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Eating disorder - suspected - Children and Adolescents
Scope
Young people under the age of 18 years with a suspected eating disorder: anorexia nervosa, bulimia nervosa, avoidant restrictive food intake disorder (ARFID).
Anorexia nervosa
- Low body weight (may be normal at initial presentation)
- Restricted food/calorie intake
- Weight losing behaviours (exercise, laxatives, vomiting)
- Altered body image, fear of 'fatness'
- Intent to lose weight, fear of weight gain
- Amenorrhoea/delayed puberty
Bulimia nervosa
- Binge eating, lack of control
- Compensatory behaviours (vomiting, exercise, laxatives)
- Preoccupation with eating and body shape
- Low self-esteem
ARFID (Avoidant restrictive food intake disorder)
- Restrictive eating that does not fit criteria for Anorexia Nervosa
- Significant consequence such as weight loss, inadequate growth, nutritional deficiency, dependence on nutritional supplements
- Includes other psychosocial issues associated with eating
The key tasks in primary care are diagnosis, risk assessment and initial management. For a patient who may have an eating disorder, rapidly exclude other causes and look for weight concern, reluctance to eat and purging.
Referral to children and young people’s community ED services in England increased significantly during the pandemic, and paediatricians reported large increases in admissions of young people with restrictive eating disorders, some case numbers even quadrupling in a year1
Patients may present with physical symptoms rather than eating concerns such as fainting, dizziness, nausea, abdominal pain or irregular periods. In this case it is important to take a food history and consider if this could be an eating disorder.
In 2022 MEED (Medical Emergencies in Eating Disorders) guidance was published superseding its previous versions (please see Red Flags for details). The older version, MARSIPAN (including junior MARSIPAN) had an emphasis on anorexia nervosa, whereas MEED covers the dangers of a much wider scope of disordered eating and covers child, adolescent and adult presentations.
Out of Scope
Please see Differential Diagnosis to ensure you have ruled out organic causes and feeding disorders as there is significant overlap in signs and symptoms of eating disorders.
Adult eating disorders – reference to spotting high risk adult presentations is included in this guidance, however the focus in these guidelines lies in patients under the age of 18.
History
- Presenting problem, who is concerned?
- History of presenting problem
- Pattern of weights/clothes size over preceding weeks/months
- Current dietary and fluid intake (including supplements, 'diet pills')
- Weight losing behaviours e.g., vomiting, exercising, laxative use, fluid overload
- Full systems enquiry regarding any secondary symptoms or symptoms indicative of differential diagnoses e.g., chest pain, palpitations, abdominal pains, bowel habit, headaches, Fits/Faints/Funny turns
- Body image, self-esteem, weight preoccupation
- Menstruation
- Sleep pattern
- Past medical history, previous feeding/eating problems, comorbid conditions likely to increase physical risk
- Family history, dieting, eating disorders, onset of puberty
- Educational history e.g. school attendance and achievement
* For young patients, obtain parents’ accounts, but see the patient alone to hear their concerns.
Examination
- General appearance
- Eye contact and engagement
- Peripheral signs of systemic illness indicating other differential diagnoses e.g., hyperthyroidism, inflammatory bowel disease, diabetes, malignancy etc.
- Knuckle callus
- Self-harming scars
- Lanugo hair
- Cool peripheries
- Peripheral skin change (examine hands and feet)
- Anaemia
- Hair loss
- Hydration (CRT, mucous membranes, skin turgor, urine output)
- Mouth and teeth (dental erosion, trauma from induced vomiting)
- Cardiovascular system including lying and standing heart rate and blood pressure.
- Abdominal examination particularly noting if bladder full (may be withholding to give falsely high weight), faecal loading.
- Temperature
- Height and weight used to calculation %median BMI see appendices figure 2.
- General neurological examination including muscle wasting
- Assessment of muscle strength e.g., see appendices figure 1 and video showing sit up squat test.
- Where appropriate inspection of perineum for pubertal staging and as necessary to exclude other differential diagnoses e.g., anal findings in Crohn’s.
Differential Diagnosis
The differential diagnosis of weight loss includes:
- Malabsorption for example coeliac disease, inflammatory bowel disease or peptic ulcer.
- Malignancy.
- Drug or alcohol misuse.
- Infection for example tuberculosis, HIV, infectious mononucleosis.
- Autoimmune disease including rheumatological disorders.
- Endocrine disorder for example hyperthyroidism, diabetes mellitus, hypercortisolism, adrenal insufficiency.
- Disordered eating leading to weight loss in the absence of signs of an eating disorder.
The differential diagnosis of amenorrhoea includes:
- Pregnancy.
- Primary ovarian failure.
- Polycystic ovary syndrome.
- Pituitary prolactinoma.
- Hypothalamic causes.
The psychiatric differential diagnosis includes:
- Depression.
- Anxiety.
- Obsessive-compulsive disorder.
- Body dysmorphic disorder.
- Substance misuse.
- Psychosis or schizophrenia.
*NICE - topics/eating-disorders/diagnosis/differential-diagnosis
| MEED2 | |||
|---|---|---|---|
| Red flag – High risk | Amber – Alert to high concern for impending risk to life | Green – low impending risk to life | |
| Weight loss | Recent loss of weight of equal to or grater than 1kg/week for 2 weeks (consecutive) in an undernourished patient34 | Recent loss of weight of 500–999g/week for 2 consecutive weeks in an undernourished patient | Recent weight loss of less than 500g/week or fluctuating weight |
| BMI and % median BMI see appendices figure 2 to calculate. |
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| HR (awake) | lower than 40 | 40-50 | greater than 50 |
| Cardiovascular health | Standing systolic BP below 0.4th centile for age or less than 90 if 18+, associated with recurrent syncope and postural drop in systolic BP of greater than 20mmHg or increase in HR of over 30bpm (35bpm in age below 16 years) | Standing systolic BP lower than 0.4th centile or lower than 90 if 18+ associated with occasional syncope; postural drop in systolic BP of greater than15mmHg or increase in HR of up to 30bpm (35bpm in age below 16 years) |
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| Hydration status |
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| Temperature | lower than 35.5 tympanic | lower than 36 | greater than 36 |
| Muscular function (Sit up squat stand test) see appendices figure 1. | Unable to sit up from lying flat, or to get up from squat at all or only by using upper limbs to help (Score 0 or 1) | Unable to sit up or stand from squat without noticeable difficulty (Score 2) | Able to sit up from lying flat and stand from squat with no difficulty (Score 3) |
| Muscular function: mid upper arm circumference. | lower than 18cm (approx. BMI lower than 13) | 18–20cm (approx. BMI lower than 15.5) | greater than 20cm (approx. BMI greater than 15.5) |
| Other clinic state | Life-threatening medical condition, e.g. severe haematemesis, acute confusion, severe cognitive slowing, diabetic ketoacidosis, upper gastrointestinal perforation, significant alcohol consumption | Non-life-threatening physical compromise, e.g. mild haematemesis, pressure sores | Evidence of physical compromise, e.g. poor cognitive flexibility, poor concentration |
| ECG |
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| Biochemical |
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| Haematological |
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| Eating behaviours | Acute food refusal or estimated calorie intake lower than 500kcal/day for 2+ days | ||
| Ability to engage |
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| Activity and exercise | High levels of dysfunctional exercise in the context of malnutrition (more than 2h/day) | Moderate levels of dysfunctional exercise in the context of malnutrition (more than 1h/day) | Mild levels of or no dysfunctional exercise in the context of malnutrition (less than 1h/day) |
| Purging behaviours | Multiple daily episodes of vomiting and/or laxative abuse | Regular (equal to or greater than 3x per week) vomiting and/or laxative abuse | |
| Self-harm and suicide | Self-poisoning, suicidal ideas with moderate to high risk of completed suicide | Cutting or similar behaviours, suicidal ideas with low risk of completed suicide | |
| Number of flags |
The following bloods are to exclude other diagnoses and assess secondary effects/risk but are not essential to referral and should not delay referral
- Full Blood Count (FBC)
- Ferritin
- Clotting
- Urea and electrolytes (U+E's)
- Bone profile
- Phosphate test (PO4)
- Liver Function Tests (LFTs)
- Amylase
- Magnesium test (Mg)
- Glucose
- Thyroid Function Tests (TFT's)
- Quantitative immunoglobulins (Igs)
- Coeliac screen
- C-reactive protein (CRP )
- Follicle-stimulating hormone (FSH) / Luteinizing Hormone (LH) / Prolactin / Oestradiol or Testosterone
- B12, folate, vitamin D
- Creatine Kinase
ECG if vomiting, cardiac symptoms/signs or low body weight (less than 85% median BMI ). Please refer to the Red Flags section for normal and abnormal QTc values and consider seeking Advice and Guidance from Paediatrics if the QTc is abnormal.
Urinalysis for ketones, blood, protein, glucose.
Faecal calprotectin in the context of significant gastrointestinal symptoms.
Any other specific investigations according to history and examination to exclude differential diagnoses
In primary care, because severe anorexia nervosa is seen relatively rarely, there can be a risk of a delay in recognition. Moreover, normal blood tests and relatively preserved energy levels can be falsely reassuring. Any patient with an eating disorder can deteriorate rapidly and should be referred without delay.
It is recommended that the GP discuss any patient of concern with an eating disorder clinician or liaison psychiatry clinician, the local CAMHS service or a paediatrician/physician, providing as much information from the risk assessment as possible (please see Referral section for contact details).
Continue to review regularly any young person with increasing risk until seen by the paediatric medical eating disorder team (usually within 0-4 weeks according to risk reported in referral information).
After initial assessment in the paediatric eating disorder clinic a joint plan will be made with CAMHS and primary care regarding appropriate monitoring of weight and/or physical health.
For young people aged 16-18 years with typical eating disorder presentations and low physical risk, assessment and monitoring can be done in primary care in conjunction with their CAMHS input.
Please consider repeating even mildly abnormal tests as a deterioration could indicate the need for more urgent assessment
Whilst awaiting assessment advise the following:
1. Meal plan of 3 meals and 3 snacks which are made and supervised by parents where possible.
2. Minimise exercising and other purging behaviours.
3. Signpost to resources , see supporting information below:
Referral Criteria
We recommend immediate referral of any young person with restrictive eating patterns or eating disorder cognitions; early intervention is crucial to increase likelihood of positive long-term outcomes. Do not wait for a low BMI before referring.
- If urgent (rated as any red flag according to MEED) call Torbay Paediatric assessment unit for guidance on 07584272641 or Derriford on 01752 437524
AND
Make a referral via a letter and send to TSDFT.DevonSPA@nhs.net
- If routine make a referral via a letter and send to TSDFT.DevonSPA@nhs.net
- If unsure call Torbay & South Managing Eating Pathway Service (TASME ) duty on 01803 763 500 or email cfhd.southedreferrals@nhs.net, duty clinician available 9-5pm (mon-fri)
Please ensure you include height, weight, lying and standing heart rate and blood pressure and any other relevant findings on examination .
Referral Instructions
e-Referral Service Selection
Specialty: Paediatrics and CAMHS
Clinic Type: Eating disorders
Service: Child and Family Health Devon
GP Information
Current waiting time for assessment is 1-4 weeks
Learning resource for clinicians:
Beat eating disorders - Training for GPs and Primary Care Clinicians
Medical Emergencies in Eating Disorders: Guidance on Recognition and Management (2022)
Patient Information
Useful links:
Children and Family Health Devon
For concerns regarding eating please contact your GP or Child and Family Health Devon team if referred to them via 03300245321 in hours or 03456000388 out of hours for emergencies.
For concerns regarding mental health contact CAMHS CRISIS Helpline: 033002 45321 8am-5pm Monday-Friday, 030055 55000 out of hours. Callers will speak to a call handler; their call will be forwarded to a voicemail service and their message will be returned within one hour. In the event of an emergency, please call 999.
Free and confidential support services for patients and carers, personal stories and clinician learning resources. Helpline: 08088010677 3pm-8pm 7 days per week.
Website for young people struggling with how they are feeling. Young person text service. Text YM to 85258 for free 24/7 support or call 08088025544 for the Parent Helpline Monday-Friday 9:30am -4pm.
Provides information to families online and via a 30-day free email subscription.
Appendices
Sit-Up–Squat–Stand (SUSS) Test
The SUSS Test is described below. However, clinical experience suggests that adolescents frequently ‘pass’ this test, especially if they are athletic. Performing poorly is therefore a concern, but it is important not to be falsely reassured if the person performs well. The SUSS Test has two parts (see Figure 1):
1. Sit Up: patient lies down flat on a firm surface such as the floor and sits up without, if possible, using their hands
2. Squat–Stand: patient is asked to squat down on their haunches then rise to standing without, if possible, using their hands or arms as levers
Scoring (for Sit Up and Squat–Stand tests separately)
Performing and scoring the SUSS Test are demonstrated in an online video:
1. 0: Unable
2. 1: Able only using hands to help
3. 2: Able with noticeable difficulty
4. 3: Able with no difficulty
Figure 1 The SUSS (Sit-Up–Squat–Stand) Test take from medical emergencies in eating disorders guideline (2022).
BMI in under 18s = % Median BMI (Weight for Height)
Figure 2 Calculating % median BMI
Pathway Group
Dr H Clamp - Torbay and South Devon NHS Foundation Trust
Publication date: January 2025
References
1 - Royal College of Paediatricians and Child Health - Paediatricians warn parents to be alert to signs of eating disorders over holidays
2 - Royal College of Psychiatrists (meed)-guidance.pdf
