Eating Disorders

  

Disclaimer These guidelines have been produced to guide clinical decision making for general practitioners (GPs). They are not strict protocols. Clinical common-sense should be applied at all times. These clinical guidelines should never be relied on as a substitute for proper assessment with respect to the particular circumstances of each case and the needs of each patient. Clinicians should also consider the local skill level available and their local area policies before following any guideline.

 

If a patient is experiencing severe physiological or psychiatric instability with imminent risk to self or others, please refer to the nearest Emergency Department

Introduction

Many psychological disorders and physical illnesses experienced by children and adolescents (young people) involve disordered eating. One third of all adolescents have experienced dissatisfaction with their body weight or had unhealthy weight control practices1.Up to 41% of adolescent females experienced disordered eating¹.

Eating disorders are highly complex, serious mental illnesses with significant physical complications and psychosocial impairment. The early identification and treatment of an eating disorder is essential for a positive prognosis. Treatment should be provided in a stepped-care approach, with young people and their families stepping up to more intensive care, or back down to less intensive care, as indicated⁵.

Services for children and adolescents presenting with eating disorders are delivered across multiple settings, including Community Child and Adolescent Mental Health Service (CAMHS), Perth Children’s Hospital Emergency Department (PCH ED), PCH Adolescent Medicine (Ward 4A) and the CAMHS Eating Disorder Service (EDS).

The CAMHS EDS is a Tier 4 state-wide specialist service, offering assessment to young people up to 16 years of age with severe eating disorders including:

• Anorexia Nervosa
• Bulimia Nervosa
• Atypical Anorexia Nervosa
• Binge Eating Disorder
• Avoidant Restrictive Food Intake Disorder (ARFID - if high school-aged)
• Eating Disorders Not Otherwise Specified (EDNOS)

To ensure a patient is accepted into this service, please demonstrate that Tier 1-3 services have been insufficient, or are unlikely to succeed. The outcome of an assessment may be to offer treatment with EDS, and if indicated can continue to be accessed up to 18 years of age.

Figure 1: The mental health tiered system of care

 

Pre-referral investigations

• Thorough history taking including:

• Seemingly unrelated psychological and physical complaints e.g. stress, depression, anxiety, menstrual irregularities, dizziness
• Exploration of body dysmorphia/over-evaluation of weight/shape
• Evidence of weight controlling behaviours (restriction, exercise, purging) including duration, frequency, severity
• Gastrointestinal symptoms including abdominal pain, nausea, vomiting, constipation & food intolerance

• Assessment of physiological compromise (see Figure 2 for admission indicators):

• Postural instability: pulse & BP on lying and standing after 1 minute
• Temperature
• Weight, Height and BMI

• Hormonal testing-TFT, FSH, LH, oestradiol, prolactin

• ECG including measurement of corrected QTc interval

• Results of any recent imaging studies

See ‘Physical Health Form’ in the Useful Resources Section below as a guide when reviewing a patient

	Admit	Concern Discuss with Adolescent Consultant	Moderate risk Weekly review
Risk	High concern	Significant concern	Moderate concern
% median BMI	<70%	>70 – 80%	>80 – 90%
Recent weight loss over 3 consecutive weeks	>1kg / week	0.5 – 1kg / week	<0.5kg / week
Awake heart rate (HR)	<45 beats / min	<50 beats / min	50–60 beats / min
Postural change	>50	>30
Rhythm	Any arrhythmia ST or T-wave change
Syncope	Recurrent	Occasional	Pre syncope
Blood pressure (BP)	<80 / 40	< 90 / 50
Postural systolic BP fall	20mmHg	15mmHg	<15mmHG
QTc ms	>450
Oedema	Present
Tympanic temperature	<35.5°C
Extremities	Cold / blue / pressure sores present
Dehydration	Moderate – severe	Mild
Biochemical	Significant electrolyte disturbance Hypoalbuminaemia Hypoglycaemia <3.0 mmol/L Hypokalaemia <3.0 mmol/L Hypophospataemia <0.9 mmol/L
	DISORDERED EATING BEHAVIOUR
Acute food refusal	3 days	<50% of required	50% of required
Purging / vomiting	After all intake	Multiple times per day
Behaviour relating to  meal support and limits	Violent	Unable to implement meal plan
Activity / exercise	Uncontained  >2hrs/day	Moderate >1hr/day	Mild <1hr/day
	SIGNIFICANT MENTAL HEALTH CONCERNS
Self-harm	Overdose	Active self-harm
Suicidality	Moderate to high	Low level suicidal ideation
Other mental health  diagnosis	Psychosis, confusion, delirium, cognitive slowing	Obsessive Compulsive Disorder, depression

Figure 2: Indicators for admission. Criteria adapted from the RANZCP (2014) and NSW (2014) Guidelines^{4, 5}

^{Pre-referral management}

Please see the management and referral pathways for patients outlined in these documents:

• Referrals pathway
• BMI for boys
• BMI for girls

Other useful resources for management:

• RACGP - Early detection of eating disorders in general practice
• RACGP - Eating disorders quick guide

When to refer

<16 years of age with significant physiological instability: 

• Promptly contact the PCH Adolescent Medical On-Call Consultant Paediatrician via PCH Switchboard to formulate a plan regarding need for assessment and/or admission

Significant psychiatric instability with non-imminent concerns about risk:

• Contact CAMHS Emergency Telehealth Service on 1800 048 636 for assessment and recommendation 

16-18 years of age with significant physiological instability:

• Promptly contact WA Eating Disorders Outreach and Consultation Service (WAEDOCS) for advice and recommendation on 1300 620 208. Open 9am-4pm Monday to Friday

How to refer

• Routine non-urgent referrals from a GP or a Consultant should go to the Central Referral Service
• Routine non-urgent referrals from private hospitals go to the PCH Referral Office
  Fax: 6456 0097 or email PCH.Referrals@health.wa.gov.au
• Urgent referrals (needing action within 7 days) are to be discussed with the Eating Disorder Service Psychiatrist or Adolescent Medicine Consultant on-call. Please call Perth Children’s Hospital Switch on (08) 6456 222

Essential information to include in your referral

• Name and details of patient and caregiver, including hospital (UMRN) number and Medicare number if known
• Current therapeutic engagement: provider/s and duration
• Current medication (including any allergies)
• Results of any investigations
• Clear documented evidence of: 
  • significant weight concerns (or restrictive diet if ARFID) and,
  • significant physical sequelae of weight loss, and
  • of body image distortions (or restrictive diet if ARFID)
• maximum weight with dates & minimum weight with dates (to enable estimation of rate of change)
• Demonstrate that Tiers 1-3 have been insufficient or why they are unlikely to succeed due to the complexity of the patient’s situation, or the family’s inability to access Tier 2-3 services (e.g. for financial reasons)

Useful resources

• Child and Adolescent Health Service – Physical Health Review Form
• Child and Adolescent Health Service – Eating Disorder Service

• Child and Adolescent Mental Health Service

• Eating Disorder Service-Information pack & referral process

• Centre for Clinical Interventions – Eating Disorders
• The Swan Centre
• Ramsay Clinic Hollywood-Eating disorders
• Womens Health & Family Service – Body Esteem Program: Eating Disorder Resources Directory
• Eating Disorders Families Australia
• National Eating Disorders Collaboration – Tips for carers
• F.E.A.S.T (Families Empowered and Supporting Treatment for Eating Disorders) 
• First 30 Days Program: Online education and support
• Butterfly Foundation
• Eating disorders | Your Health in Mind
• Royal College of Psychiatrists – Medical Emergencies in Eating Disorders: Guidance on Recognition and Management

References

1. Sparti, C., Santomauro, D., Cruwys, T., Burgess, P., Harris, M. (2019). Disordered eating among Australian adolescents: Prevalence, functioning, and help received. International Journal of Eating Disorders, 52: 246254, doi: 10.1002/eat.23032 https://pubmed.ncbi.nlm.nih.gov/30734332/
2. Telethon (2015) Second Australian Child and Adolescent Survey of Mental Health and Wellbeing
   https://www.health.gov.au/resources/publications/the-mental-health-of-children-and-adolescents
3. Hay P, Current approach to eating disorders: a clinical update, Internal Medicine Journal 50 (2020) 24–29
4. Van Eaden, A et al, Incidence, prevalence and mortality of anorexia nervosa and bulimia nervosa, Curr Opin Psychiatry (2021) 34:515–524
5. National Eating Disorders Collaboration Developing Practical Approaches to Eating Disorders, 2013

Reviewer/Team:	Adolescent Medicine & Child and Adolescent Mental Health Service-Eating Disorders	Last reviewed:	Nov 2022
		Review date:	Nov 2025

This document can be made available in alternative formats on request for a person with a disability.