Working together...5 year experience of South London and the Maudsley & King’s College Hospitals

Dr Mima Simic MSc MD MRCPsychConsultant Child and Adolescent Psychiatrist

Dr Simon Chapman BA BM FRCPCHConsultant Paediatrician

The Role of the Paediatrician in Eating Disorders

Care pathway: BEFORE 2010Child and Adolescent Eating Disorder

ServiceMaudsley Hospital, London

Referral from GP, Tier 2 or

Tier 3 CAMHS

Screening Assessment

Inpatient Treatment

Multifamily Therapy

Programme

Specialist Outpatient Treatment

Care pathwayChild and Adolescent Eating Disorder

ServiceMaudsley Hospital, London since 2010

Referral from GP, Tier 2 or

Tier 3 CAMHS

ScreeningAssessment

Brief paediatric admission

Intensive Treatment

Programme(ITP)

Inpatient Treatment

Multifamily Therapy

Programme

Specialist Outpatient Treatment

RCT of inpatient treatment for anorexia nervosa in medically unstable adolescents (Madden et al. 2014)

First study to compare different inpatient interventions

Iceland –average length of stay in AN adolescents 129.7days (Sigurdardottur et al. 2010)

France -135 days (Stirk Lievers e al. 2009) UK - 106.4 days (Gowers et al. 2010) USA – 16 days for medically unstable (Chu et

al. 2012)

Madden et al. cont…

82 eligible from 266 consecutive admission of eating disorders to two specialist paediatric units

Young people aged 12-18 years with the duration of illness < 3 years

Eligible if medically unstable: 1. temperature <35.5 C2. heart rate < 50 beats/min3. <80 mmHg systolic and < 40 mmHg diastolic4. orthostatic instability >20 beats/min, systolic

blood pressure decrease >20mm Hg or QT >0.45s

Madden et al. cont…

Randomised to1. Medical stabilization(MS) +family based treatment

(FBT)2. Hospitalization for weight restoration + FBT

All were re-fed according to standard protocol commencing with 24-72h of continuous nasogastric feeds (ceased during day if medically stable) followed by a combination of nocturnal nasogastric feeds and supported meals with the total caloric intake between 2400 and 3000 kcal/day

Cont…

Patients in MS group were discharge to outpatient FBT if they had no markers of medically instability for 72 ours of cessation of NG feeding

Patients in WR group were discharged to outpatient FBT when they reached 90% of Expected Body Weight (EBW)

ResultsFirst admissiondays

Days in hospitalat 12 months

Fully recoveredat 12 months

Partially recovered at 12 months

No Family Therapy sessions

Additional treatment in %

MS 21.73 45.20 30.00% 90.00% 24.25 30.6%

WR 36.89 65.50 32.50% 85.00% 31.30 45.5%

Results

Effect size 0.43 – moderate effect size in favour of MS group

Outpatient treatment cost 10% of inpatient treatment (Katzman et al. 2000) + prolonged admission reduces contact with the family, friends, peers and educational attainment, socialization and identity development (Meads et al 2001)

Patients with higher EDE score and higher compulsive behaviour did better in MS group - longer admission magnifies the rigidity and inflexibility (LeGrange et al. 2012)

Summary (Madden et all, 2014)

Hospitalization is shorter if family therapy for anorexia nervosa is available

For adolescents with AN of duration less than 3 years, treatment programmes that integrate outpatient family therapy with inpatient treatment for medical stabilization is likely to lead to more cost-effective care

What is a paediatrician for?■Exclude other causes■Physical Risk

assessment■Management of

refeeding■The ‘voice of concern’■Psychoeducation■ ‘The late effects’

What do the medics need to manage Eating Disorders?

• A&E, Paediatric Ward access, Adolescent policy• Access to specialties:

– Gastroenterology & Dietetics– HDU/ITU– Endocrinology– Neurology– Cardiology– Radiology– CAMHS/Liaison Psychiatry 24/7

• Pathways, Guidelines, Protocols• Time: Clinics/Admin/Discussion and Advice• Trained nursing staff• Support from the kitchens• Supportive Colleagues/OOH policy

3rd September 1967, Sweden

The barriers• Cultural: ‘Not on my ward’• Lack of familiarity and training

– Nursing– Medical– Dietetic

• Access to specialist eating disorders expertise/national shortage of in-patient CAMHS

• Access to HDU/ITU• Access to

gastroenterology/endocrinology/cardiology/radiology• Pressure to discharge

Outpatients Inpatient CAMHS (Snowsfield) - teenagers

Inpatient CAMHS (Acorn Lodge) - children

Follow Up Clinic

Intensive therapy Programme (Day

Hospital

New Patient Clinic

Paediatric Ward

Assessment

Kings

SLaM

Medical PathwayPrinciples• Paediatrician in the

initial assessment• Clear risk assessment

pathway (in and outpatient)

• Specialist Eating Disorders input for medical patients

• Regular follow up medical clinics

Physical risk assessment at The

Maudsley

TriageHeightWeight%mBMI* BPTempPulseBlood sugar

ECGGas Machine Electrolytes

Medical Assessment

Red Criteria Amber Criteria Green/Blue Criteria

Stabilize, NGT if refusing meal plan INVOLVE PSYCHIATRY

Will tolerate meal plan?AND

LOW/MODERATE RISK OF REFEEDING SYNDROME (see REFEEDING RISK ASSESSMENT chart)

Allow Home with meal plan with Eating Disorders Team follow up

Discuss with Eating Disorders Team/ Liaison PsychiatryADMIT

NO

YES

* BMI = height in metres x (weight in kg)2

%mBMI = (actual BMI/50th Centile BMI) x 100 [see chart for 50th Centile BMI Values]

exclude medical causes of cachexia

Using RISK ASSESSMENT FRAMEWORK FOR YOUNG PEOPLE WITH EATING DISORDERS

Medical Risk Assessment of Young People with Eating

Disorders in the Emergency Department

Physical risk assessment for King’s Emergency

Department

BEDREST (consider RMN)

Rewarm

Correct Electrolyte Abnormalities

Cardiac Monitor (if prolonged QTc)

EARLY REINTRODUCTION OF NUTRITION

(meal plan or NGT)

DAY 1: 1200KCAL/24H

DAY 2: 1500KCAL/24H

DAY 3: 1750 KCAL/24H

DAY 4: 2000 KCAL/24H

DAY 5: 2250 KCAL/24H

DAY 6: 2500 KCAL/D

Involve Child and Adolescent Eating Disorders Team early to plan transfer

IN HOURS: 020 32282545

OUT OF HOURS: Child & Adolescent Psychiatry On-Call

Initial InvestigationsFBC/Ferritin/filmU&E/LFT/Bone/MgGlucose (if hypoglycaemia <2.6mmol/L, also plasma Betahydroxybutyrate/Nonesterified fatty acids/Cortisol/Insulin/CPeptide/Acyl carnitines/urine organic acids, ketones (dipstick)B12/Folate/Vitamin DChloride/Bicarbonate/Potassium if history of vomitingAmylase/lipids if history of vomiting/abdominal painTFTIf amenorrhoea present: Prolactin, FSH, LH, Estradiol, AFP, BHCGCoeliac Screen12 Lead ECG: clear documentation of the corrected QT is essential (QT/√RR): note that a prolonged QTc can be associated with cardiac arrhythmia. It is sex-dependent. (See Appendix 1 for criteria)

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, M

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SIU

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PH

OS

PH

AT

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aily

NOTE: 80% of hypophosphataemia

occurs by Day 4

Medicines

phosphate sandoz 500mg bd (32mmol/d)

vitamin B complex strong (contains B1 [thiamine] and B2 [riboflavin], nicotinamide, B6 [pyridoxine)])

2 tablets TDS

or if liquid used (Vigranon B)

age: 1-12y 10ml TDS

12-18y 15ml TDS

multivitamin. (sanatogen or forceval one tab od)

NB: if strong suspicion of thiamine deficiency

Use Pabrinex instead of Vitamin B complex

Vial 1 (contains B1 [thiamine] 250mg and B2 [riboflavin] 4mg, B6 [pyridoxine) 50mg])

Vial 2 (contains C [ascorbic acid] 500mg, nicotinamide 160mg, Glucose 2000mg)

ADULT DOSE: 10ml of each ampoule diluted with 50-100ml of (0.9% saline or 5% dextrose) given over 30 mins

CHILD DOSE:

6 - 10 years 1/3 of the adult dose

 10 - 14 years 1/2 to 2/3 of the adult dose

14 years and over as for the adult dose

Avoid treating hypoglycaemia with hypostop unless symptomatic or nonketoticPhysical risk assessment for King’s In

Patients

5 year experience

19 patients29 visits

Mean Min Max

age 15.2y 11y 18.1y

sex 18/19 girls1 boy

length of admission

6 days 1 day 33 days

No significant refeeding syndrome

Start up 1200 - 1500 kCal/d

The medical admissions

Longer term outcome

Case HistoryInvolved professionals Gastroenterology

(Consultant, Dietician, Psychologist)

Gastroenterology ward at KCH

Gastroenterology ward at Private Hospital

Local hospital general paediatric team

Child & Adolescent Eating Disorders Team

Local CAMHS Specialist Inpatient CAMHS

What can the Paediatrician do?

Good at talking to children, young people and families

The voice of ‘objectivity’

The voice of concern Negotiate change

Medicalise and stabilise

‘Psychoeducation’

Thank you5 year experience of South London and the Maudsley & King’s College Hospitals