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Abstract
We present a review of the Junior MARSIPAN (Management of Really Sick Patients with Anorexia Nervosa) guideline, which provides paediatricians with a framework for managing Anorexia Nervosa in the inpatient setting.
- Adolescent Health
- Psychology
- Child Psychiatry
- Child Psychology
- Paediatric Practice
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About the guideline
Anorexia nervosa is a commonly encountered cause of severe underweight in paediatric settings that can cause potentially life-threatening physical and psychological complications.1 There is evidence to suggest that paediatricians lack knowledge and confidence in managing this condition; a survey of middle-grade doctors showed a low level of knowledge of several life-threatening features.2 It is, therefore, important that paediatricians are familiar with the key recommendations in this guideline on the assessment and management of sick patients under 18 with anorexia nervosa.
This guideline was published in January 2012 by the Junior MARSIPAN (Management of Really Sick Patients with Anorexia Nervosa) working group of the Royal College of Psychiatrists,3 and is endorsed by the Young People's Health Special Interest Group of the Royal College of Paediatrics and Child Health. It is intended to complement the Adult MARSIPAN guideline.4 The difference in (1) definition of anorexia nervosa in young people and (2) presentations of serious underweight necessitated a separate guideline. In addition, there are differences in clinical risk assessment (eg, age-specific weight/height/blood pressure centiles), legal frameworks (particularly regarding consent and capacity) and services involved in the care of young people.
This guideline aims to advise on the assessment and management of children and young people in a range of settings, including primary care, outpatients and inpatients. It addresses both medical and psychological causes for concern, and stresses the need for a multidisciplinary approach. The guidance targeted at paediatricians is summarised here.
Key issues addressed by Junior MARSIPAN guidelines
Risk assessment
A multifactorial ‘traffic light’ risk assessment system is used to assess patients from high risk (red), alert (amber), moderate risk (green) and low risk (blue). Key assessment parameters are listed in table 1.
Summary of MARSIPAN risk assessment framework
BMI alone is not a useful tool in assessing malnutrition in children due to age-related variation; therefore, percentage median BMI should be used (box 1). This involves comparing a patient's BMI against a ‘model’ individual of the same age and sex whose BMI is on the 50th (median) centile, derived from a BMI centile chart (see resources box). A percentage median BMI <70% is a marker for severe underweight, aligning with WHO child recommendations.5
Calculating percentage median body mass index (BMI)
Percentage median BMI=actual BMI÷median BMI (50th percentile) for age and gender×100
Example
A girl aged 12 years has a height of 1.5 m and weighs 25 kg
Her BMI=25/(1.5)2=11.1 kg/m2
Using the Royal College of Paediatrics and Child Health BMI chart (see resource box)—the 50th BMI centile for a 12-year-old girl is 18 kg/m2
Therefore, percentage median BMI=11.1/18×100=61.7%
Blood pressure measurements should be compared with normal ranges specific for age and gender based on data from healthy UK children and young people.6
Location of care
Junior MARSIPAN discusses available options to manage patients:
General paediatric ward
Generic Child and Adolescent Mental Health Services (CAMHS) bed/CAMHS unit with expertise in managing eating disorders
Specialist paediatric eating disorders unit (SEDU)
SEDU provision is limited, and admission may result in geographical separation of a child from his/her family. When choosing between a CAMHS unit and a paediatric ward, a decision should be made as to whether the most pressing need is for medical care or psychiatric care. Whichever unit is decided upon, there should be discussion and collaboration between teams—particularly at the time of transfer between services.
Compulsory admission and treatment
Ideally, treatment decisions should be made in conjunction with the child and his/her family. However, this is not always possible, and compulsory treatment may be required (see box 2 for relevant legislation).
Relevant legislation
Children under 16 should be assessed for Gillick competency—that is, their capacity to consent; however, they can be treated against their will if someone with parental responsibility consents.
Mental Capacity Act—patients over 16 years of age are presumed to have the capacity to consent to treatment unless proven otherwise; at 16–18 years, patients are assumed to have the capacity to consent to, but not refuse treatment
Children Act 1989—where parent and child are refusing treatment, a Care Order (section 37) can be applied to allow for compulsory treatment
Mental Health Act—allows for compulsory restraint and refeeding as a treatment for anorexia for children of any age
Feeding plans—refeeding and ‘underfeeding’ syndrome
No evidence-based guidelines exist for initiating refeeding in children with anorexia. It is important to monitor for refeeding syndrome (box 3), but Junior MARSIPAN also warns against an overly cautious approach to refeeding, which can result in further weight loss (‘underfeeding syndrome’):
Involve a paediatric dietician for specialist advice.
Refeeding should ideally mimic normal eating, that is, solid food for meals and snacks.
If the patient cannot comply with a meal plan then nasogastric (NG) feeding should be considered as early as 24 h into the admission.
For NG feeding, use a daytime bolus regimen to mimic physiological eating and give the patient options to eat.
Starting intake should not be lower than preadmission amounts; consider starting at 20 kcal/kg/day.
Aim for 0.5–1 kg/week weight gain.
An appropriate rate of increase is important 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.
Refeeding bloods (urea and electrolytes, liver function tests, phosphate, magnesium) should be performed daily during the ‘at-risk’ period of days 2–5 initially, and at 7–10 days (to identify late refeeding syndrome). Biochemical monitoring should continue for at least a fortnight, or until electrolytes become stable.
Restrict carbohydrate intake and increase dietary phosphate (eg, using milk).
If NG feeding, avoid high calorie concentration feeds (with high carbohydrate content, as this increases the risk of refeeding syndrome).
Prescribe multivitamin and mineral supplements; consider thiamine in older children based on clinical judgement.
Only individuals most at risk of refeeding syndrome (box 4) may need a more cautious approach (5–10 kcal/kg/day starting regimen) with twice daily bloods.
What is refeeding syndrome?
A potential fatal shift in fluid and electrolytes occurring as a result of hormonal and metabolic changes during refeeding. Hypophosphataemia is a diagnostic sign.
Identifying high-risk individuals
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 refeeding
Managing anorexic behaviour
Anorexic behaviour can be challenging to manage in a ward environment. Common anorexic behaviours include:
compulsive exercising—consider total/partial bed rest and supervised washing/toileting
wearing insufficient clothes for temperature
resisting feeds/hiding food—if weight gain less than expected (<0.5–1 kg/week), assume weight-losing behaviours. With excessive weight gain (eg, >2 kg within a few days), assume water loading and other fluid manipulations
purging—limit access to toilet for 1 h after a meal or snack. Limit access to syringes to prevent aspiration NG tubes
binging—monitor for food hoarding
self-harm
falsifying weight gain—for example, by water loading or hiding weights in clothes
violent/disturbed behaviour—local policy should be followed
What should I start doing?
Assess nutritional status based on percentage median BMI, and not BMI alone.
Baseline clinical assessment of risk using the Junior MARSIPAN framework—this includes baseline ECG and SUSS test for musculoskeletal weakness.
Have a low threshold for starting NG feeding and avoid an overcautious approach to refeeding (consider starting at 20 kcal/kg/day and increasing by 200 kcal/day until nutrition is sufficient for weight gain).
Always consider refeeding syndrome—monitor patient’s electrolytes (especially phosphate) before and during refeeding, and assess the risk of refeeding syndrome prior to starting feeding.
Prescribe a general vitamin and mineral supplement in younger children, and consider thiamine supplements in older children.
What should I stop doing?
Taking an overcautious approach to refeeding (may result in underfeeding syndrome)—patients should be receiving sufficient nutrition for weight gain within 5–7 days of refeeding.
For patients receiving supplemental or NG feeds, avoid calorie dense feeds, which may be too high in carbohydrates and increase the risk of refeeding syndrome.
Offer consistent support with joint medical and mental health team input—do not ‘refer to CAMHS and wait’. Recovery from anorexia requires early nutritional rehabilitation and maintaining collaborative links to specialist services.
Areas of controversy
The definition of seriously underweight in children and adolescents—there is little evidence base for what constitutes ‘high risk’.
Where the balance should lie between avoiding refeeding syndrome, and an overcautious approach leading to ‘underfeeding syndrome’? Randomised controlled trials to assess the safety of higher rates of feeding are not yet available, but some international groups use higher starting rates of feeding (eg, 1200 calories) than specified in this guidance.7
The role of thiamine supplementation—thiamine supplementation has long been a staple of nutritional rehabilitation in adults, but there is little evidence on its use in children.
Resources
Junior MARSIPAN guidelines:
http://www.rcpsych.ac.uk/files/pdfversion/CR168nov14.pdf
Adult MARSIPAN checklist for assessment, refeeding and management:
https://www.rcpsych.ac.uk/pdf/CR189checklistXX.pdf
Adult MARSIPAN guideline:
http://rcpsych.ac.uk/usefulresources/publications/collegereports/cr/cr189.aspx
NICE guideline—Eating disorders: Core interventions in the treatment and management of anorexia nervosa, bulimia nervosa and related eating disorders
http://www.nice.org.uk/guidance/cg009
UK-WHO growth charts (0–18 years)
RCPCH body mass index (BMI) chart
http://www.rcpch.ac.uk/system/files/protected/page/GIRLS%20and%20BOYS%20BMI%20CHART.pdf
Blood pressure centiles for Great Britain
Clinical bottom line
Anorexia is a serious potentially fatal disease—while refeeding syndrome can be fatal, the risk from malnutrition and ‘underfeeding’ is much greater.
Do not ‘refer and wait’—recovery from anorexia requires nutritional rehabilitation.
Risk from refeeding syndrome can be reduced by careful monitoring and paediatric dietician input into choice of feed composition.
All patients should be carefully assessed to establish their risk according to Junior MARSIPAN guidelines.
Footnotes
Twitter Follow Omer Moghraby at @moghraby
Contributors DM and SR produced the first draft; DM and OSM provided revisions to the second draft. DM made revisions to the final draft.
Competing interests None declared.
Provenance and peer review Commissioned; externally peer reviewed.