eating disorders guidelines for inpatient paediatric

Version 4.1 From: Jun 20 – To: Mar 21 Author(s) Neky Sargant, Consultant Paediatrician, Nicol Clayton, Eating Disorders Paediatric Dietitian, Lauren McVeigh, Specialist Paediatric Dietitian; Christine Spray, Consultant Paediatric Gastroenterologist

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SETTING Bristol Royal Hospital For Children (BRHC)

FOR STAFF All clinical staff

PATIENTS Paediatric inpatients with restrictive eating disorders Paediatric patients at risk of refeeding syndrome

_____________________________________________________________________________

INTRODUCTION • This protocol is intended for use by the multi-disciplinary team caring for children and young

people with restrictive eating disorders (ED) admitted to the general medical wards at BRHC• The section on refeeding syndrome is appropriate for use for all patients at risk.

CONTENTS• Referral Pathway into BRHC• Aims of Admission• Medical Management• Refeeding Syndrome• Inpatient Treatment Flow Chart• Graded Diet Plan• Discharge Diet Plan• Staff Guide for Meal Management

Clinical Guideline EATING DISORDERS: GUIDELINES FOR INPATIENT PAEDIATRIC PATIENTS MANAGEMENT OF REFEEDING SYNDROME

Extended until March 2022

Author(s) Neky Sargant, Consultant Paediatrician, Nicol Clayton, Eating Disorders Paediatric Dietitian, Lauren McVeigh, Specialist Paediatric Dietitian; Christine Spray, Consultant Paediatric Gastroenterologist

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REFERRAL PATHWAY

Medical Assessment Clinic (MAC) or CAMHS clinician

Riverside Adolescent Unit

Emergency Department

Gastroenterology Consultant on service (07789876406) – (Mon-Fri 9am-5pm) to discuss assessment oradmission.Gastro Secretary: 0117 342 9450Out of hours: Refer to General Paediatric registrar

1. ALL young people must be admitted via theEmergency Dept.

2. Start ED protocol.3. If not known to CAMHS, please refer via single point

of entry form and inform CTAO.

1. Transfer to BRHC Apollo 35 patients regardless of age2. If challenging or resistant out of hours agree on call Psychiatric input. Weekends – daily

telephone contact between medical & psychiatrist on call. If necessary, psychiatrist oncall to visit. Discuss with management re: specialist nursing support - CPS

Discharged Home If not known to CAMHS, please refer via single point of entry form, and inform CTAO.

1. Daily medical review by the Gastro team2. CAMHS team to liaise with GP/nurses/patient & family3. Any deviation from the protocol needs discussion with CAMHS and the Gastro team.4. Two weeks post admission, every YP needs an MDT clinical discussion re: discharge

planning

Discharge

Home – with Follow up in Medical Assessment Clinic (MAC) and with CAMHS.

Tier 4 Unit

Any young person who is deemed to be critically unwell by the referring clinician, should be sent to the Emergency Dept via 999 ambulance, for assessment directly. This should

be followed up with a call and completed referral form (appendix 1) to the Gastroenterology consultant/ (if out of hours) the General Paediatric registrar.



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AIMS OF ADMISSION

• Stabilise medical complications. • Safe refeeding and rehydration.• Avoid refeeding and underfeeding

syndrome.• Start to address behavioural problems with

disordered eating.• Identify discharge plan in week two and

organise safe discharge together withCAMHS ED team.

MEDICAL MANAGEMENT

• Detailed medical history• Clinical examination and minimum 4 hourly HR, BP, SaO2, temperature. Once daily lying

and standing BP (postural drop)

Weighing (Monday and Thursday) • Weight and height should be taken on admission followed by twice weekly weights using

digital scales in underwear/ night clothes at the same time of day, prior to breakfast andafter passing urine (see below)

• A urine specimen to be collected prior to weighing, and tested for specific gravity.o This results in the bladder being empty for weighing. If the specific gravity is <1010

then the patient is dehydrated. If >1020 then the patient may be water loading• Calculate percentage median body mass index

o Body Mass Index (BMI) is calculated by BMI = Weight (kgs) Height (m2)

o %median BMI = actual BMI divided by median BMI (50th percentile) for age andgender x 100

• It is important to note that a normal BMI does not exclude a serious eating disorder.An individual who has previously been overweight and then lost weight rapidly, may havedangerous nutritional and physiological deficiencies despite having a normal BMI.

Investigations and monitoring • Perform ECG – look for QTc: All <15yrs: QTc>460ms (girls) or 450ms (boys)• Check baseline blood biochemistry for: FBC/ferritin/urea and electrolytes/creatinine/

phosphate/calcium/magnesium/liver function tests• Repeat bloods daily for the first seven days of feeding• Bed rest (allowing for trips to the bathroom), wheelchairs for other trips to/from bed

Supplements • Prescribe multivitamins and minerals:

o Aged 5-12 years: Thiamine hydrochloride 50mg OD and Forceval junior(effervescent tablet) OD

o Aged 12-18 years: Thiamine hydrochloride 100mg OD and Forceval 1 capsule ODo Thiamine should be given at least 30 mins prior to starting oral/ enteral feeds

• Do not prescribe prophylactic phosphate routinely, consider if multiple risk factors arepresent.

Feeding • Start feeding on Day 1 as per Graded Diet Plan• Please note that Consultant Gastroenterologist may advise starting at a higher number of

kcal/day if previous intake has been higher than 1200kcal.



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REFEEDING SYNDROME (RFS)

• A serious potential complication of commencing feeding in children and young peoplewho have experienced starvation. It is characterised by biochemical abnormalities andclinical findings.

Who is most at risk? • ALL children and young people with restrictive eating disorders are at risk of re-feeding

syndrome regardless of weight/median % BMI.• Those most at risk however, include:

o Very low weight (<70% median BMI) or faster rates of weight loss (recent loss ofweight of 1kg or more/week for two consecutive weeks (red) or loss of weight of500g-1kg/week for two consecutive weeks (amber), acute food/ fluid refusal,previous history of re-feeding syndrome, low albumin and neutropenia.

THE DROP IN PHOSPHATE SEEN IN REFEEDING SYNDROME (RFS) USUALLY OCCURS 48-72 HOURS AFTER STARTING FEEDS.

Low phosphate (<1.1mmol/L) but no clinical signs of RFS (Most common scenario)

Low phosphate (<1.1mmol/L) with clinical signs of RFS Signs: Peripheral oedema, tachycardia, arrhythmia, resp failure, confusion, seizures, weakness, low GCS

• Start supplementation prior to startingfeeding

• If already feeding, DO NOT INCREASE feedregime until phosphate is normal

• Check Vitamin D & PTH• Always discuss abnormal results with

Gastroenterology/on-call consultant• Treatment depends on phosphate level.

0.5-1.1mmol/L • Correct orally with stat dose – 2 x Sandoz

phosphate tabs• Start Sandoz phosphate 1 tab TDS/ day• Re-check level 6-12 hours after stat dose,

monitor clinically

<0.5mmol/L • Refer to HDU team/Outreach for ongoing

management

• DO NOT START feeding until levelsnormalised

• If already feeding, reduce calories to 1200kcal• Cardiac monitor, neuro obs• Discuss with Gastroenterology/On-call

consultant and Outreach/HDU team abouttransfer to HDU/PICU

• Start slow infusion of IV Pabrinex as per BNFCguuidelines

• Start thiamine supplementation (50mg orallyTDS)

• Check bloods for: FBC/U&E, Mg, Phosphate,Calcium, LFTs, Blood gas

• Repeat ECG• Repeat bloods six to eight hourly• Check blood sugar and treat hypoglycaemia• Discuss with cardiology if arrhythmia present• Correct electrolyte disturbances• Oedema will usually complicate fluid

management. Albumin is often low. Seeksenior advice for fluid support.

CONSIDER DIFFERENTIAL DIAGNOSIS – INCLUDING SEPSIS AND OTHER CAUSES OF

ACUTE DETERIORATION.

- If on Sandoz Phosphate, continue for two weeks. Re-check levels. Stop if phosphateremains normal

- Side effects of phosphate: diarrhoea, abdominal pain. If this occurs, consider reducingthe dose if phosphate is stabilised or change to oral route if on IV.




INPATIENT TREATMENT FLOW CHART

WEEK 1 – MEDICAL STABILISATION MEALS Graded Diet Plan

Nursing staff to choose meals and snacks. Nursing staff to supervise all meals and snacks.

ACTIVITY Bed rest (can walk to the bathroom supervised), wheelchairs for other trips to/from bed until MDT suggest otherwise

SCHOOLWORK In room at discretion of team WARD LEAVE Nil HOME LEAVE Nil CAMHS Two visits per week minimum (Bristol and South Glos CAMHS)

WEEK 2 – SUPPORTED EATING MEALS Stable kcal and fluid intake

Parents to choose meals and snacks with nursing staff. Parents to start to supervise meals and snacks with support. All meals and snacks to be eaten on ward.

ACTIVITY Can walk to bathroom, school room and lounge SCHOOLWORK In school room WARD LEAVE 30 minutes with parents in hospital grounds HOME LEAVE Nil CAMHS Two visits per week minimum (Bristol and South Glos CAMHS)

To identify discharge plan

LEVEL 3 – SUPPORTED DISCHARGE MEALS Stable kcal and fluid intake

Parents to choose meals and snacks with nursing staff support if required. Parents to supervise all meals and snacks. Some Meals and snacks may be eaten off the ward Discharge diet plan provided

ACTIVITY Can walk to bathroom, school room and lounge SCHOOLWORK In school room WARD LEAVE One hour with parents HOME LEAVE Some practice meals at home CAMHS Two visits per week minimum (Bristol and South Glos CAMHS)

Organise discharge

Progression through levels to be decided by MDT and CAMHS and is dependent on clinical condition.

Frequency of visits by North Somerset CAMHS and Riverside Unit to be agreed separately on a case by case basis.



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GRADED DIET PLAN

WEEK 1 • All patients are to start at 1200kcals and will reach 2500kcals by day five. Underfeeding

increases the time period in which refeeding complications are most likely to occur andcontributes to increased cardiac risk.

• NGT feeding: consider use after 24 hours if not complaint with oral feeding and fluid.• Daily fluid intake should achieve 1800mls (but not exceed 2500ml). Include all drinks listed in

the diet plan when calculating the total fluid intake. A suggested minimum intake is 1500ml• Inpatient dietitian (0117 342 8802) should be contacted for review on day four if patient is

<20kg or <10 years of age.• Weight gain may be variable in the first week as often patients are dehydrated on admission.• Expected weight gain thereafter should be up to 1kg per week. Adjustments may be made to

the plan by the dietitian to facilitate weight gain.• Time Limits: Meals 30 minutes, Snacks 15 minutes, Supplements 10 minutes• No mobile phones are allowed during meals and snacks.• Patient to be on bed rest• Documentation: Use food and fluid chart to document any uneaten food and all fluid taken.• Toilet: Use before meals, should not be used during or one hour after meals and 30 minutes

after snacks.• Patient and family can identify up to three food dislikes (not whole food groups).• In the first week the nursing staff are to choose all meals and snacks with the parents. For

patients with anorexia nervosa, this should be food from the hospital menu only (not fromhome).

• If liquid supplement drink required, to use Nutrison Energy Multifibre (Vanilla) or Fortisip(flavoured)



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Day 1 – 1200kcal

Meal Oral Diet Plan Supplement equivalent

Breakfast (0830hrs) Two heaped tbsp (20g) cereal, 50ml whole milk, ½ slice of toast with butter

130ml

Snack (1030hrs) Snack from list below 100ml Lunch (1230hrs) ¼ main meal portion, ¼ dessert portion 185ml Snack (1430hrs) Snack from list below 100ml Dinner (1700hrs) ¼ main meal portion, ¼ dessert portion 185ml Snack (2000hrs) Snack from list below 100ml Total 800ml The food is the treatment therefore ALL of the food given must be eaten. If any food is not eaten the full supplement to be given. Do not negotiate with the patient or family.

Day 1 Snack options (choose one below)

• 250ml whole milk• One pot full fat yoghurt• One digestive biscuit and piece of fruit• One slice of toast with butter• 200ml fruit juice and pot of jelly

Fluid • Offer 200mls to drink with each meal and snack• Count any supplements given in total

Minimum: 1500mls Ideal intake: 1800mls – 2000 mls Do not exceed: 2500mls

Record all food and fluid consumed, and note any food not eaten



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Day 2 – 1500kcal


Breakfast (0830hrs) 2 heaped tbsp (20g) cereal, 50ml whole milk, ½ slice of toast with butter, 100ml fruit juice

160ml

Snack (1030hrs) Snack from list below 125ml Lunch (1230hrs) ½ main meal portion, ½ dessert portion 225ml Snack (1430hrs) Snack from list below 125ml Dinner (1700hrs) ½ main meal portion, ½ dessert portion 225ml Snack (2000hrs) Snack from list below 125ml Total 985ml The food is the treatment therefore ALL of the food given must be eaten. If any food is not eaten the full supplement to be given. Do not negotiate with the patient or family.

Day 2 Snack options (choose one below)

• 200ml whole milk or one pot full yoghurt PLUS one digestive biscuit• Two digestive biscuits and piece of fruit or pot of jelly• One slice of toast with butter and jam• Two cream crackers with butter and 20g cheese or two diarylea triangles• 35g packet of mini cheddars







Day 3 – 1750kcal


Breakfast (0830hrs) 3 heaped tbsp (30g) cereal, 100ml whole milk, ½ slice of toast with butter, 100ml fruit juice

190ml

Snack (1030hrs) Snack from list below 125ml

Lunch (1230hrs) ¾ main meal portion, ¾ dessert portion 320ml


Dinner (1700hrs) ¾ main meal portion, ¾ dessert portion 320ml


Total 1200ml

The food is the treatment therefore ALL of the food given must be eaten. If any food is not eaten the full supplement to be given. Do not negotiate with the patient or family.

Snack options (choose one below)

• 200ml whole milk or one pot full yoghurt PLUS one digestive biscuit• Two digestive biscuits and piece of fruit or pot of jelly• One slice of toast with butter and jam• Two cream crackers with butter and 20g cheese or two diarylea triangles• 35g packet of mini cheddars







Day 4 – 2000kcal


Breakfast (0830hrs) Four heaped tbsp (40g) cereal or 2½ Weetabix, 100ml whole milk, 1 slice of toast with butter, 100ml fruit juice

200ml

Snack (1030hrs) Snack from list below 160ml Lunch (1230hrs) ¾ main meal portion, ¾ dessert portion 320ml Snack (1430hrs) Snack from list below 160ml Dinner (1700hrs) ¾ main meal portion, ¾ dessert portion 320ml Snack (2000hrs) Snack from list below 160ml Total 1320ml The food is the treatment therefore ALL of the food given must be eaten. If any food is not eaten the full supplement to be given. Do not negotiate with the patient or family.

Snack options

One of the following

PLUS

One of the following • One slice toast + butter• Two digestives or three rich tea

biscuits• 25g cereal with 75g whole milk• Bag of crisps• Two cream crackers + 20g

cheddar/two dairylea triangles

• Jaffa cake bar or fudge bar• Quavers or wotsits• 200ml fruit juice or 150ml whole milk• Full fat yoghurt• One large piece of fruit + jelly pot






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Day 5 – 2500kcal Meal Oral Diet Plan Supplement

equivalent Breakfast (0830hrs) 4 heaped tbsp (40g) cereal or 2+½ Weetabix,

100ml whole milk, 1 slice of toast with butter and jam, 100ml fruit juice

260ml

Snack (1030hrs) Snack from list below 200ml Lunch (1230hrs) Full main meal portion, full dessert portion 400ml Snack (1430hrs) Snack from list below 200ml Dinner (1700hrs) Full main meal portion, full dessert portion 400ml Snack (2000hrs) Snack from list below 200ml Total 1660ml The food is the treatment therefore ALL of the food given must be eaten. If any food is not eaten the full supplement to be given. Do not negotiate with the patient or family.

Snack options

One of the following

PLUS

One of the following • One slice toast + jam + butter• 30g cereal or two weetabix

with 100ml milk• 35g bag mini cheddars• Two cream crackers + two

pats butter + 20g cheddar/twodairylea triangles

• Jaffa cake bar or fudge bar• Quavers or wotsits• 200ml fruit juice or 150ml whole

milk • Full fat yoghurt or two jelly pots• 1½ digestive or two rich tea

biscuits• One large piece of fruit or two

small fruits






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STAFF GUIDE TO APPROPRIATE PORTION SIZES OF MEALS

For hospital use only: please do NOT give to patients, use the discharge meal plan for home leave.

Patients should be offered a balanced meal which includes a protein source, carbohydrate and vegetable. Where indicated, they should also be offered a pudding. This should not be fruit or low fat yoghurt.

Listed below are appropriate full portion sizes of food groups. These are to be adapted to the portion size suggested on days 1-3.

Protein foods (meat or vegetarian alternative) • Four slices of meat in gravy• Three tbsp pasta dish (not including macaroni cheese) OR seven tbsp without

carbohydrate• Quiche or vegetable pie• Three tbsp mixed dish e.g. cottage pie, sheppard’s pie OR seven tbsp without

carbohydrate• Four tbsp meat/chicken in sauce e.g. sweet and sour chicken, chilli con carne, meat balls• Two sausages• Three fish fingers• Whole chicken escalope or whole burger (without bun) or whole meat chop• ½ cheese omelette or ¾ plain omelette• Three tbsp cheese bake/dish e.g. macaroni cheese, broccoli cheese or potato, bacon

and cheese bake• Three tbsp baked beans or pot of grated cheese or pot of tuna mayo (to go with jacket

potato)• One pasty or sausage roll

Carbohydrate Food: • Four tbsp mashed potato• Whole jacket potato• Three tbsp chips or potato wedges• Four tbsp rice• Three hash browns• Five roast potatoes• Burger bap

Vegetables: • Three tbsp vegetables (this can be made up from two different vegetables if preferred)• Salad pot

Puddings: • Three tbsp hot pudding e.g. sponge/crumble• Two tbsp hot pudding with custard or ice cream• Two individual pots of icecream with jelly pot• Full fat yoghurt with piece of fruit and jelly pot




Nutrition for Recovery

Weight Restoring Food Plan – Discharge from Hospital

During your child’s hospital admission they have been treated using a set meal plan. This meal plan is designed for achieving weight gain and managing any medical side effects whilst in hospital.

However, being in hospital is very different to being at home, during which time activity is restricted and the body is beginning to recuperate from its malnourished and dehydrated state. To continue with weight restoration at home after discharge, young people need to eat more than is contained on hospital meal plan. It can feel challenging to move away from the hospital plan, where food has been very controlled and feels safe. This plan is a guide to help you move back onto family meals.

Moving onto family meals

• The plan includes three regular meals and three snacks.

o Meals should contain two courses plus a nourishing drink (milk based or fruit juice)o Snacks should contain both a food snack and a nourishing drink

(milk based or fruit juice)o Additional water is also vital – you will see a picture of a glass of

water in the plan as a reminder. Aim for around 300mls for each glass.

• Avoid weighing, measuring and calorie counting. Discourage checking food labels.• Portion sizes should be based on previous intake when well or intake of a similar

aged/sized relative.• Additional food or increases in portion sizes may be recommended if weight gain is slow.

Tips about the food

Ordinary, everyday family foods are recommended, however, it is important that foods offered are high in energy to help weight gain. Low calorie foods are too bulky and don’t provide enough energy.

• Choose full fat versions and avoid any diet products. Use whole milk, whole yoghurts, fullfat mayonnaise, butter or full fat spreads.

• Keep portions of fruit, vegetables and salad small as these are filling and low in energy.• Milk and milk based products (e.g. yoghurt, cheese, custard, milk based sauces) are

particularly important in weight recovery, as they contain minerals for strong bones, suchas calcium. Bones can be weakened and susceptible to fracture as consequence ofprolonged starvation. Milk replacements (soya, nut, coconut milks) are often low incalories, do not contain all bone minerals and may not contain calcium. If a non-dairymilk is required, Alpro Soya Growing Up Drink (1-3 years) has the best calorie andcalcium content.

• Fruit juice and fluid are built into the plan from the start. Fruit juice contains potassiumwhich may be low and is also essential for muscle function. Many young people withanorexia nervosa are dehydrated, and as every cell in the body needs water to workproperly this is an essential part of the recovery plan.

Please note: This plan is a minimum intake and may need to be increased in line with increases in activity or slow weight gain. There will inevitably be small differences in the calories provided by each option. Avoid secretly adding in extra calories as this can lead to mistrust and food refusal, but reinforce the need to have a normal amount of fats and sugar in food.




Nutrition for Recovery – Full Portions Plan.

Meal Fluid Suggestions

Breakfast Choose one

• Medium size bowl of cereal/granola with whole milk/AlproJunior Soya Milk/yoghurt and two slices of thick toast/twocrumpets and butter/spread

• Eggs and two slices of thick toast/two crumpets andbutter/spread and a yoghurt

• Large croissant with butter, jam and a yoghurt with fruit

AND

• A glass of fruit juice

Snack Choose one ( or similar sized snack):

A drink of milk/Alpro Junior soya milk/fruit smoothie and a piece of fruit and two biscuits/a cake bar/ chocolate biscuit bar/cereal bar

Lunch Choose one

• A medium jacket potato with butter/spread and two toppings• Two slices of thick bread with butter/spread/mayo and two

protein fillings• Two slices of thick bread with butter/spread with a serving of a

fresh soup that contains protein (meat/beans/lentils) and anextra protein added

Protein fillings/toppings include: two slices cooked meat (not wafer thin), tuna, egg, cheese, houmous, cream cheese, baked beans, peanut butter.

AND

• A packet of crisps• Can include a small handful of salad or vegetables

AND dessert:

• 120g ski smooth/110g Activia intensely creamy greek style/twoscoops ice cream/150g Ambrosia custard/rice puddingpots/150g Alpro o on greek style yoghurt/125g Koyo yoghurtalternative

Snack Choose one ( or similar sized snack):

A drink of milk/Alpro Junior soya milk/fruit smoothie and a piece of fruit and two biscuits/a cake bar/chocolate biscuit bar/cereal bar



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Dinner A full sized portion of a family meal containing:

• Carbohydrate i.e. pasta/rice/potato/noodles/cous-cous/quinoa• A serving of meat, fish or vegetarian alternatives• Foods higher in fat such as cheese, avocado, cream, butter,

crème fraiche, tinned coconut milk, nuts to be included• Vegetables or salad but should fill no more than a third of the

plate

AND

• A glass of fruit juice

AND dessert:

• A cake/sponge/crumble pudding and cream/custard/slice ofcheesecake/large piece of flapjack/chocolate bar/brownie/largemuffin

Before bed

A large glass of milk/Alpro Junior soya milk/fruit smoothie. Additional slices of toast with butter/spread may be added for ongoing weight gain



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STAFF GUIDE FOR MEAL MANAGEMENT FOR YOUNG PEOPLE WITH EATING DISORDERS ON GENERAL WARDS

At start of contact, introduce yourself and try to develop rapport with young person. Explain that you will be here to help encourage them during meals and before/afterwards to support them.

Discuss with the young person (YP) what is going to be most helpful for them during meals (e.g. if distracting conversation helps and if praise for eating is helpful or not).

Inform the YP that mobile phones are prohibited during meal times.

Ensure they are aware of the time they have to eat the meal (30 minutes per meal) and give clear indicators such as, ‘time to make a start’. After this time has lapsed you will inform the ward staff what has/has not been consumed and document as necessary.

DO NOT negotiate about what is to be eaten but DO acknowledge that it is hard to do what is being asked and that you are there to support them.

Patients should be asked about likes and dislikes. They are allowed three dislikes only and this should not be whole food groups e.g. dairy foods.

Staff together with parent/carer can use these dislikes when choosing meal options from the main menu.

The patient should not be given a choice on what to choose or be shown a copy of the menu unless advised that it is helpful by the CAMHS team.

Always set the expectation that the meal will be eaten.

During the meal time, engage the young person in conversation (if they agreed this is helpful). Usually direct discussion about food is not helpful.

Try not to use phrases such as ‘well done’ as this can sometimes make young people feel bad for eating (but check out whether this is helpful or not with them as each person is an individual).

Challenge the young person if you see any ‘cheating’ behaviours e.g. hiding of food, pushing food over the side of plate, leaving some fluids in bottom of cups). It is important to let them know you have seen and to set clear boundaries. This is helpful and containing for the young person.

Don’t get into any lengthy debates about the food or body concerns or why someone can’t eat during the meal. This time is to focus on the task at hand. Reassure the young person that you can talk about this afterwards.

Document what has and hasn’t been eaten (food and fluids) on the appropriate chart after each meal.

Offer some support after the meal when a young person can be consumed with guilty feelings. They may wish to talk about these feelings or to be distracted by other things. Ask them what is most helpful.

Patient is to remain sitting for 30mins post meal/supplement. No toilet breaks during this time due to risk of vomiting/exercising.



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DO NOT feel responsible for the young person eating. You are there to help but cannot make them eat. Ultimately it is their choice.

Obtain a verbal handover from ward staff about the young person, any risks, and particular issues which have been occurring over recent hours/days with food/exercise and whether toilet breaks are to be supervised.

Find out from ward staff how meals are run (timings, if supplement is to be used if meal is not eaten and if NG tube will be used if none of the above is consumed). This will help you to be clear with the young person what is expected of them.

Be aware of description of patient in case of absconding and document.

Identify if daily plan has been established, follow if already in place – if not create one in conjunction with patient.

Discuss with ward nurse if clinical holding is required and if so are you trained to hold.

Check with ward staff if you need to carry out any observations (pulse, blood pressure, temperature) and where to document these, your summary at the end of the shift and dietary intake throughout the day.

Discourage young people from exercising. This may include posturing or ‘stress’ positions (exercise includes squatting, sitting forward, pushing feet on floor, awkward sitting positions, sit-ups/push-ups/star jumps and tapping legs).

Overall remember that engaging with the young person is the best way to support them through this difficult time.

Helpful Things to say at mealtimes

Children and young people find different things helpful. These guidelines will support your discussions. Adopt a firm, patient and non-judgemental stance

Helpful things to say include:

“I understand it’s difficult…” “I appreciate you don’t want to do this…” “I know this won’t be easy… but this is what you have to/need to do…” “you really need to eat you are very underweight…” “this will help you get out of hospital/to go home…” “you can do it…” “this is what will help you to get better…” “psychological work / working on other concerns (such as low mood or anxiety) cannot

be started unless you are eating…” “we won’t think that everything is OK just because you are eating, we know that it is more

complicated than that”

Unhelpful things to say include:

you are looking so much better/healthier…” “your parents will be proud of you if you eat…” “why don’t you just eat?...” “I’m glad you ate breakfast/lunch/dinner…” “you look anorexic” Avoid talking about food, calories or diets in any form



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Appendix 1 - Acute admission referral form

Type of Referral *(Emergency/ Urgent/ Routine) Referred To

Referrer Name Referrer Contact Number

Referrer Trust

Patient Name DOB / Age

NHS No: Gender

Patient Home Address Current Location

GP Name Parent/ Carer Name and relationship to young person

GP Address and telephone Parent Contact details

Weight Height BP Lying Standing Heart Rate Temperature

Safeguarding (Known safeguarding concerns? New concerns? Known social worker?)

SITUATION (Reason for referral, purpose/goals of assessment/ admission)

BACKGROUND (Primary & comorbid diagnoses, Family/ Socal context)

ASSESSMENT (Physical presentation eg dizziness, pallor, fainting), Are the young person/ family consenting to assessment/ admission)

RECOMMENDATION (What would you like from the assessment? What question are you asking?)

Please note that information included in section 1 above need not be repeated.


eating disorders guidelines for inpatient paediatric

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