Bartelds AI, Van Furth EF, Hoek HW (2006) Time trends in the incidence of eating disorders: a primary care study in the Netherlands. Int J Eat Disord 39:565–569

    Article  PubMed  Google Scholar 

  • Wagstaff G (2011) Dietetic practice in refeeding syndrome. J Hum Nutr Diet 24:505–15

    Article  CAS  PubMed  Google Scholar 

  • Weinsier RL, Krumdieck CL (1981) Death resulting from overzealous total parenteral nutrition: the refeeding syndrome revisited. Am J Clin Nutr 34:393–9

    CAS  PubMed  Google Scholar 

  • Whitelaw M, Gilbertson H, Lam PY, Sawyer SM (2010) Does aggressive refeeding in hospitalized adolescents with anorexia nervosa result in increased hypophosphatemia? J Adolesc Health 46:577–82

    Article  PubMed  Google Scholar 

  • Winick M (1979) Hunger disease. Studies by the Jewish physicians in the Warsaw. Wiley, Ghetto

    Google Scholar 

  • Winter TA, O’Keefe SJ, Callanan M, Marks T (2005) The effect of severe undernutrition and subsequent refeeding on whole-body metabolism and protein synthesis in human subjects. J Parenter Enteral Nutr 29:221–228

    Article  CAS  Google Scholar 

  • Wrate RM (2012) Death and risk in adolescent anorexia nervosa. The Psychiatrist 36:316–317

    Article  Google Scholar 

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Authors and Affiliations

  1. Great Ormond Street Hospital, London, WC1N 3JH, UK

    Lee Hudson

  2. Eating Disorders Service, Great Ormond Street Hospital, London, WC1N 3JH, UK

    Graeme O’Connor

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  1. Lee Hudson
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Correspondence to Lee Hudson .

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Editors and Affiliations

  1. Research Dept, St Ann’s Hospital, London, United Kingdom

    Paul H. Robinson

  2. Department of Psychiatry, Great Ormond Street Hospital, London, United Kingdom

    Dasha Nicholls

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Hudson, L., O’Connor, G. (2015). The Role of the Paediatric Team in the Management of Young People with Severe AN. In: Robinson, P., Nicholls, D. (eds) Critical Care for Anorexia Nervosa. Springer, Cham. https://doi.org/10.1007/978-3-319-08174-8_3

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