Medical Assessments in Adolescence

Junior MaRSiPAN

Dr Mark Anderson

Background

• 0.5% of adolescent females have anorexia nervosa

• 1-5% of adolescent females have bulimia nervosa

• 5-10% of eating disorders occur in males

• Early recognition and intervention are thought to improve outcome

Whose problem is it?

• Psychiatric disorder• Significant physical issues

– Starvation– Growth– Re-feeding syndrome – Long term sequelae

• Acute medical issues• Safety in community• Multi-disciplinary approach

What can paediatricians offer?

• Medical assessment– Junior MaRSiPAN– Determine “risk”– Investigations

• Admission– At risk– Medical complications– Risk of re-feeding syndrome– Break the cycle, relieve pressure

Newcastle routes of referral

• CYPS (CAMHS)

• GP

• Emergency department

• Mostly via myself

Initial assessment

• Full history and medical assessment• Blood tests and ECG

• Risk assessment according to Junior MaRSiPAN– Management of Really Sick Patients with

Anorexia Nervosa (Junior!)

Junior Marsipan Risk Assessment

• Semi-objective• Aims to give an overall assessment of risk• It is not:

– A scoring system– Validated to predict need for admission,

specific management or outcome• Needs to be seen as part of the gestalt of

assessment

Measurements

• Percentage median BMI– >85%– 80-85%– 70-80%– <70%

• Recent weight loss– No change– Up to 500g/week for 2 weeks– 500-999g/week for 2 weeks– >1kg for 2 weeks

Cardiovascular 1

• Heart rate (awake)– >60 bpm– 50-60 bpm– 40-50 bpm– <40 bpm

• Cool peripheries

Cardiovascular 2

• Blood pressure– Normal– <2nd centile– <0.4th centile

• Syncope– No symptoms– Presyncopal symptoms– Occasional syncope with postural drop in BP– Recurrent syncope with marked postural drop

Cardiovascular 3

• Arrhythmia– Normal– Irregular heart rhythm

• ECG changes– QTc <450ms– QTc <450ms and taking QT prolonging

medication– QTc >450ms– QTc >450ms and evidence of arrhythmia or

electrolyte disturbance

Other physiological parameters

• Hydration– Not dehydrated– Mild dehydration– Moderate dehydration or peripheral oedema– Severe dehydration

• Temperature– <36°C– <35°C

Biochemical abnormalities

– Hypophosphataemia– Hypokalaemia– Hyponatraemia– Hypocalcaemia

– Severe abnormalities of above

Calorie intake

• Moderate restriction or bingeing

• Severe restriction (<50% of requirement)• Purging

• Acute food refusal or <600kcal/day

Activity & exercise

• No uncontrolled exercise

• Mild uncontrolled exercise (<1h/day)

• Moderate uncontrolled exercise (1-2h/day)

• Severe uncontrolled exercise (>2h/day)

Muscular weakness

• SUSS test– No difficulty– Unable to get up without noticeable difficulty– Unable to get up without using arms– Unable to get up at all

Engagement with management plan

• Some insight and motivation, not ambivalent

• Some insight and motivation, but ambivalent

• Poor insight and motivation; parents unable to implement meal plan

• Violent when parents try to implement plan; parental violence

Co-morbidities

• Deliberate self harm

• Suicidal ideation

• Other major psychiatric co-diagnosis

Outcomes of medical assessment

• Mostly blue-green, no red– Outpatient follow-up

• More amber, or some red– Admission for period of assessment

• No definite “admission criteria”

Admission

• Decision re: feeding method• Dietitian input – daily• Set nursing guidance – obs, bed rest,

“rules”• Make plan with YP (and family)• Daily review – close medical monitoring• Regular input from CYPS• Plan discharge

What we have learnt…

• AN is very difficult• The illness makes it hard• Staff often feel manipulated• Nursing time is a major issue• 16-18 year olds fall through the gaps

Longer term issues

• General health• Bone health

Bones

• Low bone mineral density• Critical time

• Risk of later osteoporosis• Back pain • Chronic ill health

Bones

• Nutrition• Hypogonadism• Relative hypercortisolaemia• Low IgF1

• Weight and nutrition improve BMD• Residual defect left

Bones

• Possible options– OCP (high dose OE)– Bisphosphonates– Low dose OE– Transdermal OE– Calcium/Vitamin D

Toronto study 2011

• Randomised placebo controlled study• 40 girls normal weight - controls• 110 girls AN – randomised

– OE +– OE –

• OE transdermal 100mcg patch twice weekly OR escalating doses of oral OE 3.75mcg daily increasing over 18 months

• OE + given medroxyprogesterone 2.5 mg daily for 10 days every month

• OE – placebo patch and placebo medroxyprogesterone• Controls followed for 18 months no intervention• ALL had calcium carbonate and Vit D

Results BMD change

Results

• No change in weight• No change in lean body mass• No change in percentage fat mass• No change in BMI• No change in IgF1

Recommendations

• DEXA scan – ?when

• Commence OE replacement – ?when

– Who should do this/monitor progress– What happens >18 years of age– What about the boys?

Conclusions

• Acute management • Good liaison• Easy for <16 year old• Need to support 16-18 year olds• Long term input• Bones and future health

Questions?

• Junior MARSIPAN: MAnagement of Really Sick Patients under 18 with Anorexia Nervosa– College report CR 168, January 2012 RCPSYCH

• Norrington, Stanley, Tremlett, Birrell. Medical management of acute severe anorexia nervosa Arch Dis Child Educ Pract Ed 2012;97:48-54

• Physiologic Estrogen Replacement Increases Bone Density in Adolescent Girls With Anorexia Nervosa. Misra M, Katzman D, Miller K , Mendes N, Snelgrove D, Russell M, Goldstein, Ebrahimi M, Clauss L, Weigel T, Mickley D, Schoenfeld D , Herzog D, Klibanski A. Journal of Bone and Mineral Research, Vol. 26, No. 10, October 2011, pp 2430–2438